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AANP Member Spotlight: Starting a Virtual Practice

Virtual Practice

Discover the rewards and challenges of telehealth from AANP Fellow Joshua Hamilton, DNP, APRN-CNP, PMHNP-BC, FAANP.

The COVID-19 pandemic put a renewed focus on telehealth, though technology has always been a vital tool utilized by health care providers to better reach and serve patients. What has changed is that innovations within telehealth have increased exponentially over the last few years. This heightened pace of progress has led health care providers, including nurse practitioners (NPs), to consider how they can best leverage telehealth in their own practices.

The American Association of Nurse Practitioners® (AANP) Fellow Dr. Joshua Hamilton was an early adopter of the technology that has become so commonplace in health care today. He now works completely via telehealth in private psychiatric practice in Las Vegas, Nevada. Hamilton spoke with AANP to offer insights for NPs who may want to begin their own telehealth practice and to discuss his early experiences at the intersection of patient-centered care and technology.

Q: When you were interviewed by AANP at the 2022 AANP Fall Conference for episode 61 of the NP Pulse: The Voice of the Nurse Practitioner® podcast, you mentioned that you have been working via telehealth “before it was practical or necessary.” How did you become an early adopter of telehealth, and when?

Josh Hamilton: I began a version of telehealth back in 2012 and 2013, and it’s just sort of grown and taken on a life of its own. When I built my practice, I had moved back to the Las Vegas metro from a visiting professorship in Canada. We were trying to be unique at that time, saying, “How we could best meet the needs of an ambulatory care behavioral health audience?” We were doing some neat stuff. We were using separate waiting rooms so that patients didn’t have to share common space and were checked in and checked out privately. That went really well — I think we had 633 patients at the height of that practice.

It was around the time we were hitting our stride that I was called back into a full-time academic leadership position. My deanship at the College of Southern Nevada came calling, and I was thinking, “How do I condense this? How do I go take a 40-to-50-hour workweek academic position and still maintain continuity with patients?” I kept about 200 patients, and we taught them how to use video conferencing and how to use email and to really relate to the practice of telehealth. These patients who were tech savvy and relatively stable would join me on a scheduled basis during my lunch hour. It went really smashingly, just in terms of patients saying, “Why weren’t we doing it this way all along?”

Q: What advancements have you seen in telehealth over the last few years?

Hamilton: Telehealth improvements were initiated well before the pandemic, but we did see a real escalation of the timeline. My electronic medical record (EMR) vendor had been talking about a telehealth option for eight years. And it wasn’t until mid-to-late 2020 that they actually said, “We’re going to deploy this. It’s probably not ready for primetime, it’s still buggy,” but that’s when we actually saw what I believe was the first integrated telehealth option within a behavior health EMR.

We did see a big escalation in terms of how fast things changed. There were a lot more integrations that came out, a lot more one-touch stuff and a lot more attention to the patient portals. Payment, the ability to pay with online payment systems or with a credit card — they really doubled down on some of those layers of features in mid-to-late 2020. Things that were five years away became five minutes away during the pandemic.

Q: What advice or information could you share with entrepreneurial NPs interested in starting and maintaining their own telehealth practice?

Hamilton: Take your time and really vet your options. We have so many proper telehealth services now. Really take some demonstrations and find out what — for your price point — will a vendor be able to do for you in terms of integration of scheduling, documentation, conducting the visit, any follow-up you may have, any portal relationship in terms of documents being exchanged, data being exchanged, payment information, referrals, education … it’s amazing what we can deliver asynchronously now for patient education via telehealth. Use this opportunity to envision a different way to interact and enrich the patient encounter that probably transcends what you’re used to.

The telehealth world is getting really creative, so reflect on what you want to look like in the virtual space. Consider your volume of workflow, your bottom line and your margin. A lot of people get “sticker shock” looking at the cost of some of these software solutions, but what I have found in the last few months is that a lot more of the commercial insurers are paying for this type of visit, and sometimes reimbursements are actually more competitive. Crunch your numbers and really think about rebranding yourself in this new context.

Q: We’ve heard about the positives of telehealth, but what struggles have you encountered?

Hamilton: There are two things — and they’re still relevant — for me as a psych mental health provider. First, what do you do with a patient when they appear on camera and they’re not doing well? Do you have a contingency plan? Do you have those touchpoints for a welfare check? How do you get someone to go out there and check on a patient who is not at the camera as scheduled, or someone who is making statements or appears in a way that gives you a real bona fide concern about them in a physiological sense? With crisis care and critical situations, you need to map that out and think it through before it happens.

And the other is that word of mouth is important — especially for NPs — and if you’re good at what you do, and your “webside manner” is good, people will call you from adjacent states or states abroad. Licensure is still a real sticky wicket, especially for NPs. I was surprised by how many patients call me from Idaho, for example. I had to really think about the threshold for the number of patients who want to see me before I can justify the time and expense of an additional license. I guess in some instances the latter one is a good problem to have, but it’s still a real math problem.

Learn More About Starting an Independent Practice by Joining AANP’s Entrepreneur Community

The AANP Entrepreneur Specialty Interest Group (SIG) is a network of NPs interested in starting and maintaining their own practice. By joining the Entrepreneur SIG, you will gain access to a community of like-minded NPs exchanging support and expertise — which includes an online forum featuring a number of discussion topics. The Entrepreneur SIG is co-chaired by AANP Fellows Lynn Rapsilber, DNP, ANP-BC, APRN, FAANP — the CEO and co-founder of the National Nurse Practitioner Entrepreneur Network (NNPEN) — and recent winner of the Johnson & Johnson QuickFire Challenge and CEO of C3: Community Concierge Care, Erin Athey, DNP, FNP-BC, RN, FAANP.

Help support you and your colleagues’ success as you develop your own place of practice. Come learn, share and help progress the development of theory and practice by joining the AANP Entrepreneur SIG today — one of 28 vibrant AANP Communities.

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