The DPC NP
From Burnout to Breakthrough: Helen Tackitt’s Journey to a thriving Direct Primary Care Practice
Can burnout lead to something profoundly positive? Join us as we sit down with Helen Tackitt, a remarkable nurse practitioner from Mebane, North Carolina, who proves it can. Helen’s journey from the high-pressure world of inpatient nursing to successfully opening her own direct primary care clinic is nothing short of inspiring. She shares how her initial career in urology and oncology, working at prestigious institutions like Duke and the Cleveland Clinic, eventually led her to seek a more fulfilling path, especially after experiencing the pandemic's impact firsthand.
Setting up a clinic in a small community comes with its own set of challenges, and Helen candidly discusses her strategies and setbacks in marketing and patient care. Despite traditional marketing efforts falling short, she found unexpected success through Facebook, allowing her to build a patient base of around 465 individuals. Helen's pursuit of a functional medicine certification to better serve her patients underscores her commitment to integrative care. She also highlights the importance of finding the right team members and the invaluable experience of precepting students in healthcare.
From switching management systems to ensure better patient care to setting boundaries for a healthier work-life balance, Helen shares the nuts and bolts of running a direct primary care practice. She offers practical insights on restructuring membership fees, managing patient communications, and the crucial steps in opening a DPC clinic. Helen’s story is packed with lessons and advice for anyone looking to navigate the complexities of the healthcare system and make a meaningful impact in their community. Don't miss this episode filled with actionable wisdom and heartfelt experiences.
Thank you for joining us today!
Be sure to follow and share, and leave a review!
If you have questions, comments or want to be part of our community, follow us on Facebook at The DPC NP!
Can burnout lead to something profoundly positive? Join us as we sit down with Helen Tackitt, a remarkable nurse practitioner from Mebane, North Carolina, who proves it can. Helen’s journey from the high-pressure world of inpatient nursing to successfully opening her own direct primary care clinic is nothing short of inspiring. She shares how her initial career in urology and oncology, working at prestigious institutions like Duke and the Cleveland Clinic, eventually led her to seek a more fulfilling path, especially after experiencing the pandemic's impact firsthand.
Setting up a clinic in a small community comes with its own set of challenges, and Helen candidly discusses her strategies and setbacks in marketing and patient care. Despite traditional marketing efforts falling short, she found unexpected success through Facebook, allowing her to build a patient base of around 465 individuals. Helen's pursuit of a functional medicine certification to better serve her patients underscores her commitment to integrative care. She also highlights the importance of finding the right team members and the invaluable experience of precepting students in healthcare.
From switching management systems to ensure better patient care to setting boundaries for a healthier work-life balance, Helen shares the nuts and bolts of running a direct primary care practice. She offers practical insights on restructuring membership fees, managing patient communications, and the crucial steps in opening a DPC clinic. Helen’s story is packed with lessons and advice for anyone looking to navigate the complexities of the healthcare system and make a meaningful impact in their community. Don't miss this episode filled with actionable wisdom and heartfelt experiences.
Thank you for joining us today!
Be sure to follow and share, and leave a review!
If you have questions, comments or want to be part of our community, follow us on Facebook at The DPC NP!
Welcome to the DPCNP. I'm your host, Amanda Price, family nurse practitioner with two decades of experience, including 16 years as a business owner. Hey everybody, welcome to the podcast. And today I have Helen Tackett with me from Mebane, North Carolina. Helen, welcome to the podcast. And today I have Helen Tackett with me from Mebane, North Carolina. Helen, welcome to the podcast. Thank you, You're welcome. I'm excited to hear about your story today. I think it's going to be so informative and educational for everybody that's listening. So let's start off with tell us how you became a nurse practitioner.
Speaker 2:Within a couple years of being out of nursing school and working inpatient on the floor, I decided that I didn't want to do that forever. It is why I decided to go back and be a nurse practitioner. Okay, what school did you go to? I went to Regis University in Denver, colorado.
Speaker 1:Oh, okay, what brought you to North Carolina then?
Speaker 2:Yeah, so I never really loved Denver, colorado. I grew up in Florida, so I was close to the beach, close to the water, and you know there isn't that in Denver, and although the mountains are beautiful, it was not the same. And so one day my husband said he was listening to the radio and some kind of like Southern rock, and he goes. I can move back to the South.
Speaker 1:So I jumped on it. You kind of got to the South. You're like at that edge of the South You're not Florida, but you're up there, you're close.
Speaker 2:I'm still in driving distance from Florida, where I was not in Colorado. So then he was like well, if you can find a job and at that point I was in urology at university, colorado so he said if you can find a job there doing what you love to do and what know what you're? Doing here, then I think we can make the move. So I ended up just basically sending a fax to Duke's urology department and then a couple other places and they called me and flew me out here and the rest is history.
Speaker 1:So how did the transition go between you working for Duke urology to deciding you were going to open a direct primary care clinic?
Speaker 2:Yeah. So there was a long road. So I did 10 years in urology and then I actually jumped to oncology. So what happened was I got my doctorate degree graduated in 2016. I had been doing management and seeing patients at that point, opened the urology clinic for Duke that's in Raleigh and then realized that I was a little bit feeling, a little bit burned out as far as the whole urology world was going leader. So I started seeking those jobs and so ended up in Ohio at the Cleveland Clinic.
Speaker 2:Don't like snow, but I put my feelers out there to really try to stay in North Carolina. But there just wasn't at that point. So that was 2016. There wasn't a lot of APP leader positions. There's way more now, so that was kind of the new thing at that point. So there really wasn't places within North Carolina where these jobs were even available. So I started having to seek other places within the country, put an application in the Cleveland Clinic in their oncology area, and didn't think that I would end up getting the job, because you know they're the Cleveland Clinic, but did end up getting the job and so we said, well, I'm not going to love the snow, I probably won't love Ohio, but we figured, you know, we could do it for five years and then see what would happen from there.
Speaker 2:So I lasted three and a half years, four winters, and I said I cannot do this anymore. I'm going to cry if I have to go through one more winter. And so then ended back up here in North Carolina and did back up at Duke. That was comfortable for me. So went back to Duke, back in oncology, and then COVID hit. And so COVID didn't give me the warm fuzzies about the medical field anymore and I really was disappointed with how the medical system handled COVID. And at that point I said I really I just can't be part of this. And so I told him. I came home one day and I just said to my husband I said I'm going to open my own practice and he thought I lost my mind. So what are you going to do? And I said I have no idea, but it's not going to be working for a big health system and being told what I can and can't do anymore.
Speaker 2:And at that point I really honestly didn't know anything about direct primary care. So I was working with out here in North Carolina there's a group of hospitals or group of clinics where you work with them. It's almost like a franchise kind of thing. You open up a clinic with them, they do all your billing, you use their name, but they basically set it up. They tell you how to set it up. They're supposedly your patients.
Speaker 2:Anyway, I was working on that and then I read their contract and it after a number of years they said you could either continue to buy in or the patients belong to them. And I'm like, well, I'm not going to put all my money up front and then not even have these patients and have put all this time and energy. So, interestingly enough, I ended up reaching out to try to find a supervising physician. And at that point I was still going down that track with this other group and the only supervising physician because I had been away from North Carolina that I knew was a gentleman who I knew had left Duke but used to refer me patients in urology. He was primary care. So I gave his office a call and the gentleman who, when I stepped down from my leadership position at Duke, who took my position, answered the phone. So I was like oh well, what are you doing over there? And that was a direct care practice, a direct primary care practice. So through that conversation he said, oh, you should just open a direct primary care practice.
Speaker 2:But then what happened is I ran into researching what that is, thought maybe he would help me. He didn't want to be my supervising physician, which is fine. He didn't want the liability, but initially said he would give me some information and help me with opening a practice. Said he would give me some information and help me with opening a practice. Well then, as we kind of see, physicians aren't very friendly a lot of times to APPs within this environment. So I never heard from him. After that I called, I left messages, nothing, so realized I was just going to have to figure this out on my own. I listened to a number of old presentations from the DPC frontier because he at least had dropped that little bit of information about.
Speaker 2:Oh, look at DPC Frontier, there's information out there on the rules in North Carolina and because I had had the experience of opening the practice at Duke from nothing. So I had to figure out what supplies we needed to order, what staffing we needed to have procedure equipment. I wrote all their policies and procedures, all their nurse triage stuff. I was like I know how to do that piece. I just have to understand this whole direct care model. So after I listened to a number of old presentations through there, I went to the Hint Summit that year and spoke to a few of their reps and got some information. That's where I met the people who actually do my website and then from there just opened the practice and I'm in my third year now and it's been great.
Speaker 1:Wow, you have managed to answer like almost every question I was going to ask you in that one conversation, that one conversation. That's incredible, though, that you are so independent minded, obviously, that you could go from just hearing someone suggest something to just actively formulating a plan. That's amazing. So take us through. Like, how did you pick the name of your practice?
Speaker 2:So that's really more my husband. So he said you know? So we looked, there's a number of direct primary care practices in our area. There wasn't anything in Mebane. So here in the area that I'm in we have Mebane and then there's Graham and then Burlington and then Greensboro and this is the triad and then Hillsboro is on the other side of us. There wasn't any direct care practices within this area.
Speaker 2:So I had this area, which is nice because this is where I live, but in other parts, more towards, like the Raleigh area or the Durham area, there was a number of DPC practices, all physician ran and owned and they all had names that didn't really tell you what they were. And my husband has a background in marketing. So before now he's a nurse but prior to his degree was in business and marketing and he actually worked with an advertising firm and he said people need to know what you are by your name. And so he said this is direct primary care. So we're going to call it direct primary care and we live in Mebane, so it's going to be direct primary care.
Speaker 1:Mebane. Well, that's very easy to differentiate what kind of practice that you are providing to your people in your community.
Speaker 2:Yes, the this community, though, had no clue what direct primary care was. There's some savvy people in the Raleigh kind of carry area, because I think actually one of the very first direct primary care practices was here in North Carolina, Apex, and I think he opened in 2008. And Apex is about an hour, 45 minutes to an hour, from where my office is. So in that area there are some people who are savvier and know what direct care is, but here at Mebane they thought I made it up.
Speaker 1:Well, what kind of marketing then did you have to do to educate people? Because it's the same in my area, in my entire county. I'm the only DPC practice and I live in the same county as Memphis, tennessee, so there's no DPC clinic except for me. Now there is MDVIP.
Speaker 1:So a lot of people have heard of the concierge concept but we're a little bit different in respects there, but I know how I had to market. But I had already had my clinic open for 16 years, so my marketing was just convincing already established patients of the new practice model. So what did it look like to start your clinic from scratch and have to market to a clientele from scratch as well?
Speaker 2:Yeah, and it's evolved, so the practice model has greatly evolved since I opened it. There's about 17,000 people in this area of Mevin, and I have never been in primary care in this area, so I didn't have a group of patients who were just transitioning to me from a traditional or conventional practice over to my practice, and so I ended up joining the Mevin Business Association and attended a number of those meetings. I was a little bit disappointed with those meetings, though, because I thought it was going to be more networking and really getting to talk about my practice and what I do, and instead it was more sitting in a room with other business people while people from the community came in and gave presentations about a new building or apartment complex or something like that that was happening.
Speaker 2:So, I only stayed a member of the Mevin Business Association for about six months. I did get to talk to a few other business people in that group who owned their own like electrician business or something, but I honestly there was not the return on investment there. I didn't get any business out of being within that group. I went to a couple. So we have B&I meetings here. I don't know if you had those in your area so I did go to. I didn't join a B&I group because it was very expensive and I didn't know if coming in from a provider's office if it was going to work as far as how they were going to send me referrals and things, because that's their big thing within BNI is we're going to give you referrals? I went to a few meetings just to get my name out there in what I do and met some really great people. You can go to a number of meetings I think it's two or three a year for free. So I did a couple of those, got a few people more people who were in BNI who came to me more than them, referring me patient.
Speaker 2:We did a few radio ads. We have a local station it's a local country station out here. So we did run a few months of ads with them. Once again. We got a couple of patients that way, but not the great return on investment that we thought it would. I tried WebMD. That was a little bit pricier than I would have liked. Got one patient through that and had to commit to six months with them. But honestly, what has given me the most bang for my buck is Facebook. So Facebook has definitely been how I've gotten majority of my patients and now it basically word of mouth. I don't advertise that much. I will occasionally run an ad, but most of my patients come word of mouth now.
Speaker 1:And how many patients do you have?
Speaker 2:So currently I have, I think it's 465.
Speaker 1:And is that your goal? Are you? Is that a comfortable amount for you?
Speaker 2:So I thought 500 was going to be my mark. And then once I started doing functional medicine, so that was something that had evolved from the practice as well, not something I initially set out to do. Those patients are very, very, very sick. So I started, started, and so how that happened was I had been open. I opened in January and in April I got a patient who was a long COVID patient and at that point COVID was still a pretty new thing. Long COVID, even newer and nobody really knew what to do.
Speaker 2:So the frontline physicians I don't know if you're familiar with them and their protocols none of that stuff was out yet, so there wasn't any guidance from those groups about what supplements, nutrients, things to treat these patients. So what happened was this very lovely woman ended up in front of me one day super sick, just going to help her, no matter what I had to do. So I spent hours just trying to think of different things that could be triggering her symptoms and doing research and coming up with treatment plans and tweaking things, and took me a year and a half to get her better. But she's better she hardly. She's still a patient. I just don't see her much because she really doesn't need me anymore. But she said she thinks God first and me second, and what I ended up figuring out was a lot of the things that the frontline physicians figured out, but had to figure it out myself instead of with a group of other providers to help support. So it was just a lot of hours of research and then, because I helped her word of mouth, I started getting other patients that were just super, super, super sick and trying to figure out what was going on with them. And then from there I finally said, well, I need to get a certification in functional medicine because, even though I've been successful at trying to figure these things out and come up with these treatment plans and learning the functional testing and all that, I really want to know what I don't know. So I did end up going through a certification and ended up getting that, and now I would say about 150 of my patients are functional patients. They take a lot more of my time.
Speaker 2:So what happened was I got to about 350 patients and I said, oh my gosh, I need help. So I did end up hiring somebody. That's probably the biggest weakness within that I've found. You know, everybody has their little struggle. For me it's finding the right fits for my practice.
Speaker 2:I did find one woman and I hired her because I wanted somebody who's Christian, somebody who shared my beliefs and how to care for my patient. And she was wonderful, except for that six months in she went on a mission trip and she came back and I'm sitting here going oh, we just got a new business, we have more DOT physicals coming, we have all this growth. And she said I'm leaving. Oh, no, I'm excited. And she said I'm leaving, oh, no, I'm excited. And then I did try to put out some ads and find somebody, but it's really hard because you know they want all these benefits and insurance and retirements and just can't give people what the big health systems can. So my nurse is in NP school and she graduates next fall and she's amazing and she's going to be an amazing nurse practitioner and she has, through working with me, learned some of the functional stuff and is very interested and wants to do it as well. So honestly, I've given up on hiring anybody. I'm just going to wait it out until she graduates anybody.
Speaker 1:I'm just going to wait it out until she graduates. Yeah, that reminds me of a podcast that I did with Monica McKitterick. She's out of Austin, texas, and she gave me some really good advice, and that was that she had the best success hiring students that precepted in her clinic. And when I was looking for who I was going to bring on as the second provider in my practice, I couldn't think of a better choice than the student that had just gone through, because she learned how I treat my patients, how I communicate with them.
Speaker 1:I was able to spend lots of time and hours of downtime when we didn't have patients coming in. I could talk to her about the functional medicine side, just getting to the root cause of people's problems and how. You know, her school was not teaching her anything even related to that. She wasn't learning how to show patients appropriate nutrition. She wasn't learning what supplements that she could offer patients that would inadvertently work just as well, if not better, than some of the medications. And so I was kind of on this journey to teach her how to better take care of patients instead of all of it being straight pharmacology. And she loved it, she embraced it and I was able to see her for those months of that semester. Just soak all that in. So if there is any advice I could offer to anybody listening is like don't discount your students that are precepting under you, because they are putty in your hands, really Like you could mold them to be that wonderful provider that patients deserve to have.
Speaker 2:No, that is true, I did have. I've only precepted one student. I'm just honestly, I'm so busy that I'm a little hesitant to have too many students because I just can't have somebody slow me down. I have two exam rooms too.
Speaker 1:I only will precept a student if I already know who that person is.
Speaker 2:Yeah.
Speaker 1:So I already knew who this girl was. So a perfect stranger does not get to come in precept.
Speaker 2:Yes, yes, no, that is true. So the one that I did take, she pulled at my heartstrings because she goes to Liberty University and so I took her and she just it's so funny to see, just like you were saying, so they're being trained in this conventional way and then they're listening to me talk to patients in a whole different way, because most of the patients that when she was here that I was seeing were my functional patients, and now she's like this is what I want to do.
Speaker 1:Where did you get your functional medicine certification from American?
Speaker 2:Academy of Health, functional health. Was it a long course? It was. It's work at your own pace. I was taught of different training modules in there, but I had a goal set that I was going to get through it in six months. And so I just was constantly either here at the office or I was listening to a training session all weekend long. That's what I would do, and then my nurse would know when I was doing it, because then I'd start posting things on my Facebook page different things that I had learned but kind of had aggravated me about our health system, and she thought no, you must. What are you listening to now? So I ended up getting through it in six months, but I tell you they have a final that you take when it's over, and that was, honestly, I think their final was harder than taking my board for my oh, oh, my goodness.
Speaker 1:But look at you now. Look at all of the different avenues of which you can help somebody. I saw on your website that through that functional medicine, let me say, you are offering hormone replacement therapy and treatment for leaky gut and all the things yeah.
Speaker 2:So I do a little bit of everything when it comes to the world of functional health. I have UNC and Duke providers who will send me their patients that they have no clue what to do with they're super sick patients. So that's a little bit interesting that they'll even refer to me. But they do and I have a lot. I would say honestly, most of my functional patients I end up finding mold in. So I have done a lot of mold detox and mold toxicity and you know those patients usually have gut health problems and it's multifactorial, but mold is usually one of their main issues. But one of the other things that I do that brings great joy is cancer survivorship patients. So I basically took what I had, my knowledge from working in oncology with the Cleveland Clinic and then when I went back to Duke I was at the Duke Cancer Network and I set up the survivorship program at the Cleveland Clinic. But it's really following the guidelines for cancer survivors and what I figured out and done with a functional world is diving in to look at for things that could have caused or triggered their cancer to begin with. And so once again, I have a number of cancer patients who have mold toxicity as a big trigger for their cancer.
Speaker 2:But Dr Anderson I don't know if you're familiar with Paul Anderson at all. He is amazing. He has been an integrative oncologist for about 30 years. You can actually join. So he has a page where he has all kinds of different podcasts and education around chronically ill patients as well as cancer patients. He really touches on a little bit of everything with.
Speaker 2:He's a naturopathic doctor within the world of functional naturopath and even though I learned a lot within my program, I probably learned more from him and listening to his podcast. So for $60 a month you can become a member and you can listen to any. He puts one new podcast out a month, but he has all of his old podcasts on there, so you have access to all of them plus his new stuff for 60 a month and you get to join his private Facebook page and he will actually respond to you. So if I have a really complicated patient like I want to because I will do stuff with cancer patients too so I will add different supplements and different repurposed medications and IV therapy to help them with their cancer and so if I'm going oh, I don't know if I can give this treatment with their chemo. I will send him a message through his Facebook page and he will answer it. And he'll really quickly. He'll usually answer me within 20 hours.
Speaker 1:That is amazing. Paul Anderson is his name.
Speaker 2:Yes, he is amazing and he I love, love, love listening to him. He will tell you like it is In his educational stuff. He'll say, well, that would just be stupid. And then they do have so every year. He it's not just him, but you know other doctors and stuff that he works with. But there is a conference and so every other year the conference focuses around oncology, integrative oncology. So last year's was integrative oncology, neurodivergence or something was this year's something around there. But yeah, so good group of people.
Speaker 1:Wow, is finbendazole on that list of repurposed medications?
Speaker 2:Yes, there's so many that's the thing there's so many, but yeah, so for repurposed meds yes the finbendazole is on there, and Metformin, ivermectin so yeah, there's a number of different, some of the antifungals, some antibiotics as well, and then as far as supplements I mean, there's just so many different supplements that can help with cancer.
Speaker 1:Tell us about. You're the only provider now in your clinic. The other nurse practitioner is gone. You did not hire another one, but you're waiting for your nurse to finish up her program. So what kind of hiring structure do you have in mind for her? Tell the listeners. What do you see as how you're going to pay her? Is it going to just be based on how many patients she takes on and stuff like that?
Speaker 2:So I'm going to do things completely different with her than I did with the nurse practitioner that I had hired.
Speaker 2:So with the person that I had hired previously, what I ended up doing was giving her about half of the membership fee. So essentially it was you can build a practice inside of my practice. These will be your patients. You get half the membership fees. Anything else that you would like to do, I will support you and help you do. If she wanted to do aesthetics or whatever she wanted to do, as long as it wasn't something that I was already doing, so anything that could complement the practice.
Speaker 2:I didn't end up actually loving that model and it's really more that I don't think she really had the dedication that I was hoping to really take the ownership for those patients and I didn't feel that they were getting the same care that I would have given them and I was taking more of a hands off approach at that point. So I learned a lot of things that I wouldn't do again. Essentially so, because what happened with that also is I kept all my patients and it was just new primary care and she was in functional medicine, so I was still taking all of them, but as new primary care people came in, I was putting them on her schedule, but so, as it helped me a little bit, I still kind of felt like I was drowning a little bit as far as all the functional people and weight loss people and stuff that was coming in, and then my own primary care patients when they were getting sick, because last fall winter, as you know, was horrible sick season and so people trying to get in same day next day was really difficult. I'm usually booked out about three weeks for a new patient appointment. I do hold one slot a day for an add-on patient, but when you're getting two or three patients a day who are sick and needing an add-on it's a little bit stressful. But I wouldn't ask her to see those patients because that wasn't part of our agreement. It was like these are your patients and these are my patients. So what I'm going to do with my nurse when I hire her is it'll be a salaried position and so because it'll be a salaried position, she can pretty much see anything within the practice.
Speaker 2:The other thing is the nurse practitioner who I had. We had talked to her in the beginning about getting her DOT certification and she said she wanted to do that, but she never really initiated and got that training, and so that was another thing. I have an agreement with one of the trucking places here and I do all of their DOT physicals, so I didn't have to help with that either. So that's another thing. With my nurse, she will get DOT certified and so she will help with those DOT physicals as well. So, yes, it will be a salaried position.
Speaker 2:With the nurse practitioner that I had, I did have her pay for her own supervising physician, but then I paid for and I found her supervising physician, but I ended up paying for all of the other benefits, but I didn't. I don't offer retirement or health benefits. She was still working at the hospital as a hospitalist as well, so she also didn't opt down to Medicare and so I saw all patients who were 65 or older, and so that's another thing is I'm still trying to figure out with my nurse if we will pay for the supervising physician or if she will, but as far as other benefits, we'll be paying for the rest of those things.
Speaker 1:How much do you have to currently pay for your supervising physician?
Speaker 2:Yeah, so I go through doctors for providers, and so it's $750 a month. That's what I pay as well. Yeah.
Speaker 1:Yeah, and that's kind of the going rate, I think, for a practice of our size. Now, will that same collaborating physician not be your other nurse practitioners? Collaborating physician, you have to find a different one.
Speaker 2:Well. So the thing is he has he decided he didn't want to work for doctors, for providers anymore. He kept me, but he let everybody else go. So when I hired her I didn't know he had done that. So I was like, oh, just add her to him and I'll. And so that was a little bit of a mess, because I called him and I was like what, what do you mean? But then he did. He did because we have a good relationship. He was like y'all take her. So I don't know if, when my new person comes in, if he will end up being her supervising physician or if we'll get somebody else. So we'll see how that goes.
Speaker 1:What other staff do you have in your practice? So?
Speaker 2:I have two nurses, two RNs, and they one works. They're both part-time, one works a little bit more than the other. I have a medical assistant who happens to be my son. He'll be 18 in a couple months, but he has been homeschooled. He finished high school early, and so then we put him through an MA certification program. So he's been working with me. So I have him, and then my husband. He is a nursing instructor, so when he can he does help me and he so really he's kind of in the shadows doing the tax stuff, working with our accountants and making sure the bills get paid.
Speaker 1:That's good that you have somebody that can do that, because that saves you from having to hire an office manager, because he's kind of the stand in office manager.
Speaker 2:Yes, and that's what I tell him when I need something. I'm like manager, we'll take care of that for you.
Speaker 1:Well, what electronic medical record system did you choose, and why did you choose that one?
Speaker 2:So I did elation. So when I went to that HINT summit because at that point I didn't really know anything I learned about MD Atlas and elations. I didn't know about any of the other ones. So basically I went between those two. There was a lady at the HINT summit who I think she's actually the daughter of the doctor who created Violations Platform, but she did presentation and then I ended up meeting with her to do a demo and really liked it and then reached out to MD Atlas and didn't really know much about that company. I didn't know much about either one of them. But somebody answered the phone and he was just really laid back and really acted like I should be asking the questions, like he didn't even tell me much about the platform or what they had to offer. So then I had to ask for a demo and then he's like hey, I'm just very nonchalant and walk through a couple of things and I just wasn't impressed with him. I don't know if it's the gentleman who owns the company. I know the gentleman answered the phone was a physician, that's all I could tell you. But you know it was just he didn't try to sell it, he didn't. He would only answer the questions that I asked and that was pretty much it. So, really honestly, I wasn't very impressed with that one and so I ended up going with Alations. When I had my other nurse practitioner here to save money, I ended up for her doing the free version of Charm because that one is cheaper than Alations. When I did the demo with that, they made it look really great.
Speaker 2:Honestly, I did not like Charm. I did not like it. I did not like their support people. You can't get a hold of anybody. You'll never get somebody on the phone. I sent multiple messages before anybody would even message me back trying to get her set up to e-prescribe. I mean, she was here for six months and the six months she was here we never did end up getting it set up. We worked on the lab integration with LabCorp that didn't get set up within six months. The company was not helpful in trying to do anything to figure out what was going on or be helpful. Maybe, if you have the paid version, maybe they are more helpful, but with the free version I did not see it and so I won't use charm again when I bring on my new nurse practitioner. I will just suck it up and I will pay the money to have her on elation.
Speaker 1:Does elation keep up with your membership management?
Speaker 2:as well it does. It's lovely. I don't do anything, I just enroll them and then it bills them every month and it's really easy for me to go in and just see if somebody's declined cards declined, and then I just reach out to them and have them update it.
Speaker 1:Oh, so you do have to call the patient if their payment didn't go through, to be like, hey, you still owe me money this month.
Speaker 2:So the system will send them a reminder and it'll say that they need to update their card, but, honestly, a lot of people just ignore it. So what I do is I just send them usually just send them a message through the portal and let them know that their card declined. For most patients, that's all I need to do and they'll go ahead and they'll apologize and they'll update it. Honestly, if I have to call a patient they really were what they were doing was canceling their membership without actually giving me the notice to cancel their membership, and that doesn't happen that often, but we do have a six month membership agreement, so then after six months, they can cancel with 30 days notice, and so sometimes what I see happens is after the six months, they just let their card decline instead of giving me the 30 days notice.
Speaker 1:And there's no way for you to know that that is what the case is until you reach out to them. So they might as well reach out to you and let you know. Hey, I'm canceling my membership.
Speaker 2:Yeah, correct. So what I do is I will usually leave them a voicemail, I will send them a message through their chart and then that's it. So we have a membership agreement. Our membership agreement does say that it is your responsibility to keep your card up to date on file and that they will no longer be patients of the practice if they don't make that monthly payment. And so after I reach out to them one time by phone and one time through the portal, I just unenroll them if they don't make that payment. So by the next month when that payment declines, I unenroll them.
Speaker 1:Well, what percentage of patients do you feel like you lose each month?
Speaker 2:So it really comes in waves. I would say this year and I think it's just with inflation and things changing this year I probably have had more people drop off than I ever have being open, and usually they'll tell me that it's a financial decision, that they just can't afford to keep paying the membership. But I also expect it. So there's not a ton of that have happened on the primary care side. But with the functional medicine stuff I'm really working with you to make you feel better. I expect you to go. I don't expect them to stay patients forever. So there's some of the patients with hormones that will stay. But other than that, if I'm working with a chronically sick patient, then there comes a time that either they get to the point that they know that they're feeling good and they'll give me the notice, or I say to them well, you don't need me anymore, You're great.
Speaker 2:So, there's that, and then with the weight loss patients, once they reach their goal weight or if they just basically give up on their weight loss, then they cancel their membership.
Speaker 1:So it's been a little bit more this year but, like I said, some of it is to be expected because of those reasons, Do you have a separate payment that functional medicine patients have to pay, or is your fees all the same, regardless of whether or not they're just family practice versus functional medicine?
Speaker 2:No, I keep it completely separate. So my rate for an adult well, even a child. So basically what I realized is people undervalue themselves in direct primary care when it comes to children. This $20 to $30 rate which actually I mean I started at that but this $20 to $30 rate for children really is not enough, because children are the ones that are getting sick, get sick more, and they're the ones that the parents want to bring them in. They're the ones the parent you know, they want to message you about things. And so I went from $20 a month for children with an adult and then had to have an adult member, then raised it to $30 a month for children with an adult member. I started my adult membership at $60 a month. 65 and older has always been 99. I raised it after my first year to $75 a month for an adult, $30 for the children. But then I realized why am I undervaluing? When you look at these pediatric CPCs, they charge a lot of money for those kids. So I raised my child rate up this year to the same as my adult. So from so now from one to 65 is $75 a month and babies from birth up or 99, because I have to see them every two months and they're the ones that need more care.
Speaker 2:So in the beginning that $60 a month that I had for the adult also covered functional medicine, and so that was the first year. Second year so now I'm in third year I decided that that wasn't. I was basically giving it away and I spent a lot of time learning and stuff. So I said you know, I'm not going to keep doing this for the $60 a month. So I raised, so I split it out. So functional medicine was 115 a month and then I had raised the primary care adults to 75 for a little bit because people were asking me. Then I had a primary care functional membership which was 150. But then I don't like that because I think that money's the waters. I would really rather be your functional provider and let you have a primary care provider somewhere else. So I did away with the functional primary membership and then this year I raised my functional rates to 150 a month.
Speaker 1:So what do you do then? If one of your functional medicine patients has, like poison, ivy or sinus infection, they just have to go somewhere else. Yeah, they go to their primary care provider, okay. And then, in the same token, what if you have a family practice patient that starts asking you questions that you recognize are getting into your functional medicine, but they're only paying the $75? So how do you bridge that gap right there?
Speaker 2:I tell them that it's functional medicine and I offer, if they want to change over to the functional medicine, membership. That is the only time I will offer a dual, still offer them to have the dual membership. So if I was already seeing you for primary care and then you start asking me things that are functional and they decide to change to that they want functional, I will for $199 a month I will do both for them. But unless you are already a primary care patient of mine, I don't do that. And now there have been a few and this is just happens in the last couple weeks. I have a couple who, well, they were with the other. The nurse practitioner used to be here and so they were here for primary care and now they want to change over to functional and so they are going to become functional patients. I offered them to see if they wanted to just do functional or do the dual membership and they decided to just be functional. So I made I've changed a couple people over just to functional.
Speaker 1:So your functional medicine patients are only paying that monthly fee for a period of time because ideally, if you can help them get to the root cause, then there's healing. So do you allow those patients to then drop their membership back to a regular membership if they choose to do that?
Speaker 2:Yes, so once we've gotten to the point that everything's good, then they can either go back and become primary care here or they just go and stay with whoever their primary care was.
Speaker 1:That's a good concept. I like that. So let's go back to. You've got elation for your EMR and that also manages your memberships, so what do you use for your communications with your patients?
Speaker 2:It's all through elations, so elation is all in one.
Speaker 1:They'll do communication, so are you able to do video calls and text messaging through that, not text messaging.
Speaker 2:I did away with that so I can do video calls. There's a portal through there so they can send me messages. So in the beginning because you know, here's the thing, and this is why we wrote the book there's this cookie cutter model that they believe that these physicians set up, that they make you think that you have to set your practice up that way when you don't, when you don't have to offer these people all of your time and all of these things, you don't have to offer them 24-7 care and you don't have to have a pulmonary function testing in your office, you don't have to have a DHE machine and all these expensive things, that for these patients. And so in the beginning I had an app that was through the people who do my website, so they had an app that would allow patients to text. So I use that for texting. That was the phone number I gave out, and then, of course, I have my email. So what happened was I had and I did not give that phone number out to everybody, that was only given out to certain patients, you know, when I thought that they needed it, they wouldn't have the ability to text me. Most patients were very respectful with it. There were some who would text me about silly things after hours. That could have waited.
Speaker 2:Most of my patients do not expect me to respond back to them right away. They say I'm sending this to get it out of my head, but I don't expect you to respond to me after hours or on the weekend, because I got busier and busier and busier and then I would have people emailing and I'd have people texting and I'd have people calling and I'd have people going through elations. I said I cannot do this. There needs to be one way for people to communicate with me, and that is it. So I did away with the texting and I let everybody know this is going away. I have a bounce back email that you probably saw on my emails that says please send all questions through elation passport. We will not answer email communications, and so that is it. That is the way that they get to communicate to me is through their chart and I do respond to them very quickly and I do check my messages, usually one time on Saturday and one time on Sunday, but if something big comes up on the weekends they go to urgent care. My membership agreement states that I am allowed to take vacations and if I'm out of the office they will go to urgent care. So they don't have these great expectations that I'm going to be at their beck and call 24-7. That's in my mind. If you want that, that's more concierge medicine and so. But what they do appreciate is that I do message them that quickly, that we know each other personally.
Speaker 2:I mean, there's a lot of just, you come in for a visit and I'm going to ask you about your kids and your grandkids. I really get to know them. It's more of a family environment. You know it's very embracing. There's a lot of hugging with the patients and stuff they get you know that different level of care. A lot of my patients don't want to be on medication, so they come to me, even my primary care. You know they'll come to me for those alternative, those herbal kind of things instead of pharmaceuticals. A lot of my patients are distrusting of the conventional healthcare model, since COVID or the conventional model has failed them in some way. So they are getting what they want in this relationship and over 90% of my patients have insurance. They're getting what they want in this relationship and over 90% of my patients have insurance. They're getting what they want. They don't expect me to be there for every little after hours thing.
Speaker 1:That's good that you set up boundaries like that, because for some people it's really hard Because, as you said, you know you're hugging, you're asking about their kids and their dogs and all this kind of stuff.
Speaker 1:The patients turn into an extension of your family and so it becomes really hard. The lines become blurred with how to create boundaries because you look at these patients now as your friends, you know, and or extensions of your family. So you're not going to want to tell them that there's going to be a hard stop on our communications here for this time period, or I'm not going to respond on tell them that there's going to be a hard stop on our communications here for this time period, or I'm not going to respond on the weekends, even though I treat you like you're a really good friend, right? I want you to also respect that I have this other family that really is my family, without making them feel unimportant, you know. So the fact that you're able to draw those boundaries and still maintain a good relationship says a lot about how much they respect you as their provider.
Speaker 2:Yeah, some haven't gotten mad at me. If I have answered their email or their message on a like a weekend or an evening, they're like what are you doing? You're not supposed to be. They said. I'm just want to get this out of my head so I don't forget. You should not be messaging me. You should be with your family. So, which they do. They get upset with me if I answer them.
Speaker 1:But that gets complicated because I don't. You may not be like me, but I can tell you this much If there is a message in there, it's going to eat at me and drive me crazy until I get it cleared out of the queue, because I can't just leave these messages laying there for days. I need it to be on zero all the time. So if you send me a message on a Saturday or a Sunday, I'm working on that, because I need it to be zero by Monday morning.
Speaker 2:I do like my stuff to be at zero. I do respond back very quickly. I have learned to set those boundaries. On the weekends, though I used to just message it, you know, to clear everything out and stuff. But what I have learned is that encourages people to send you more messages on the weekends or after hours, because they know that they'll get that answer. So what I do now is when I log in on Saturday or Sunday, I him them for anything that's urgent, like anybody who thinks they have a UTI or an earache or whatever, and I take care of those patients. But then anything that's just like I need a med refill or read to reschedule my appointment or any of those, I let those just sit and I have given myself because Monday seems to be the day that LabCorp wants to release all the labs. And then you have all of the messages from the weekend that have sat there and I don't think my patients have anything else to do on Sunday night besides send me messages, because I won't have a lot on Saturday or Sunday afternoon, but come Monday morning I now have 15.
Speaker 2:And I'm like what did you do after church? You messaged me. Oh, I can relate with this. I started taking from 11 to 12. I closed from 12 to 1 for lunch every day, but 11 to 12 is now admin time, and then my urgent care add-on slot is 1 to 1.30. So I have enough time on Monday, so that's Monday, so I have enough time on Monday to get caught up on those things, and now I also. I used to be open every day 8 to 5. Now on Fridays I'm only open a half day as well.
Speaker 1:That's good. Well, I want to get into talking about your book, because I know we're getting close to the end here. So tell us about when you and your husband decided y'all were going to write a book and help all these other entrepreneurial nurse practitioners open their own direct primary care.
Speaker 2:So very early on. My husband being the wonderful person that he is, he said so as I was going through the process of opening this practice and seeing that physicians just don't like us and aren't helpful. He said you know, we really need to be writing down every step of what we're doing so that we can write a book and that way other APPs will have a resource, so that they don't go through what we went through. And I thought he was crazy. I'm going, I'm still working at Duke, virtually I'm opening my practice and now you're talking about writing a book. One more thing I'm like. He's like don't worry, I'll write the book. And I'm like well, if you want to write the book, you write the book, but I cannot write the book.
Speaker 1:That's probably the same conversation I had with my husband when I said I think I'm going to start a podcast. He's like you're what, you're gonna do, what? We hadn't even gotten this DPC clinic off the ground and you're already ready to just shout it to the world. I'm like, yes, I the world. I'm like, yes, I'm doing this, we're doing this. Yeah, so anyway, tell us about the book. Yeah, so your husband, basically, is the front runner here.
Speaker 2:Yeah, so essentially what happened is he just kept track of everything that we did as far as our initial list of flies, that we figured out, that we needed All of the different sites and everything that we went to to gather the information about the local area that he wrote the business plan, because I would not have known him to write the business plan. I did help him find the information about the area and stuff but and the information that I thought would be important in the business plan, but he ended up writing that because of his business background. We actually did. There is a physician who he also wrote a book and he has his business plan. You can purchase his business plan and I won't say his name because his business plan was awful and I don't want that to be anything that stands out with him. But we bought his business plan and it was like I think, like two or three pages and it was just more like an emotional like you should give me money, I'm such a nice guy and these are the things that my husband, with his business background. He's like no one's gonna give you money based off of this. And so he, you know, started with all the data and the facts and everything, and we did not have any problems finding people that would loan money.
Speaker 2:Now I honestly didn't even really use the money. We had a line of credit that was extended to us by the bank that you paid to have access to it. I never ended up using it. And then we did have another line. We did take a loan but I kept my job at Duke and then I didn't take a paycheck. For the first. It was six months before we ended up breaking even and then I could have taken a paycheck but my husband said I don't want you to take, I want you to not take a paycheck as long as you can, and we'll just let the money build in the business account. And his income was enough to pay all the bills and can. And we'll just let the money build in the business account. And his income was enough to pay all the bills and everything. So we have access to the money. We just never really needed it Because you know the goal is just to keep everything as cheap as possible.
Speaker 2:And so the book really goes through that, because, being in listening to the DPC, frontier and some of the stuff, this physicians and maybe they have more money to throw at things than I did, but they just they make you believe you need to have this equipment. Like I said, that is like more expensive and these build-out that is not a good idea to do a build-out of your clinic. It's really better to find a space that's already perfect for what you want. If it takes you a little bit longer to find a space that's already perfect for what you want, if it takes you a bit a little bit longer to find that, then you should do that. So we're in a.
Speaker 2:We outgrew our first space within the first year and so now I'm in a new building. Both buildings I did no build out, everything was just perfect and it doesn't you. There is no joint commission with this and so people don't. You know they come from the hospital setting and they think you need to sink in every room and you need you know all these things that you had with joint commission and stuff, and there isn't any of that. So what we need to learn in this you know the book talks about this, but what we need to learn is being able to take a space and look at that space very differently than what you would look at a normal medical space and there's so many things that you can make work if you just get that idea out of your head of what a cookie cutter medical office needs to look like.
Speaker 1:Yes, I completely agree with that. So your book just kind of lays out all the intricate details of starting a practice. So if anybody is listening out there and you are trying to start your clinic from scratch and you don't have you're not married to a business minded spouse, or or you don't have business knowledge, you know which most medical providers don't. We have a medical brain. We don't have business knowledge. You know which most medical providers don't. We have a medical brain. We don't have a business style brain, so very few people that actually have both.
Speaker 1:And so if you don't have that, the name of her book is how to Open your Own Direct Primary Care Practice, and I think I saw you could buy this on Amazon. Is that right? Yes, so it would behoove you listeners, if you're looking to open up your own practice, to buy this book so that you can learn some good pearls of wisdom. Highlight through the book, and I saw on the description on your website that you offer a business plan that you can legit copy and make it your own, and it's much more detailed than the one that you tried to operate by in the beginning.
Speaker 2:Yeah, yeah. So things like the business plan and stuff are in the book, the supply list that you need. But also one of the things is that you can reach out to us and my husband has a business plan that you. You know you need the copy of a plan that you can edit and stuff as well. So, yeah, there's a lot of resources like that and it talks about marketing and stuff as well. So, basically, anything that we learned along the way stakes that may have been made or pearls, and all of that is in the book. Because I'm telling you, if you focus on those kind of cookie cutter models, you will spend way more money than you need to spend to open a practice.
Speaker 1:And I can understand why people would just become hyper focused in that, because we're trained to come out of school and work for a place and take insurance and abide by insurance rules and everything that you have to do in order to get a reimbursement from the insurance company on the patient.
Speaker 1:So this goes all the way down to how you chart and how many review of systems you need to, how many points you have to have and how much do you have to document even on the assessment and how many diagnoses do you have to have in order to have a 99214. And so everything that you're saying about the clinic is also true about how you chart and you throw all that out the window because we're going back to the basics here. We're going back to the relationship of patient and provider. We're not putting all of the bureaucracy, we're not leaving the bureaucracy part of it in the middle of the relationship here. We're taking that part out. So if you want to chart, if somebody comes in for poison ivy, like you said, you don't have to have a sink in the room to look at their rash and be like, oh, that's definitely poison ivy, and you also don't have to document on a 12 point system to make sure you get reimbursed.
Speaker 1:Just put on the note, patient came in with a vesicular rash, yeah, and now I've diagnosed poison ivy and this is what I gave them the end of story. It's literally that easy.
Speaker 2:Yeah, yeah, there's a lot less charting. I mean, of course I still chart, as we all should cover our tails, and so I still do soap notes on people. But you know, I take my life. I don't know that everybody can type fast. I type really fast. I just take my laptop in the room and I'm typing as they're talking to me. So by the time I walk out of the room I basically just have to do my plan, put in the lab orders and close their chart. I'm done.
Speaker 2:And I'm always like usually on average about eight patients a day. So these 20 something, 40 some patients per day is ridiculous.
Speaker 1:Do you remember? Did you ever work in that environment where you saw that many patients a day?
Speaker 2:I was seeing about 24 patients a day, so return patients were 15 minutes and new patients were 30 minutes. And what really stunk is when you had to tell somebody that they had cancer in 15 minutes and what the treatment plan was, what their options were for treatment all in 15 minutes, yeah. So you stayed in there longer than 15 minutes. And then you walk in the next patient room and then they're mad at you because they had to wait and sometimes I would literally look at them and say, oh, I'm sorry, had to tell the other patient that they had cancer and if you had cancer you would want me to spend more time with you. So and then they just shut down at that point because then they feel bad.
Speaker 1:Well, we could get into all the reasons why we run behind, and it's not because we're sitting in our rooms twiddling our thumbs doing absolutely nothing, while we're completely wasting your time, yeah yes, but it's lovely now because so for a new functional patient, I take two hours.
Speaker 2:For a new primary care patient, I take an hour. New weight loss is 45 minutes and then basically any of my follow ups are now, that's wonderful and it gives you that work and home life balance that you're looking for, because work should not have a reign over us.
Speaker 1:We should be able to enjoy our life and enjoy coming to work. So I don't hear about too many people burning out in DPC, if any.
Speaker 2:I'm out of here by 4.30. I used to take a patient and finish up at five and I said why am I doing this? This is my practice and I don't have to function this way. And so now I'm the last patient is definitely out the door by 430. That way, if I have to wrap up anything, usually I'm done with everything by then. But if I have to wrap up anything I can, and I live five minutes from my office and so I can still be home just after five o'clock.
Speaker 1:Yes, it's so wonderful. I will never go back to regular health care again. No, absolutely not. It has been such a pleasure to speak to you and I'm completely impressed that you wrote the book and how that will be so helpful to nurse practitioners and physician assistants to help them open their own direct primary care practice and maybe, through what you mentioned today in your podcast, it'll just be an encouragement to them. So thank you for that.
Speaker 1:It's scary, but you can do it. Yes, I have no doubts that if we could just convince all nurse practitioners to just take 500 patients, everybody, everybody, everywhere, will be so happy. I'd love to follow up with you in the future sometimes so we can see how everything's going and how your clinic has grown and so you take care. And until then, all right.
Speaker 2:Thanks, bye, all right.
Speaker 1:Bye-bye. Thank you so much for joining us today on the DPCNP. We hope you found our conversation insightful and informational. If you enjoyed today's episode, please consider subscribing to our podcast so that you do not miss an update, and don't forget to leave us a review. Your feedback means the world to us and it helps others discover our show. We love hearing from our listeners. Feel free to connect on our social media, share your thoughts, your suggestions and even topic ideas for future episodes. As we wrap up today, we are so grateful that you chose to spend a part of your life with us. Until next time, take care. This is Amanda Price signing off. See you on the next episode, thank you.