–Medium

I knew it will get rough but my goodness! I still expect things to get worse because well NO ONE is tending to our domestic issues!! This post is mainly about surviving. I still think we’re in a depression and maybe I’m exaggerating but it’s not getting better anytime soon. Here are some personal considerations:

• Don’t Rely on Mainstream Media: regular Americans are giving us better insights, tips, and awareness of industries, costs, etc., however, caution -like the news it’s also negative but at least you hear the reality and nothing sugar-coated. I list some helpful YouTube channels in the prior post and another channel that I’ve been watching is Snyder’s Report but yes the near-future is going to be bleak. I usually watch the videos if I have a break or charting to not think about this when I’m done with the day or going to bed. If you’re still struggling with sleep then watch the videos early in the day or only on the weekends but unfortunately we have to have means to stay inform with this war/economy.
• BE NICE: this is not the time to fight each other. I have love ones, co-workers, and patients, that voted for President Trump and they truly believed he was going to do something right. I remained neutral because overall, I don’t want to argue… but this is definitely not the time to fight. Some still believe the president will help and do something good… the cope is no joke and I feel sorry for them since our political system is basically failing everyone. Don’t kick people when they’re down or having remorse, be mindful that the guilt and shame can cause SI thoughts. We just all have to do better and focus on not making anything worse.
• Make everyday easy for yourself: I’m primarily working from home and if you’re not, make a separate budget for transportation, gas, car repairs even if you stay close to the job. These things will go up so if there’s an option to work from home or do public transportation, continue to make the something more affordable. Also, making a separate budget is important for the tax write off. What made things easier for me was making myself a corporation/company, and just hoping for the best but for normal people, yes have a CPA.
• Support Our Troops/Vulnerable Populations: I try to make my services more affordable for single mothers, elderly, veterans, special needs, etc. Our social programs are drying up and after the Iraqi War, I was informed that the access to care is also impossible if it was ever acceptable. I don’t know if people notice, but usually around VA hospitals the people that hang out there is um let’s just say it’s not the most functional people laying out… it’s also a taboo: if someone in the military disclose any psych issues they risk getting kicked out and losing everything that they’ve worked hard for … many suffer in silence. Again, pay attention to males or people going off the deep end.
• Continue to Evolve (more complexities are coming): One of the many conflicts in psych is how we have to be mindful of medical issues. People are having a hard time finding specialists, getting referrals, wait lists, affordability/insurance issues… however, after the pandemic there’s an uptick in autoimmune and rare conditions that’s causing “anxiety/brain fog/depressive symptoms” when it’s really (also) undiagnosed medical conditions.

According to Chat GPT:

Top 25 Medical Conditions Mental Health Clinicians Should Rule Out

Thyroid Disorders

• Hypothyroidism – depression, fatigue, slowed thinking
• Hyperthyroidism – anxiety, irritability, insomnia

Vitamin and Nutritional Deficiencies

• Vitamin B12 Deficiency – depression, psychosis, memory problems
• Folate Deficiency – depression, irritability
• Vitamin D Deficiency – depression, fatigue
• Iron Deficiency Anemia – fatigue, poor concentration

Neurological Disorders

• Traumatic Brain Injury – personality change, mood instability
• Alzheimer’s Disease – memory loss, behavioral change
• Parkinson’s Disease – depression, hallucinations
• Multiple Sclerosis – depression, cognitive dysfunction
• Temporal Lobe Epilepsy – anxiety, psychosis

Sleep Disorders

• Sleep Apnea – depression, irritability, cognitive issues
• Insomnia – anxiety, mood instability

Metabolic and Endocrine Disorders

• Diabetes Mellitus – mood swings, confusion
• Cushing’s Syndrome – depression, irritability
• Addison’s Disease – fatigue, apathy, depression

Infectious Causes

• Lyme Disease – anxiety, depression, brain fog
• HIV/AIDS – cognitive impairment, mood disorders
• Syphilis – psychosis and personality changes (neurosyphilis)
• COVID-19 – depression, anxiety, cognitive impairment
• Long COVID – fatigue, brain fog, mood changes

Autoimmune Disorders

• Systemic Lupus Erythematosus – psychosis, depression
• Hashimoto’s Thyroiditis – depression, brain fog
• Anti-NMDA Receptor Encephalitis – severe psychosis, agitation

Substance or Medication Related Conditions

• Alcohol Use Disorder – depression, anxiety, cognitive impairment
• Substance Use Disorder – psychosis, mood changes

Common Lab Work Often Ordered in Mental Health Evaluations

• TSH / thyroid panel
• CBC
• CMP
• Vitamin B12
• Folate
• Vitamin D
• Iron studies
• HbA1c or glucose
• RPR (syphilis screening)
• HIV screening
• Urine drug screen

• Don’t Rely on AI: Yes it’s helpful but it can’t replace humans or their experiences. Evolving also includes using the brain more often… with Chat GPT/AI the responses are usually generic… It doesn’t make it completely wrong but it can only help so much in making complex medical decisions. It’s also getting more banned in schools because more children are struggling to read and write let alone understand concepts. I also think Autism is over-diagnosed but that’s another issue. I was going to do a post about it, but I’m sure it was going to offend too many people. So I just mentioned to people, computers can’t replace parenting or the care provider.
• Be Careful with Politics/Sensitive Topics: I understand the grievances in this political climate but as long as I have a mortgage, I’m not acknowledging any type of World War 3. If you have a family, bills, rent, etc. do not crash out or say/do things illegal, hostile, threats, racists, or anything questionable. The government is creating a system (AI) that is going to track everything and keyboard warriors can send whatever to your employer and that can cause you to lose a job, limit your resources, destroy educational opportunities, or have crazy people show up at your house. It’s not worth the risk and it’s sad when someone has their life turned upside down for free speech, when nothing in life is free. The risks aren’t worth it for most people.

In Conclusion

I wasn’t expecting to make a post today, but wanted to mention since this war started, I hope people continue to stay level-headed. It’s not because I don’t want to go scream somewhere, but I want to make people aware that you are being watched. Not just with big brother, but especially The YOUTH and yes make it a priority to give them hope and understanding. Millennials have been through countless threats, crisis, natural disasters, and problems… it’s never been right since 9/11, but it doesn’t matter, put on a united front and direct the youth on how to handle themselves in a manner that’s expected. Continue to not smoke or drink or at least not in their presence, do healthy planning/activities, watch educational content, ask about their hobbies or start one, go over money and finances, ask about their future plans… or validate their concerns, it’s a scary world to them as well and being their advocate and providing guidance is crucial right now.

I still recycle, support local businesses (still trying to work on the section for local shops), clean eating, etc. My younger sibling recently called me Mother Teresa, but he’s always sarcastic and annoying BUT he watches me like a hawk so I don’t get offended. I just try to be a positive influence, but if patients are stubborn, obnoxious, argumentative, or fussing -let them vent, discontinue services, find another provider, go ghost or magically pop back up… I just act like nothing has happened and go back to the drawing board/helping them have (mental) stability. Remember our MAIN job is to keep people from hurting themselves or others, not to fix everything. I tell patients, my job is to hopefully prevent you from being institutionalized. I don’t want anything to get worse, but I’m realistic and know a person can only help so much. Continue to stay grounded out there and focus.

How I feel about 2026 already

At this point, we—the American people—must acknowledge that we are largely on our own and be honest about the gravity of the situation. I do not believe we have previously faced a moment quite like this. The most prudent course of action is to brace ourselves for potential hardship, as conditions may continue to deteriorate. That said, DO NOT DESPAIRIt just means it’s time for me to ramble!

This reflection was inspired by the growing need to mainly disconnect from government systems and to begin thoughtfully considering how we would sustain our lives in the absence of modern conveniences—such as electricity or internet access—along with potential disruptions to food supplies, healthcare access, and banking systems. Preparing for the worst is not an act of fear, but one of foresight and resilience here are some suggestions to handle this upcoming year:

Spread the Content: Most people don’t have an attention span or the tolerance for hearing a lecture. Therefore,  I send out video clips to my family and friends to help people be aware about the state of our country. Here are some of my main channels that I check out:

• A Homestead Journey: really nice and wholesome videos about everyday Americans and trying to help others including in the comment sections. The lady and her husband recently started a podcast –The New Exodus
• Jay Reed: he’s just spewing out multiples videos per day because it’s just a lot of content of people having a hard time in America and in general.
• Life Priced: also show’s a compilation of people dealing with this country
• Yak Motley: great videos discussing the current real estate market and the brutal reality of housing market and support Veterans.
• Zac Rios: he has the charm of a father just giving advice to not make dumb decisions and got 2 channels; Zac Rios 1 and Zac Rios 2

Support Local Businesses: dear farmers and anyone growing something in their backyard…. Start making/storing common goods. One of my patients gave me a dozen of eggs and of course I was over the moon and would gladly pay her as opposed to going to Wholefoods for anything. I also plan to starting a new section on the website: American Products/Businesses and here’s an example of some American markets I’m trying to promote (again people can send suggestions but no adult/illegal/witchcraft products)-eventually the plan is to put local markets up of the 50 states… here are some examples:

• Blue Rock Farm Market (Idaho) 
• The Chatham Berry Farm (Upstate New York) 
• Summers Fruit Barn (Southern Arizona)
• Rocky’s Candy Store: A beloved candy store around Eastern Market (in metro Detroit) that closed after >60 years, therefore supporting local businesses truly matters in this economy

Focus on the Youth: the children represent our future! Yes, I know it’s not easy to talk with them but it’s heartbreaking when they tell me that they want to be a garbageman (no offense)… and basically not striving for any kind of career/future may lead them into the streets or bigger problems. Therefore, we must intentionally guide them toward greater resilience and the development of practical skills. Here are some suggestions I try to focus on:

1. Avoid drugs and ETOH: there’s no other way to flip it… it costs your physical and mental health…even if they get sick of me I still tell them the same thing.
2. Be Financially Aware: it’s simply about holding them more accountable and not relying on the parents or the government…not to spoil them until their aware of the cost of living and life in general… making sure they know or can READ the fine print with loans and credit -but preferably avoid them… and if college isn’t affordable or focus on skills/trade and balancing costs.
3. Don’t catch a case: professional jobs, wealth, and opportunities will be MORE limited if you have a felony. So I tell adults and kids, don’t catch a charge, preferably EVER…
4. Focus on peace and not trends: I try to tell my young patients to not listen to these influencers, avoid social media and online games… it’s giving access to MORE mental distress… (sidebar: be aware that AI/Chat GPT is also causing issues and somewhat making a person more vulnerable and isolated leading to SI…. asked younger populations about their online activities to r/o if they really need to have additional mental health services vs. turning to AI that may encouraged or trigger severe psychological distress).
5. Reiterate HEALTHY/SAFE Options: so if you take away people videogames, outside fun, gimmicks, thrills what can you replace it with? In general I try to have people focus on health and education or a means to be MORE disciplined… Usually this is when people lash out at me since humans hate change…. and with the youth, believe it or not -they DO PAY ATTENTION. I have patients that would literally tell me that they can hear my voice in their head so I hope it’s something NICE or positive such as a career, goals/job/trade options, skills, or resources to learn (below for example)… remember we have to replace the bad with something GOOD so the humans won’t get bored and upset.

To the Boomer Generations: again keep it simple with older populations because they can’t focus to save their life either. I mentioned this before but I can add some resources here:

1. Monitor/Promote ADLS, Quality of Life, and Emergency Planning: ….check out the PDF downloads for elderly emergencies and future planning … and I also mention how OfficeMax/Depot has legal documents that are affordable vs. using a lawyer….Cont. to make sure they’re not being taking advantage and try to point to affordable options. (Sidebar-this is off the record, don’t put this in your patients notes! We’re not legal or financial advisors if anything it’s similar to a bootleg social worker but again this is a quick disclaimer to not put anything outside patient care in your notes) -I just simply document ‘additional resources were discussed’
2. Be Frugal: it’s sad when the older-elderly has to continue to work… and for those who are retired, I have to remind them what’s happening in the world or the rising costs that have changed even over the last 10 years… so therefore, let them know not to just spend their money like water or caution/avoid casinos. Also help them be aware of scams… it’s been times when I would have to tell my patients, don’t do crypto, give sensitive information out, actually go to the bank to make formal changes or handling money, not to open weird emails, not to respond to celebrities, etc. and to be vigilant to not get scam.
3. Make them show empathy/restrained their critical words/negativity: I only mentioned this because this holiday season unfortunately many older people were ALONE. and it’s usually because of their attitude. I would simply explain to them…. why don’t you have a PHD in saying something KIND? And they would give me this death stare, but I reiterate how if you are not racing to be positive or nice, you’re NOT easy to be around. They still look at me dumbfounded but I mention AGAIN how they can’t have it both ways and be cruel and then play the victim. Eventually they understand or I just increase their meds, unfortunately some don’t care but I still tell them to watch their words… because they absolutely care and want a pity party. Here’s some situations I tell the old people to restrain their words or I would cover my mouth so they can actually visualize how they need to NOT talk, but mainly in social gatherings. Tell the older folks not to talk about:
   • Anything with fertility, the kids, or super personal (medical/mental health conditions)
   • Things that are broken in the house, the car, yards, the body, or requiring finances
   • Parenting (unless it’s an emergency or safety hazards)
   • Marriages (unless someone formally file for a divorce, everyone needs to remain NEUTRAL)
   • Avoid Hot Topics: things that will cause a trigger (politics, beliefs, intimacy, any trauma, confrontations, etc.)
   • Any Criticism (restrain yourself, unless it’s an emergency any sharp word is just being petty and mainly uncalled for)

2026 FOR EVERYONE ELSE 

• Be minimalist: I’ve always lived below my means. What does that mean? I give myself a little golden rule (time for some girl math)… Picture basically taking a dollar (the paycheck), divide it by half -and divide it again and that’s my spending or saving budget. If my paycheck is $1000, divide half (for taxes) and half again (bills, food, utilities, etc.) and the remaining half is your spending (<$250)/per (whatever) paycheck. I’m not a financial person but I do plan on doing another post about budgeting…. but the moral of the story is to -FOLLOW A METHOD THAT HELPS YOU LIVE BELOW YOUR MEANS or BUDGET….here are some other tips

• Take Care of Your MIND: I don’t care if providers go back to bedside or to another country.. I want EVERYONE to consider how to have a better work/life balance… I’ve taken in less money just in general, but at least I have a peace of mind! Here are some other ideals outside of healthcare:

• Find Other Work: I plan on putting up more posts, but I’m focusing on another business so I’m not as active here or even as dedicated in healthcare in general. I honestly believe our country/healthcare system is currently at it’s peak right now and I can only bark so much. Maybe with another government or someone who’s not a corporation can help us, but we need to burn the whole system down. Unless someone is talking about resetting this sinking ship, I’m not watching the news or even paying attention to all this background noise.
• Prioritize Yourself/Community: consider growing your own food and volunteering. If I didn’t have a cat that knows not to dig up my plants and throw them on the floor, I would check out indoor vertical gardens. I still grow a lot of produce in my backyard or you can use a deck … I would consider a shop but unsure with HOA’s… so check out local laws before building or selling in general… Overall, take care of yourself and others in the most organically way possible. I was able to get a free book online by Barbara O’Neill, who has been my role model to heal naturally. I still believe in prescribing because well people still hurt themselves and others, but hopefully my posts can help people who don’t have insurance or have the means to go to the doctor to get regular care. And consider Bone Broth!

In Conclusion

I have more to say! lol but I think people get the gist. Ignore the man behind the curtains or your government and don’t panic. I know somebody will always disagree or just crash out but stay calm. I even had to argue with my friend about paying taxes… listen people PAY YOUR TAXES. The revolution will not be televised or on Facebook, many people have already incriminated themselves on social media and putting themselves at risk just saying anything online. BIG BROTHER AND DATA CENTERS ARE WATCHING or the feds… Sometimes I tell people, learn from me! Don’t expose yourself and don’t catch charges…. continue to pay your taxes, pay your bills, don’t steal, etc. I’ll tell you another secret, MANY people are still working, living well, and making tons of money… I will help you, you don’t have to break the law. My plan for America this year is to do the opposite of this administration and do things legally. Happy 2026!

I respect physicians deeply, but we’re in a mental health crisis with far too few psychiatrists or doctors in general, not including the red tape—insurance panels, DEA barriers—that keeps most of the care out of reach. I’ll keep speaking up, not out of anger, but because people are suffering in silence. We need change—real, compassionate, structural change—so that healing is possible for everyone.

Therefore, providers have to continue to speak out and advocate, but MORE strategically. Chat GPT has formatted a great formal way to contact our representatives (below). I’m going through different channels all the time and hopefully others can find creative ways to reach out besides voting. Formulating our laws and policies can take YEARS to manifest, therefore think of being creative from the very beginning via social media, emails, grass roots, etc. For example, in the past I have discussed with local reps about the lack of access and NP restrictions mainly because they usually really don’t know… But how can I be more creative? Well now I am considering sending reps a list of crimes related to insanity in Michigan and how a lack of treatment can cause poor impulse control, mental distress/trauma, substance abuse, and how it’s affecting our quality of life and much more:

Crimes in Michigan Linked to Mental Health or Insanity (2015–2025)

• 2016 – Kalamazoo Uber shootings (Jason Dalton): Six people killed; suspect claimed a mental breakdown and bizarre delusions. Insanity defense considered but later pled guilty.
• 2016 – Berrien County Courthouse shooting (Larry Darnell Gordon): Inmate killed two bailiffs during escape attempt; history of severe mental and substance issues surfaced afterward.
• 2017 – Flint airport stabbing (Amor Ftouhi): Canadian suspect stabbed a police officer; underwent psychiatric evaluation for radicalization and competency.
• 2018 – Lenawee County family homicide (Bradley Miller): Man with documented schizophrenia killed relatives; found not guilty by reason of insanity (NGRI) and committed to a forensic hospital.
• 2019 – Grand Rapids mother–child murder case (Amber Smith): Diagnosed with bipolar disorder and psychosis; pleaded guilty but mentally ill (GBMI).
• 2020 – Battle Creek shooting (William Jones): Former Army veteran with PTSD killed a coworker; experts testified about mental-health deterioration due to untreated trauma.
• 2021 – Oxford High School shooting (Ethan Crumbley): 15-year-old opened fire at school; journal entries and behavior showed deteriorating mental state. Parents also charged for ignoring warning signs.
• 2021 – Detroit serial stabbings (Arthur Williamson): Claimed voices told him to attack; mental evaluations ordered repeatedly to assess competency.
• 2022 – Detroit random killings (Dontae Smith): Killed three people at random; pled guilty but mentally ill, diagnosed with paranoid schizophrenia.
• 2022 – Kent County domestic double homicide (Cristian Lopez): Young man killed parents during psychotic episode; found not guilty by reason of insanity.
• 2023 – Lansing apartment standoff: Suspect fired at police while in mental-health crisis; later committed to a psychiatric facility after competency findings.
• 2024 – Midland County assault (Brien Burton): Assaulted stranger during delusional episode; accepted NGRI plea and transferred to Michigan Center for Forensic Psychiatry.
• 2024 – Detroit police shooting of man in crisis (Porter Burke case): Fatal encounter sparked protests and reform calls around crisis-intervention response for mentally ill individuals.
• 2025 – The most recent includes Grand Blanc Township church attack and a Nanny charged in murder of child’s grandfather at Royal Oak home

In addition to Michigan, I’m keeping an eye on other states facing similar barriers. The South and East Coast continue to struggle, and while the West is more progressive, it’s still restrictive in its own ways. This post was also inspired by a friend (who received an alert from MANA) and urged me to write to legislators about Michigan’s House Bill 4399. I initially thought nothing could move forward during this government shutdown—but then  I thought well advocacy doesn’t have to stop just because Congress does. We can still flood their email, vote, or make noise! The fight for better healthcare access should never stop—so keep fighting (for your own state and others).

About the House Bill 4399 (2025) 

What the bill does? House Bill 4399 would amend Michigan’s Public Health Code to broaden the scope of practice for advanced practice registered nurses (APRNs) who hold nurse practitioner specialty certifications. If enacted, NPs would be authorized to perform comprehensive assessments, diagnose and treat acute and chronic conditions, order and interpret labs and imaging, prescribe medications (including controlled substances under specified conditions), and otherwise practice in their certified specialty area without a required supervisory/collaboration agreement with a physician.

Why it matters? Proponents say full practice authority (FPA) will increase access to primary and specialty care — especially in rural and underserved communities — and let highly trained NPs deliver the full spectrum of services they were educated for. Opponents (including some physician groups) argue the change removes safeguards and that post-graduate experience and collaborative oversight improve patient safety.

Where the bill stands (status snapshot)? HB 4399 was introduced in the Michigan House on April 29, 2025 and was referred to the House Health Policy Committee. The bill has had committee hearings and actions in 2025 and was reported with recommendations as it moved through the legislative process.

How to contact lawmakers about HB 4399 — what to do right now?

If you want to support (or respectfully oppose) HB 4399, the fastest routes are:

1. Contact your state Representative — tell them you are a constituent and whether you support or oppose HB 4399. Find your representative and contact form at the Michigan House site (enter your address).
2. Contact the bill sponsor — Rep. Dave Prestin is the primary sponsor; contacting the sponsor’s office is a direct way to register support or feedback.
3. Contact the House Health Policy Committee chair — committee members hear testimony and vote on referral recommendations; chair contact is important for timing and hearings.
4. Send a short, personal message (draft below) by email or call the offices listed on the Michigan House directory and on your representative’s official page.

Sample email (but PERSONALIZE IT)
Subject: Please support full practice authority for NPs — HB 4399

Dear Representative [Last name],

My name is [Your name]; I live in [Town], MI (House District [#]). I’m writing to ask you to support House Bill 4399, which would grant full practice authority to nurse practitioners who hold an NP specialty certification.

As an [NP/patient/primary care consumer/health-care worker], I believe this bill will expand access to care in [your area/describe need], reduce wait times, and improve care for underserved communities. I respectfully ask you to vote yes on HB 4399 and to support policies that maximize the role of NPs in Michigan’s health care system.

Thank you for your time. Please let me know if you would like additional information or data about NP outcomes and patient access.

Sincerely,
[Your name]
[Address — street, city, zip]
[Phone] | [Email]

Simple phone script (60 seconds): “Hello — my name is [Name], I’m a constituent from [Town]. I’m calling to ask Representative [Last] to support HB 4399 (full practice authority for nurse practitioners). I’m concerned about access to care in our area and believe this bill will help. Thank you for passing my message to the Representative.”

Want a shorter social/post message? Use: “I support HB 4399 (FPA for NPs). It will expand access to care in MI—please vote yes. #HB4399 #FullPracticeMI”

Here are key email contacts you can use to reach out about House Bill 4399:

• Primary sponsor: Dave Prestin, Rep. (R-108) — DavePrestin@house.mi.gov (MichiganVotes)
• General contact for the Michigan House of Representatives: BusinessOffice@house.mi.gov (Michigan House of Representatives)
• Contact for the House Health Policy Committee (which handles HB 4399): Committee@house.mi.gov (Michigan House of Representatives)

TO THOSE WHO DISAGREE

Be aware of the opposition even among those you work with, including physicians who may act as gatekeepers. Stay polite toward those who disagree, but don’t waste energy arguing—focus your efforts on formal, effective actions that create real impact. Here are some of the key organizations and agencies opposing House Bill 4399 (HB 4399) in Michigan — along with how to contact them:

Major Opponents & Their Contact Info

Michigan State Medical Society (MSMS)

• Position: Strongly opposed. MSMS states the bill “jeopardizes patient safety” by removing physicians from the care team. (Michigan State Medical Society)
• Contact: They use a general form, but one public email is for the House Health Policy Committee Clerk which MSMS suggests using to submit opposition: hcrawley@house.mi.gov (Michigan State Medical Society)
• Also general contact email / form for MSMS: Through their “Contact Us” page. (Michigan State Medical Society)

Michigan Academy of Family Physicians (MAFP)

• Position: Opposed. MAFP wrote a piece titled “Protect Physician-Led Care: Take Action and Oppose HB 4399…” noting the risks to care quality, access and patient outcomes. (Mafp)
• Contact: They list a specific email for questions: (Chief Executive Officer) Karlene Ketola, MSA, CAE at [email protected] according to their article. (Mafp)
  • Note: The actual email address appears truncated in the article; you may need to go to their website for the full address.

How to Use This Info

• If you or your readers oppose HB 4399, you can direct them to submit comments to the House Health Policy Committee via the contact email hcrawley@house.mi.gov (as MSMS recommends) to formally register opposition.
• You could also encourage readers to contact MSMS or MAFP directly if they want to coordinate or align with organized advocacy efforts.
• When messaging these groups, you might write something like:
  

  “I’m a [NP/physician/health-care professional/resident] in Michigan concerned that HB 4399 will reduce care coordination and patient safety. I’d like to support your work in opposing this bill. Please let me know how I can help.”

A full list of all stakeholder organizations for and against HB 4399 (including smaller specialty groups, rural health associations, NP associations) with direct contact emails and links:

Here are several useful websites related to the issue of full practice authority (FPA) for advanced practice registered nurses (APRNs) in Michigan:

1. Michigan Council of Nurse Practitioners (MICNP) — Full Practice Authority page
   • https://micnp.org/page/fullpracticeauthority (MICNP)
   • Provides background on Full Practice Authority legislation in Michigan, fact sheets, and advocacy information.
2. American Association of Nurse Practitioners (AANP) — Michigan State Practice Environment
   • https://www.aanp.org/advocacy/michigan (AANP)
   • Overview of NP/ARNP scope of practice in Michigan, regulatory structure, and requirements.
3. Website titled Full Practice Authority (by “Mi Patients First”)
   • https://www.mipatientsfirst.com/ (Full Practice Authority)
   • Advocates for FPA for nurse practitioners in Michigan; gives legislative status, arguments, and how to support.
4. Citizens Research Council of Michigan — article on scope of practice expansion for NPs
   • https://crcmich.org/expanding-nurse-practitioner-scope-of-practice-deserves-serious-consideration-to-address-primary-care-needs (Citizens Research Council of Michigan)
   • Research/policy discussion of how expanded NP/APRN scopes might address primary care shortage in Michigan.
5. Michigan Legislature — legal statute pages for APRNs
   • Example: Michigan Compiled Laws (MCL) Section 333.17201 (Definitions for APRNs) — https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-333-17201 (Michigan Legislature)
   • Statutory foundation for APRNs in Michigan’s Public Health Code.

The AANP is a selfish, greedy, unethical and unprofessional organization as it relates to providing Board Certifications for NP candidates, they hijack the scores and test results of the examinees for months to benefit themselves while depriving the candidates of the income and opportunities they’ve worked hard to earn, using the excuse of getting their credentials to be approved to provide certain NP exam. Though they were quicker in scheduling my Psych NP/ PMHNP Exams than the AANC. I later had the most terrible experience with them. Apparently it’s not just the ANCC that offers the PMHNP Certification, the AANP is now pretty much entrapping New Graduate Psych NP students into helping them get accreditation to provide the PMHNP Exam without their full knowledge & agreement. Only after they sit the exam are they sent an automatic refund of a portion of their money telling them its an incentive to wait 3 months or more for their results, whether they had agreed to that or not in the first place. The worst part is that they initially told me I passed my Psych NP Boards with them, then later, after I reluctantly waited 3 months for the results, they then told me I had not. Needless to say I found this to be cruel, unprofessional, and unethical, especially since I spent so much time studying for my exams. money and driving 2 hours to sit my boards. Not to mention several job offers in hand and employers who’ve been waiting patiently for me to complete my credentialing, as well my family and friends who were all excited and happy, only to be told otherwise. NP students should be aware of this scheme from the AANP, in order to avoid a similar encounter on their part. This to prevent the mental, financial and emotional trauma, caused from this experience. We expect the AANP as an Certification Board to know and do better, to hold themselves to a much higher standard, just as they expect from the NP candidates.

Another main concern is how, almost most agencies and logistics are not aware of the AANP/PMHNP option. I actually forgotten about AANP until I was reading complaints on Facebook about the difficulties of the credentialing, dealing with insurances/coverages, etc. and what’s also (personally) odd is how ANCC is completely silent like really?? So that’s disappointing because it adds to the general confusion… For example, are certain qualifications, updates, trainings, preparations more important than what ANCC offers and how does it affect the process of being qualified or  certified. If none of it really matters, then why did this change happen in the first place, other than possibly to make more money? But if it ultimately leads to better access to care, then hopefully it raises more awareness about EVERYTHING. People who just passed their boards continue to check out After the Boards to help with the process. Per Chat GPT, here’s a breakdown of the certifying governing bodies: 

Core Differences of AANC VS. AANP

Here are the advantages and disadvantages of each, especially as they might apply to someone deciding which to use:

AANP-PMHNP

Pros

• More clinically focused—if your work is mostly direct patient care, diagnostics, treatment, etc., this tends to align well. (Walden University)
• Simpler question format: all multiple choice. Less variety = fewer surprises, potentially easier to study for. (Indeed)
• Shorter exam duration. Slightly less time burden. (Walden University)
• Lower cost (especially if member discounts apply) and maybe lower renewal overhead depending on what you choose. (Spring Arbor University)

Cons

• Doesn’t cover as much in the “professional role” side (e.g. policy, ethics, legal, leadership, theory) — may leave gaps if you move into roles that require those competencies. (Nursejournal.org)
• Less question-format variety means less preparation for “trickier” formats (if you ever decide to take ANCC or another exam).
• Some employers, academic settings, or specific states may prefer or give more weight to ANCC certification because of its broader scope.
• If you want to move into leadership, research, education, or policy, the more limited “non-clinical” content may require additional self-study anyway.

ANCC-PMHNP

Pros

• Broader content: theory, professional role, ethics, legal issues, etc., which can provide stronger foundational knowledge, especially if you might shift into roles beyond direct care (education, policy, leadership). (Nursejournal.org)
• More types of question formats; some say this reflects more realistic, complex scenarios and may test adaptability and higher order thinking. (Indeed)
• Potentially more recognition in certain academic, institutional, or leadership settings—some employers may prefer the “BC” (Board Certified) credential by ANCC.
• If interested in specialties or sub-areas that ANCC offers but AANP does not (depending on your career path), ANCC gives more flexibility. (Spring Arbor University)

Cons

• More expensive exam fee. (Spring Arbor University)
• Longer exam, more questions, more possible formats — so potentially more prep time, more stress around unfamiliar question types.
• More “non-clinical” content may feel like extra burden if your focus and strengths are purely clinical.
• The maintenance / renewal requirements may be more involved, especially if you’re required (or want) to maintain leadership/academic‐oriented competence (publishing, etc.).

What Matters Depends on Your Goals

Here are some questions for future considerations:

1. What kind of work do you plan to do now and in the future?
   • If you’re going to stay in direct patient care, outpatient or inpatient psychiatry, medication management, etc., AANP may be enough.
   • If you think you might move into administration, policy, leadership, teaching, or research, ANCC may serve you better long term.
2. What are employer or state preferences?
   • Some institutions (especially teaching hospitals, or “Magnet” hospitals) might favor ANCC credentials.
   • Also, check your state’s Board of Nursing and any insurance/payor credentialing; sometimes they list preferred certifying bodies or acceptances.
3. Testing style & your comfort level
   • Are you comfortable with mixed question types (hotspots, drag-and-drop, multiple responses)? If not, the AANP exam format might be less stressful.
   • Time pressure: more questions and longer exam with ANCC means pacing is more critical.
4. Cost & renewal burden
   • Upfront costs (exam fee + preparation) and ongoing costs (CE, possibly more professional development) differ; you may want to balance those against expected return (pay, job opportunities, satisfaction).
5. Flexibility & prestige
   • For some, ANCC carries a certain prestige or recognition in academic/policy circles.
   • But prestige matters only if it translates into better job opportunities, higher pay, or roles you want.

Conclusion

There is no universally “better” certification version, but I would continue to lean towards ANCC because it may take longer for insurers and the logistics to occur with AANP. If you don’t mind waiting longer or if you already have a job, patients, or have super front/back end support, then it shouldn’t be an issue to complete the PMHNP boards with AANP. However, it could change and be easier with time or additional consideration, but  I tried to write out a process that has been useful @ After the Boards and hopefully it’s not too much of a difference to get things situated.

• Start lean and scale slowly: Begin with telehealth or a hybrid model to reduce office rent, utilities, and overhead before expanding into physical space. Usually people stick to their full/part-time job while building their practice, thus you can start your private practice with a system you’re already familiar with or shop around.. Before this stage, consider the BRANDING, work on a website/online presence, business cards, what your focus or niche or the theme, for example mine was community/traditional. START TRACKING COSTS.  
• Use cost-effective technology: Choose affordable EHR systems (like SimplePractice, TherapyNotes, or Jane) that combine billing, charting, and scheduling. Use free or low-cost HIPAA-compliant tools (e.g., Google Workspace with a BAA, Doxy.me, or Zoom for Healthcare). Automate tasks such as reminders, intake forms, and payments to save time and admin costs. Choose a system that you’re already working/set-up in and/or a system that YOU ARE comfortable with and able to be SUPER efficient. I’m not familiar with the ones Chat GPT listed, but there are some things you have to splurge on in practice and the EHR should be one of them! 
• Outsource smartly: Hire virtual assistants or billers part-time or per-claim instead of full-time employees. Use freelance marketing or bookkeeping services instead of large agencies. Before hiring assistance, be familiar with what you can/cannot delegate, costs, the expectations, and what EHR system they need to be familiar with and usually ask the EMR company if they have resources/tools for the staff, all of this have save me time and headaches. 
• Reduce administrative waste: Go paperless with digital records and e-signatures. Streamline documentation and use templates to minimize time spent on notes. Documentations are sometimes provided in billing services for free, but have your own legal forms/documentations for backup and in general.
• Negotiate and shop around: Compare malpractice insurance rates and request discounts for multiple providers or low-risk specialties. Negotiate rent, software renewals, and vendor contracts annually.
• Collaborate and share resources: Join or form group practices or co-ops to share office space, staff, and marketing costs. Partner with other clinicians for shared CEUs, supervision, or community workshops.
• Leverage free marketing: Use social media, Google Business Profiles, Psychology Today, and local directories for organic reach instead of paid ads. Network with primary care providers, schools, or local nonprofits to gain referrals.
• Maximize reimbursement and cash flow: Optimize coding and billing accuracy to reduce claim denials. Offer self-pay packages or memberships for stable revenue without insurance delays.
• Use tax deductions effectively: Deduct expenses like office supplies, professional dues, continuing education, software, and part of your home office. Work with a tax advisor familiar with healthcare practices to ensure full compliance and savings.
• Invest strategically: Focus spending on tools that directly increase efficiency, client satisfaction, or revenue, such as scheduling systems, telehealth platforms, or SEO-friendly websites.

Personal Tips that has Helped My Practice

Here are some additional saving/business tips that has helped me in this crumbling economy. I would like to believe that I organize stuff, but it’s these suggestions are mainly impulsive and just happen to work for me….  I would also put in risks to consider, but at least this is more information that I have ever received, including how the future of psych/mental health can help others be MORE prepared:

• Consider having a Google Account for Your Practice: my assistant and I share the email, google docs, etc. It’s easier to communicate, send PDF, and it’s free. I didn’t realize how helpful this was and how you always need a backup means for communicating and in the business world in general. Risks: mainly security risks, but have a strong vetting process and I’ve limited this to one person, if I add more staff or become a major clinic, then I can worry about stronger security measures but will have the $$$$$ to afford that or worry about that later if that occurs..    
• Consider a Business Microsoft Account: I use Teams and again another means of email, communicating, etc. and Teams is free and secured for patients, but most EMR/billing platforms also offer free telehealth options.
• EHR: I use Valant and it’s been really helpful, yes it’s costly but I gauged a system by how efficient I can be without having issues… some EHR’s are cheaper/free, but you have to consider more glitches, tech failures, etc.. I’ve heard Icannotes is another great system -therefore, aim for a EHR that handles schedule medications, documentations or data really well… Risks: well having a crappy EHR can be costly, cause work/charting delays, and ultimately cause more burnouts…
• Use Google Docs: to track my expenses, notes, everything. It’s FREE. Use Chat GPT (it’s also FREE), I use it to find local resources, help with letters, create infographics, etc. Here are more considerations to use Chat GPT:
  • Educational support: Provide clear, easy-to-understand explanations of mental health conditions, treatment options, and coping strategies—reinforcing what clinicians discuss in sessions.
  • Resource curation: Quickly generate tailored lists of community resources, such as crisis hotlines, low-cost therapy options, housing support, or substance use programs.
  • Administrative efficiency: Draft patient handouts, follow-up summaries, consent forms, and wellness guides, freeing clinicians’ time for direct care.
  • Therapeutic tools: Create personalized journaling prompts, mindfulness scripts, or CBT-style reflections for clients to use between appointments.
  • Communication aid: Help clinicians write supportive messages, newsletters, or psychoeducational materials that maintain a compassionate tone and clear language.
  • Cultural and accessibility adaptation: Adjust written materials for different reading levels, languages, or cultural contexts, improving inclusivity and understanding.
  • Program and curriculum design: Assist in developing mental health workshops, support group materials, or educational presentations tailored to specific populations or settings.
• Have an assistant: you have to have someone available to board the patients/grow the practice, while you work or do patient care. Also, my assistant is a nurse/familiar with commercial insurance -so I didn’t have to train her as much…. and it’s been my lifesaver. If you don’t have the funds to factor in an assistance, then probably wait to start your practice/patients aren’t pouring in to be able to take on more financial burdens…. Risks: if you do everything by yourself, you risk burnout, confusion, delays, missing opportunities also caution if you’re trying to save money using your partner/spouse, family/friends… try to keep your clinic MORE professional and formal. 
• Consider having an (as needed) office:  here’s a secret, I have an office and it’s the last weekend day of every month and it’s about 5 hours. Yup, it’s not much! But it’s something until I grow more and/or I don’t have to worry about the costs or DEA -but my patients are aware that how this may be the future. Again, try to save money and prepare for the future
• Additional Factors: Pay Attention to Laws/Regulations: as money dwindles, the last thing we need is a lawsuit, etc. With some options to do a MedSpa, HRT, Integrated Care, TMS, etc. make sure you’re malpractice insurance covers your services, etc… Lastly, in your practice, treatment, notes/charting, or in general continue to focus on PREVENTATIVE CARE… always try to avoid complications/crises:

5 Rambling Lessons this year as an NP

Welp, I’m still in the trenches but here are some lessons since I’m in my 5 year anniversary of being a NP.  Yes I’m over it and question why I put myself through this but here we go!

1. Time to get political: I know it’s painful but advocacy can only do so much in a 9-5 office. I wrote about some up coming laws and how to make a huge impact in healthcare. Please continue to advocate for psych. Make sure you’re social media is clean and not sociopathic, flirty, or abusive!  
2. I Don’t Like Matt Walsh: yes very random, but there are prominent voices (including doctors) in the media that downplay mental health and feel like it’s useless. He’s one of MANY that has made brutal comments about mental health, antidepressants, ADHD, and in general. People are facing major traumatic events and men are having a mental health crises as evidence by the news and violent crimes. People are looking everywhere for mental health services mainly due to a lack of access and you have famous influencers who are millionaires…with the privilege of just doing a talk show … Telling the working class to stop complaining or not take medications or get treatment and it’s extremely irresponsible. I guess this tangent is about having to educate the public about avoiding these voices online or in media and I feel like it’s just getting worse. I’m still working on my male section
3. SHAME on the Government: during the pandemic and till this day, I’ve accepted that many people are simply just not going to make it. It’s a bitter pill to swallow, but it’s NOT enough help and our government has failed us.  I’m working out my own feelings of how the powers that be would rather have us die than to offer, anyone who’s not rich, a helping hand. Canada and other countries are already offering euthanasia and death itself, can turn into a money maker -pandemic meds, organs, funeral homes, etc. but don’t give up! I’ve started a new series on lifestyle that’s discussing stuff in general… basically I’m putting more hope into the youth and not the politicians.
4. Alternatives: While I may not be starting my bakery, I plan on doing more in alternatives/complimentary health…  I’ve always believe in a combination of regular/Western care and using supplements, vitamins, etc. many bodies don’t respond to regular treatment and I know teas, soups, broths, have helped me tremendously… I’ve mentioned before to not put all you eggs in one basket (whatever that ONE job is) and to focus on a niche/or what you’re passionate about. When you love doing something, it truly doesn’t feel like “work” and that’s how you go to new levels and not lose your mind.
5. I’ve also given up on entertainment: because of the ads!! I’m also not paying for premium or any subscription, I’ve found more helpful ways to handle stress like watering my plants, writing, and cooking. The goal is to be more grounded and less dependent on cheap dopamine rushes. It’s time to get locked in!

1. If you get denials, etc., talk to the insurance company. Yes it’s painful but you’ll get insight on how to move forward and if you need to provide more/less documentation or services. Also, when you talk to these companies/get their names. Make it formal so they can actually take it serious.
2. In the documentation, I note how the insurance or lack of coverage has affected the care or outcomes… insurances blame the providers -I put the blame back on them. I would literally write, due to the lack of coverage -patient is still affected by lack of coverage, the symptoms, the lack of adherence, etc.
3. Inform the patient about what the insurance is/isn’t covering… sometimes my patients will call their insurance company to get assistance, but make sure they don’t threaten them! It is a crime to make threats and the calls are recorded.
4. If I have patients that are lawyers/in politics, etc. I just nudge them or people in general to consider our fight. Also fill out surveys and attend local chapters/gatherings in your professions.
5. Change the way you practice. Work smarter not harder, if someone is too high of acuity, don’t play superman. If I’m able to help great, but if not, I will refer out, it’s actually my secret weapon…  I do community and private practices plus a billion other major things… I can handle high stress, but if you look at me the wrong way, I’m referring you out. I don’t care anymore. It’s not worth the headache. If things get more under control, yes I can put more humans on my plate, but until then I pass out community resources.

2025-2026 CPT Updates

I have another secret. I’ve never had an insurance denial. Over the course of my career, I’m sure I’ve seen over a 1000 patients and wanted to go over some tips that I feel are important. There are formal classes, books, conferences, etc. in the universe -but I have no time for that therefore, I may be horribly WRONG so that’s my disclaimer. Alright, I’ve covered some of these points before but I can add some context so here we go:

1. For Intake Codes use 90791 (for therapy ONLY) or 90792 (for therapy and/or medications): I covered the format for an intake note) and just tailored it to your liking as long as insurances accept it or the billing company. If you start with a therapy (intake) code/90791 and then switch to prescribing meds, you’re still not technically supposed to use an intake code, I just add a medication code with a therapy code. I just wanted to note here to make sure you have ALL the proper information to bill the intake note.
2. Maintain each note like an intake: so for the follow up (f/u), continue to have the CC/chief complaint, HPI (What’s being maintain or changed and the indication), review of systems (ROS), mental statues exam (MSE), any medical updates/changes, PSFH (work/school/living/housing situation), and when to follow up (RTC/return to clinic). Plus, with EACH note you have to have patient demographics, patient/provider location, time frames… I don’t use AI with my notes and THIS IS WHY. If you do each note like this (since it’s saved from the prior note), it eliminates the need to use, rely, or pay for AI. I’m also done with my charting a lot faster with no additional costs.
3. Optional: I still use rating scales, but I don’t submit them in private practice (it’s not needed)…but it’s in the patient’s EMR and I make it mandatory if I’m doing FMLA. I do submit them in community health and with Athena’s EMR because it’s automatic so it’s a nice bonus that I don’t have to worry about.
4. What’s in my patient’s EMR: prior medical/paperwork (PPW), labs, additional testing, GeneSite, rating scales, consents, etc. This is due to if insurances/billing companies, jobs, other clinics or someone requesting records and by law it has to be noted/secured. Also, make sure you get CONSENT before sending records/that’s also the law.
5. Therapy Codes: this can be tricky but the system I use is if I’m refilling medications it’s 99213 or 99212 with the therapy code (90836/45 min) and if I didn’t refill or prescribe medications I ONLY use 90837 (60 min). The reason why this is controversial is because I’ve been reading how people try to use a therapy code and bill 99214 or 99215 –This is the problem. Even in community -I rarely use this codes… I actually haven’t used them in years because insurance will say it’s a red flag. I just don’t have time to fight the insurance company so I don’t recommend using them, but I’ve also notice how I get MORE pay (by having recurring patients) if I stick to my system. Recurring 99214 or 99215 will NOT work with insurances no matter how much you try to justify it…  
6. Concierge Vs. Insurances: some providers are opting out of insurances all together by providing concierge or a flat monthly/yearly rate fee.. I don’t agree with it because the patient will still have to pay for medical insurance but it’ll weed out many (poor) people. I’m also concerned about the ethics like am I obligated to give certain medications, treatment, or special privileges… even if it’s not in their best interest just because they pay me. It’s almost the same dilemma with the student paying the preceptor to pass them, despite having major red flags… However, if concierge practices give people better access to care, I super understand.
7. Additional Thoughts: If you want to use fancier or very particular/rare/extra CPT codes, consider consulting a peer, a biller, or taking a class, paying for resources or help prior to this…Some providers have lost thousands using the wrong codes… I’ve witnessed it and it’s sad to see someone have a breakdown because they’re not understanding the importance of how to bill and losing money…  I try to keep my billing and everything else simple but since I’m going to start doing Medicare/Medicaid, I’m using a 3rd party (billing) until I’m more comfortable in my private practice. Lastly, I wanted to note having a good EMR is essential to helping you stay on track, Valant has been awesome for me… The problem with Athena is that it’s too glitchy and confusing with medications, but the charting and patients communicating in the portal has been getting easier…  I’m also using Valant for my Medicare/Medicaid patients (but there are free versions that are state specific/but again it’s more work and can be another learning curve).I also see patients in other states so having a solid EHR is essential.

Lastly, I’m aware I do a lot for free (like this website)… I could charge patients more, but I try not to and some people asked about how to charge. You can get estimates from Chat GPT for example… but overall code/charge with what you’re comfortable with and can justify. Even if I have someone in crises, which is like everyone, I don’t code 99214/99215 or up code. A list of what I don’t charge for/but may change if I get busier: no shows, FMLA/documentation, records, phone calls, consultations, Prior Auths. However, I’m updating my policy if I have to go to court or legal fees, fees for a school/students, other misc. costs, but it’s for future reference…

Here’s Chat GPT to help with charting your therapy notes/sessions:

Insurance companies scrutinize therapy documentation closely, especially if they want to deny or limit care. The goal is to show medical necessity and compliance with CPT coding rules. Here are the top factors to include when documenting therapy sessions so you’re protected in case of audit or denial:

Key Documentation Factors for Therapy Sessions

1. Patient Identifiers & Session Details
   • Date of service
   • Start and end times (to justify time-based codes: 90832, 90834, 90837, etc.)
   • Modality: in-person, telehealth (audio/video), or audio-only
   • CPT code used, and any modifiers
2. Reason for Visit / Medical Necessity
   • Current symptoms and impairment (functional, social, occupational)
   • Clear link between diagnosis (DSM/ICD code) and why treatment is required now
   • Note any safety risks, relapse potential, or worsening if therapy is not provided
3. Treatment Type & Techniques Used
   • Identify the therapy modality (e.g., CBT, DBT, supportive therapy, trauma-focused therapy)
   • Specific interventions applied in the session (e.g., cognitive restructuring, exposure hierarchy, motivational interviewing, coping skills practice)
   • This shows insurers you’re delivering skilled, structured care, not just supportive conversation
4. Patient Response & Progress
   • Document how the patient engaged (active, resistant, avoidant, cooperative)
   • Patient’s progress toward goals — even small steps
   • If no progress, document barriers (e.g., external stressors, comorbidities) and adjustments made
5. Treatment Plan & Goals
   • State active, measurable treatment goals (e.g., reduce panic attacks from 5/week to 2/week; improve sleep from 4 to 7 hours/night)
   • Update plan periodically (insurance may deny if it looks “stagnant”)
   • Tie today’s session back to the overall treatment plan
6. Risk Assessment (when relevant)
   • Suicide, homicide, or self-harm risk: “denies SI/HI” if not present, or detailed plan/level if present
   • Substance use updates
   • Safety planning if indicated
   • This protects you legally and shows medical necessity
7. Coordination of Care / Collateral
   • Note if you consulted with PCP, psychiatrist, school, family, or other providers
   • Shows integration of care, which insurers value
8. Homework / Assignments
   • Document skills practice, behavioral experiments, journaling, relaxation exercises assigned between sessions
   • Shows structured therapy and patient responsibility
9. Plan for Next Session
   • Outline what the focus will be (e.g., continue exposure hierarchy, review coping logs, address cognitive distortions)
   • Reinforces continuity of care

Common Pitfalls That Lead to Denials

• Only writing vague notes like “talked about problems” or “patient feeling better”
• No time documented for time-based codes
• Treatment plan not updated in months
• No clear functional impairment described (insurance may say: “not medically necessary”)
• Same “cookie cutter” note every session — insurers flag patterns

Example Template Flow (SOAP or DAP style)

• S (Subjective): Patient reports panic 3× this week, poor sleep, conflict at work.
• O (Objective): Affect anxious, fidgeting, logical thought, no SI/HI. 45-min session.
• A (Assessment): Ongoing GAD with panic; barriers include job stress. Patient using relaxation with some effect.
• P (Plan): Continue CBT focus on cognitive restructuring; assign thought log; next session review triggers.

Insurance reviewers want to see that therapy is structured, goal-oriented, medically necessary, and progressing — even if slowly.

 

Time to Talk Politics

Welp this is going to be rough but here we go! President Trump recently signed orders to restart psych institutions. At first, I didn’t believe it but what many people haven’t connected or realize is how America is going to be hosting the Olympics in 2028 (in Los Angeles, CA) and how LA has one of the highest homeless populations. I like the Olympics, which is why my red flags went up immediately because other countries/cities also implemented similar laws when they hosted the Olympics. And I’ve been thinking nonstop, like what does this means for psych providers?!! Especially if we don’t have any experiences working in mandatory institutions/insane asylums. With the help of Chat GPT, we can summarize some major issues:

Overview: Trump’s Executive Order on Homelessness (“Ending Crime and Disorder on America’s Streets”)

• Trump signed an executive order on July 24–25, 2025, directing states and cities to clear homeless encampments, and prioritize federal grant funding for jurisdictions enforcing strict bans on open drug use, camping, loitering, and squatting. Yahoo+7Reuters+7CalMatters+7

• It authorizes involuntary civil commitment for unhoused individuals with mental illness or substance use disorders, pushing them into long-term institutional care—claimed to restore public order. American Civil Liberties Union+6Axios+6The White House+6

• The Attorney General (Pam Bondi) is instructed to reverse judicial precedents or consent decrees limiting local authorities from removing homeless encampments. The White House+2Reuters+2Fox News+2

Shifts in Policy Philosophy

• The order proposes ending federal support for evidence-based “Housing First” and harm reduction programs, which currently allow housing without requiring sobriety and promote safer drug use strategies. Fox News+15CalMatters+15American Civil Liberties Union+15

• It establishes expanded data collection on unhoused individuals—including health and mental-status data—raising privacy and surveillance concerns. American Civil Liberties Union

State-Level Dynamics: How Does It Compare to California’s Approach?

• California under Governor Gavin Newsom has pursued anti-camping laws, encampment sweeps, and expanded treatment mandates—but retains support for Housing First and harm reduction programs. Reuters

• Experts note that while both Trump’s order and California share enforcement elements, Trump’s goes further by removing protections tied to evidence-based models and shifting federal funding away from them. CalMattersNational Alliance to End HomelessnessAP News

Bottom Line

• New policy shift: Trump’s order enforces national encampment clearance, expands forced treatment, and penalizes homeless populations through civil commitment.

• Funding mechanism: It reallocates federal grants toward enforcement-heavy jurisdictions and defunds programs that focus on housing and harm reduction.

• Major criticism: Civil liberties groups warn it effectively criminalizes homelessness, may increase unsheltered populations, and undermines decades of evidence-based policy.

Can you do a case study of how this will impact Psych NP’s

Absolutely. Here’s a case study exploring how Trump’s proposed homelessness executive order could impact Psychiatric Nurse Practitioners (PMHNPs), with a realistic patient scenario, clinical workflow, legal implications, and ethical considerations.

Case Study: “Michael” – A Homeless Patient with Schizoaffective Disorder and Substance Use

Setting: Urban community mental health center in a state that complies with the federal executive order mandating involuntary care and strict encampment bans.

The Clinician: Jasmine, PMHNP-BC, works in both a clinic and a street psychiatry outreach program. She manages ~80 patients monthly, many with severe mental illness and co-occurring substance use. Under the new executive order, her clinic now receives conditional federal funding tied to patient compliance and removal from unsheltered settings.

The Patient: Michael, 39, is living in a tent near a freeway. He has:

• Schizoaffective disorder (untreated for 2 years)
• Methamphetamine use
• Multiple ER visits for psychosis and paranoia
• Refused shelter repeatedly due to mistrust and fear
• No family support
• Recently assaulted someone during a paranoid episode

Clinical Impact on PMHNP Role

Legal & Procedural Impacts

• Involuntary Hold Initiation: Jasmine fills out a 72-hour hold for grave disability and danger to others based on Michael’s erratic and aggressive behavior.
• Court-Ordered Treatment: Within 5 days, Jasmine must testify in court or via affidavit to justify Michael’s forced placement in a locked facility.
• Federal Documentation Compliance: She now completes detailed behavioral risk assessments, substance use logs, and compliance reports for federal oversight audits.

Ethical Dilemma (Considerations)

Burnout Risk and Moral Injury

• Moral distress: Jasmine feels guilt over forcing a patient into a locked facility with limited recovery focus.
• Time Pressure: Each civil commitment case now consumes hours of paperwork, court prep, and follow-up, reducing time with other patients.
• Loss of therapeutic alliance: Several unhoused patients now avoid her, fearing involuntary hospitalization.

Summary: Takeaways from This Case Study

Recommendations for PMHNPs

1. Get training in civil commitment and forensic psychiatry practices.
2. Develop scripts and workflows for documenting danger, noncompliance, and grave disability.
3. Join advocacy efforts through APNA or state boards to preserve ethical standards and patient rights.
4. Create internal protocols for trauma-informed care even under policy mandates.
5. Maintain peer support/supervision to process moral distress and prevent burnout.

How Trump’s Homelessness Executive Order Could Affect Psychiatric Private Practice Providers?

Even if you don’t work in shelters or public hospitals, policies like Trump’s homelessness executive order can ripple deeply into psychiatric private practice. Here’s how.

1. Shrinking Clinical Autonomy

Under new mandates that prioritize public safety and law enforcement over patient care:

• You may be pressured to report or refer patients for involuntary treatment, even if it doesn’t align with your clinical judgment.
• Courts and law enforcement could override your treatment plan, especially for patients with psychosis, addiction, or who are unhoused.
• Clinical decisions may be second-guessed or legally challenged based on public safety framing.

2. Increased Legal and Documentation Burden

Expect a sharp rise in administrative work, including:

• Writing affidavits or court letters to justify or defend treatment plans.
• Maintaining forensic-level notes to track “danger to self or others,” noncompliance, and behavioral risk.
• Submitting compliance reports to federal or local agencies monitoring care outcomes.

These aren’t just chart notes—they could become part of a legal process that influences patient freedom.

3. New Ethical and Legal Dilemmas

You’ll likely face moral and legal crossroads, such as:

• Privacy vs. Reporting: If a patient admits to drug use while living outdoors, do you report it or protect their confidentiality?
• Consent vs. Coercion: Will housing or services be denied unless patients comply with mandated treatment?
• Advocacy vs. System Pressure: Will you be expected to “clear out” difficult patients to preserve your professional standing?

4. Disruption of Referral Networks

As funding is pulled from harm reduction and Housing First programs:

• You may lose access to local social services that accepted patients regardless of sobriety or compliance.
• Shelters and housing agencies may tighten eligibility, referring only patients who are court-ordered or on strict treatment plans.
• You might be asked to collaborate with outreach teams more focused on enforcement than recovery.

5. Insurance and Reimbursement Changes

Changes in funding and oversight may affect how (and whether) you get paid:

• Insurance or Medicaid may deny coverage for patients who aren’t “compliant” with treatment or considered stable.
• Reimbursement may be tied to outcome-based metrics that favor medication adherence over holistic, patient-centered progress.
• You could be asked to participate in treatment plans more focused on public safety checklists than therapeutic goals.

6. Becoming a Gatekeeper

You might see a spike in non-psychiatric tasks like:

• Performing psychiatric evaluations for court or housing eligibility.
• Justifying whether someone poses a “public threat” or meets criteria for involuntary treatment.
• Managing patients diverted from jail or ERs, even if your practice isn’t built for forensic or acute stabilization care.

This adds stress and liability to roles typically focused on voluntary care and long-term support.

7. Shifts in Patient Demographics

With policy changes, your patient base could shift dramatically:

• More patients might be referred through the courts or treatment mandates rather than voluntarily.
• Some unhoused patients might disappear from your practice if shelters or services become too rigid.
• Others may seek you out in desperation, fearing they’ll be locked up or lose access to housing without documentation of compliance.

How You Can Prepare

• Clarify Your Role: Know whether you’re willing to testify in court, initiate holds, or participate in mandated care systems.
• Review Consent Forms: Add disclosures around reporting laws, involuntary care risks, and the limits of confidentiality under current policy.
• Join Advocacy Networks: Collaborate with APNA, AANP, or private practice alliances to shape ethical, evidence-based responses to these policies.
• Build a Safety Net: Develop relationships with low-barrier providers, legal aid, and advocacy teams to support vulnerable patients safely.
• Protect Yourself: Use structured documentation tools and regular clinical supervision to minimize legal risk and ethical compromise.

These new policies don’t just change how the government addresses homelessness—they redefine how mental health care is practiced. For psychiatric providers in private practice, the risk is becoming involuntary enforcers in a system that increasingly values control over compassion. By staying informed, connected, and clear in your clinical values, you can protect your practice—and more importantly, your patients.

The Reality 

Unfortunately, much of the healthcare system remains significantly behind the times. We lack the necessary laws, regulatory agencies, and systemic support to effectively manage the current needs—largely because these structures were developed only after many of the original institutions, such as state hospitals, were dismantled. This absence of foresight and infrastructure is reminiscent of how poorly the pandemic was handled, particularly in the realm of psychiatric care. At the time, the government lacked a clear response, and even now, there appears to be no comprehensive plan or understanding of how to address the long-term consequences.

I recall when state hospitals closed, and patients were pushed off into the streets without any adequate support. There was no meaningful policy in place for managing individuals with severe, chronic mental illness, nor were there mechanisms to hold facilities or providers accountable for poor outcomes. Similarly, during the pandemic, we have yet to see what lessons have truly been learned or what policy reforms have followed.

I continue to see the ongoing effects in my practice. Just this week, two patients tested positive for COVID-19, and many others continue to suffer from communicable illnesses or long COVID effects, lack of transportation, job loss, and declining access to essential resources. Meanwhile, reimbursement rates are lower than ever, and small practices are struggling to stay afloat. It raises a critical question: Where is the relief or compensation for small healthcare businesses and providers who have been disproportionately impacted by these systemic failures?

In Conclusion 

However, we (private practices/providers) must fight to keep some checks and balances in this country and in our home. I believe capitalism is a coded word for monopolies so therefore, do not treat your business/practice/home as a small business. Treat it like a monopoly. I have to speak in a hidden way because well big brother is watching, but big brother isn’t smart. Use it to your advantage… Implement your own policy/needs for your business for helping the homeless or severe mental illnesses… and write everything off. If someone or a law official looks at me the wrong way, I’m writing it off for damages. I wrote off my pavement, because I need a pave sidewalk to get to my office (house)…if my cat sneezes, I’m writing the vet off because he’s my emotional support animal. I was planning to do my lifestyle sections but now it’ll be more political/business/financial related to help others in the next few years of this craziness… Don’t worry! hang in there, now is the time to be brave/practice safe autonomy at your practice (with some tips above), and get prepared.

Here’s a breakdown of the current (as of 2025) implications and possible outcomes in the next four years across the areas you’ve mentioned:

1. Mental Health Care Practices

• Current State: Increased public awareness and bipartisan acknowledgment of the mental health crisis (especially post-COVID) have led to more openness toward integrating mental health into primary care.
• Impact of Government Changes:
  • If funding is prioritized, integrated care models (mental + physical health) will expand.
  • If budget cuts target public health, community mental health centers may shrink, pushing care into already-burdened ERs and jails.

2. Telehealth

• Current State: Telehealth usage surged during the pandemic and remains critical for rural and underserved populations.
• Impact:
  • Federal and state-level legislation determines reimbursement parity with in-person visits. If rolled back, many providers may abandon telehealth services.
  • Cross-state licensure remains a hurdle. Uniform interstate compacts could help, but these need governmental support.

3. Psychiatric Nurse Practitioners (PMHNPs)

• Current State: They help fill the psychiatrist shortage, especially in rural areas.
• Impact:
  • Scope-of-practice laws vary by state. If federal incentives support full-practice authority, PMHNPs can offer broader services.
  • Resistance from physician lobbies and lack of standardized training across states may hinder growth.

4. Socioeconomic Programs

• Current State: Mental health outcomes are deeply tied to housing, food security, education, and employment.
• Impact:
  • Cuts to Medicaid, SNAP, or housing support would likely worsen mental health and substance abuse crises.
  • Expansion of these programs under a progressive government would improve upstream social determinants of health.

5. Insurance Coverage Problems

• Current State: Mental health parity laws exist but are poorly enforced. Many insurers still reimburse mental health at lower rates.
• Impact:
  • Stronger enforcement and expansion of the Affordable Care Act (ACA) would push insurers to comply with parity laws.
  • If the ACA is weakened or repealed, millions could lose mental health coverage.

6. Special Populations (e.g., veterans, minorities, incarcerated individuals)

• Current State: These groups face major disparities in access and outcomes.
• Impact:
  • Programs like the VA or community mental health grants for minority populations depend heavily on federal funding.
  • Criminal justice reform could shift the system away from incarceration toward treatment—but only with sustained policy support.

7. Lack of Access to Psychiatric Care

• Current State: Over 150 million Americans live in mental health provider shortage areas.
• Impact:
  • Government investment in loan forgiveness, residency slots, and rural mental health incentives could slowly improve access.
  • Lack of investment will worsen the bottleneck, especially for low-income patients.

8. Prognosis & Solutions for the Next 4 Years

• Prognosis:
  • If mental health remains a bipartisan priority, improvements could be made in tech (telehealth), workforce expansion (PMHNPs), and funding (especially Medicaid).
  • However, deep political divisions may lead to piecemeal changes rather than comprehensive reform.
• Key Solutions:
  • Federal Level: Enforce mental health parity laws; expand Medicaid; fund school- and community-based mental health programs.
  • State Level: Allow full-practice authority for PMHNPs; adopt telehealth compacts.
  • System Level: Integrate mental and primary care; increase culturally competent care; incentivize psychiatric residencies/(many AI or computer systems still try to rely on doctors).

In Conclusion 

We have to prepare that it’s going to be very little improvement if not worse for the next few years especially in psych. The focus has to be in caring for ourselves and helping others if we can. If you’re not in the capacity to add more to your plate (like ME ), the goal is to do LESS! not more… I’ve been cautioning people not to make crazy purchases, leave the country, get impulsive or risky, etc. in these unpredictable times unless super necessary. Instead, prioritize protecting your peace, self-care, enjoy your loved ones, and stay grounded in what you can control. Try to keep having some kind of fun.

Electronic comments must be submitted, and written comments must be postmarked, on or before March 18, 2025. (Comment Here Before the Deadline)!

The Background

The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 (Ryan Haight Act) included an in-person medical evaluation before prescribing controlled substances but allowed exceptions for telemedicine during the COVID pandemic. The proposed regulatory plans to have additional registration mandates with 3 types of “Special Registration”, implementing stricter prescription, recordkeeping, and reporting requirements to prevent misuse and diversion. (-Special Registrations for Telemedicine and Limited State Telemedicine Registrations). Additional Information: 

• DEA Unveils Long-Overdue Special Registration for Telemedicine in Proposed Rule -Foley
• DEA Releases Long-Awaited Telehealth Special Registration Proposal, but Adoption Is Uncertain -JD Supra
• DEA announces proposed regulations on telemedicine prescribing of controlled substances -Nixon Peabody

What’s the Problem?

The DEA’s proposed rule limits practitioners to prescribing no more than 50% of controlled substances via telemedicine without an in-person evaluation is arbitrary, overly restrictive, and threatens patient access to necessary care for the following reasons:

1. Lack of Justification – The 50% cap lacks evidence proving its effectiveness in preventing misuse or diversion. During the COVID-19 pandemic, telemedicine prescriptions were allowed without arbitrary caps, with no widespread abuse.
2. Disproportionate Impact on Vulnerable Populations – The rule would significantly affect rural, underserved, and marginalized communities, as well as individuals with disabilities and those facing financial barriers to in-person care.
3. Negative Impact on Providers and Telemedicine Growth – The rule creates administrative burdens, discourages providers from offering telemedicine, and conflicts with state laws that support telehealth as a long-term solution.
4. Public Health Risks – Limiting telemedicine access could undermine addiction treatment efforts and worsen the mental health crisis by reducing access to necessary medications.
5. Better Alternatives – Rather than imposing an arbitrary cap, the DEA should enhance prescription monitoring, focus on high-risk prescribing, and support provider training to ensure responsible telemedicine use.

Conclusion: The proposed rule would hinder progress in telehealth and reduce access to essential care. The DEA should reconsider and collaborate with stakeholders to develop evidence-based policies that balance oversight with healthcare accessibility. These stats are expected to get worse: 

Someone recently asked me to precept and I swiftly declined. I’m already pushed to the maxed. Hence, I use this website to help people and ramble. To give a more honest reason, when the person contacted me, my first impression was just irritation. Clearly, these psych programs need to stop accepting student if they can’t find preceptors… I’ve also precepted residents and PAs but at least they don’t have to worry about not completing their programs. The person went to an online school, which is quite a common problem… so take precautions future NPs! this is still unacceptable, especially if you’re paying tens of thousands of dollars and in general.

My second thought was, since I have my own practice this isn’t like a teaching hospital that already has a system for students, therefore, I really needed to put some thought into this or have my own standards, which my brain cells simply don’t feel like doing right now. Furthermore, the expectations in psych/the demands, lack of preceptors is a relatively new issue in the profession that I didn’t deal with in school. Thus, this post is for the many providers out there in my boat and need additional guidance…

It’s also currently like a forbidden topic of discussion, but it’s no excuse…I usually have a system and didn’t think about sharing it with others until I’ve heard a few horror stories. I’ve also recently saw a story where an NP precepted someone who was bad fit, spoke poorly of their practices, that resulted in the school reporting the NP and getting their license flagged, which basically impacted everything… Yes, it’s more sides to the story, but the point is in YOUR practice, YOU (the provider) will assume ALL responsibility. Therefore, for the sake of your sanity, license, finances and livelihood.. Have a vetting process before accepting a student or decline like I did until you’re able to handle the extra obligations:

Considerations Before Accepting a Student

Before committing to be a preceptor, consider the following practical, legal, and professional factors to ensure a smooth experience.

1. Your Time & Availability

Do you have the bandwidth? – Precepting requires extra time for teaching, documentation review, and feedback.
How many students can you manage? – Some preceptors limit to one student per semester to avoid burnout.
Does their schedule align with yours? – Ensure their required clinical hours fit your availability and workload.

Red Flag: A student who needs a highly flexible schedule that disrupts your workflow.

2. School & Program Requirements

Does their school provide a contract? – Some universities require a formal affiliation agreement.
Are you required to submit evaluations? – Some schools demand frequent progress reports, adding to your workload.
What type of setting do they need? – Ensure your practice meets their clinical requirements (e.g., outpatient vs. inpatient experience).
Does the school offer compensation? – Some programs pay preceptors, while others expect students to arrange payment.

Red Flag: A school with excessive paperwork or unrealistic expectations.

3. Student’s Experience & Competency

What is their background? – Do they have prior psych experience as an RN, case manager, therapist, etc.?
Have they completed foundational coursework? – Ensure they understand basic psychopharmacology, assessment, and DSM-5 criteria.
Do they have strong clinical reasoning? – A vetting interview can help assess their critical thinking skills.
Are they professional and open to feedback? – Look for good communication skills, willingness to learn, and adaptability.

Red Flag: A student with no mental health experience, poor communication skills, or who is resistant to feedback.

4. Legal & Liability Considerations

Are you covered by malpractice insurance? – Some preceptors require personal or employer-provided coverage.
Does the student have liability insurance? – Many schools require students to carry their own malpractice coverage.
Will they be charting under your license? – If so, you must carefully review their documentation.
Are there state regulations on NP student supervision? – Some states require specific supervision ratios or physician oversight.

Red Flag: A student without malpractice coverage or who expects too much autonomy too soon.

5. Patient & Workflow Impact

Will patients be comfortable with a student? – Some may decline, especially in sensitive psych cases.
Will it slow down your workflow? – Initial training can increase visit times, so plan accordingly.
How independent will they be? – Decide when they can lead assessments vs. observe.

Red Flag: A student who expects full autonomy before demonstrating competency.

6. Compensation & Benefits

Will you charge for precepting? – Common rates range from $500–$1,500 per semester.
Does the school compensate preceptors? – Some programs offer stipends or faculty titles.
Are you doing this for professional development? – Teaching can be rewarding but should not become a burden.

Red Flag: A student expecting free preceptorship when it’s too demanding on your time.

Bottom Line:

Assess if you have time and patience to mentor a student.
Clarify school expectations (paperwork, evaluations, contracts).
Vet the student (experience, professionalism, ability to take feedback).
Ensure legal and liability protections (malpractice coverage, supervision rules).
Decide if you’ll charge for your time.

Some Drawbacks to Precepting

Precepting a student can be rewarding, but there are definitely challenges to consider. First, make sure you’re able to take care of yourself, the main job and tasks, and personal responsibilities… before adding more obligations. Obligations = Stress, even if you’re like me and love to teach and train, take precautions. Here are some common negatives to consider and ways to navigate them:

1. Time-Consuming

• Teaching and supervising a student slows down workflow, especially in a busy clinical setting.
• Solution: Set aside structured teaching moments rather than trying to teach during every patient encounter.

2. Variable Student Skill Levels

• Some students may be overconfident or underprepared, making it hard to find the right balance between guidance and independence.
• Solution: Assess their baseline skills early and tailor your approach accordingly.

3. Increased Liability & Risk

• Letting students conduct interviews, make assessments, or suggest medications increases legal risk.
• Solution: Always review their clinical decisions and double-check documentation before signing off.

4. Resistance to Feedback

• Some students may struggle with constructive criticism or appear defensive.
• Solution: Use a coaching approach—frame feedback as a learning opportunity rather than a critique.

5. Disruptions to Patient Flow

• Patients may be less comfortable with a student present, leading to longer visits or refusals.
• Solution: Introduce the student properly and allow patients to opt out if necessary.

6. Emotional Toll

• Students may have strong emotional reactions to difficult cases (e.g., suicide risk, trauma).
• Solution: Encourage self-care, debriefing, and supervision to help them process challenging cases.

7. Student Dependence

• Some students may rely too much on the preceptor instead of thinking critically.
• Solution: Push them to develop clinical reasoning by asking questions rather than giving immediate answers.

8. Unclear Boundaries

• Some students may overshare personal issues or struggle with professionalism.
• Solution: Set firm boundaries and expectations from the start.

Bottom Line: Precepting requires patience, structure, and clear expectations. While it can slow things down initially, a well-trained student can eventually become an asset to the team.

Some Practical Tips for Training Students

Let’s say everything checked out well and you’re ready to start the training. I usually start off by sending the student a chart to review of a simple patient and ask questions about it for next session… Depending on their experience, it can be more than one chart like a kid/adult, male/female, or a complicated case, but don’t give too many chart reviews to not overwhelm yourself or the student. From there, I’ll do mock intakes or encounters, I don’t just immediately send anyone to a patient because even if they don’t say it, yes the student is scared or intimidated. I also don’t blindsight patients, make sure they’re stable, you have permission and they’re comfortable with having a student, it is their right to know and/or declined.

I treat every student the same, whether they’ve been in the healthcare field for a year or 80 years, I start with a chart review… and pace the training until the student is more comfortable to be on their own. Precepting can be a wonderful journey but it also requires a structured approach to ensure they gain both the knowledge and confidence. Here are some additional key tips to make the experience effective:

1. Establish Clear Expectations Early

• Discuss goals, scope, and level of independence at the start.
• Clarify documentation standards and workflow expectations.
• Define the balance between supervision and autonomy based on their experience level.

2. Encourage Critical Thinking

• Instead of giving answers right away, ask:
  • “What do you think is happening?”
  • “What are possible differential diagnoses?”
  • “What evidence supports this treatment plan?”
• Push them to justify their clinical decisions.

3. Gradually Increase Responsibilities

• Start with mock patients and shadowing → move to co-assessing patients → eventually let them lead visits with supervision.
• Encourage them to develop their own treatment plans before discussing.

4. Provide Constructive Feedback Regularly

• Offer specific feedback after sessions:
  • What went well?
  • Areas for improvement?
  • Strategies for growth?
• Use the “compliment-suggestion-compliment” method to keep it balanced.

5. Teach Practical Documentation Skills

• Help them master SOAP notes, risk assessments, and psychotropic medication rationales.
• Emphasize concise and clear charting that meets legal and billing requirements.

6. Role Model Professionalism & Patient Interaction

• Demonstrate therapeutic communication and boundary-setting with patients.
• Guide them in handling difficult conversations (e.g., suicidal ideation, medication refusal).

7. Integrate Evidence-Based Practice

• Encourage the use of clinical guidelines (APA, AACAP, SAMHSA).
• Discuss recent research or case studies to reinforce learning.

8. Expose Them to a Variety of Cases

• Ensure they see a diverse mix of disorders (e.g., mood disorders, psychosis, PTSD, personality disorders, substance use).
• If possible, provide multidisciplinary exposure (therapy teams, case managers).

9. Support Clinical Decision-Making with Medications

• Walk them through pharmacological and non-pharmacological treatment plans.
• Discuss medication side effects, monitoring, and patient education.

10. Foster Confidence & Independence

• Reinforce positive progress and encourage self-reflection.
• Let them know it’s okay to not have all the answers—the key is knowing how to find them.

What About the Money?

I don’t charge students because I believe it’s unethical. I know not everyone agrees, but if a provider is being paid, there’s an expectation that the student will pass—even if they shouldn’t—simply because money was exchanged. There are times when I felt like the student wasn’t good fit and didn’t precept even if they did wanted to pay…. For my practice or future reference, I probably would make some kind of contract with the school to pay or make it a tax write off (with the rates below for example). At the hospital, I was paid a dollar extra to precept.

To future students, I urge you to have a vetting process when choosing a school. Ask if they provide a preceptor or consider the costs of securing one yourself. If you have to find your own, it might be worth attending a school that offers that support. I’ve seen students fall behind by a year or two, and some never graduate because they can’t complete their clinical placements. However schools, should pay NP’s to precept because it’s their responsibly provide the student’s education:

How Much to Charge?

Common Rates for PMHNP Preceptors:

• $500 – $1,500 per semester (flat rate)
• $10 – $25 per clinical hour (hourly rate)
• $50 – $100 per week (if charging weekly)

Higher rates may apply if:
You work in a private practice or specialized setting (e.g., forensic psych, addiction).
The student requires more intensive supervision.
Schools do not offer any stipend and expect students to pay out-of-pocket.

Lower or no charge if:
The student’s school compensates preceptors directly.
You’re doing it for professional development or networking benefits.

How to Set Up Payment?

Student Pays Directly – If the university doesn’t provide preceptors, students often expect to pay.
University Pays You – Some schools offer a stipend or honorarium. Ask the student if their program provides compensation.
Written Agreement – If charging, ensure you outline the fees, payment schedule, and refund policy in writing.

Alternative Benefits (Instead of Charging)

If you prefer not to charge, you might negotiate:
Continuing Education (CEUs) from the school.
Letters of recommendation or faculty titles (e.g., Adjunct Clinical Instructor).
Networking opportunities with the university for future teaching/precepting roles.

Bottom Line

Charging is reasonable, especially given the time and effort required.
Rates vary, but $500–$1,500 per semester is typical.
Always clarify payment expectations upfront (with the student or their school).

In Conclusion 

When I precepted people, I generally had an understanding what to do, information about the person, or had the support of my facility. However, this post is related to people who got their own practice or encountering people/strangers, which will cause more risks and liabilities. Therefore, I’m glad I didn’t blindly go into the situation like I was working in a hospital or had some legal protections. What’s funny is how some of my patients are in the medical field, so I’m still somewhat precepting for free lol but to wrap this post up, I wanted to mentioned some more key points:

Here’s a Great Tip or Mindset

Treat this like a future employee! Ask for their resume, CV, and a time to interview them. This is also good for professors to practice with their students. This person may very well be able to work with you or in YOUR practice… Plus we need to keep the standards high. Do not blindly accept anyone. Good luck everyone!

Key interviewing questions to help you determine if a student is a good fit for preceptorship. These will assess clinical knowledge, professionalism, critical thinking, and adaptability. Here’s 15 questions and a score card below (I don’t use one, but this is just for educational purposes):

Clinical Knowledge & Experience

1⃣ “Tell me about your experience working in mental health.”
Good Answer: Prior experience in psych as an RN, crisis worker, case manager, therapist, etc.
Red Flag: No psych background, unrealistic expectations.

2⃣ “What are the most common psychiatric conditions you expect to treat, and how would you approach them?”
Good Answer: Can name major disorders (MDD, GAD, Bipolar, Schizophrenia, PTSD, etc.) and describe basic assessment & treatment.
Red Flag: No real understanding of psych conditions.

3⃣ “What are your thoughts on using medications vs. therapy for mental health treatment?”
Good Answer: A balanced view that considers both options based on patient needs.
Red Flag: Either over-reliance on meds or anti-medication stance.

Critical Thinking & Clinical Judgment

4⃣ “A patient tells you they are suicidal. What are your next steps?”
Good Answer: Immediate risk assessment, safety planning, hospital referral if needed, collaborative care.
Red Flag: No clear safety plan, lack of urgency.

5⃣ “How do you differentiate between Bipolar Disorder and Borderline Personality Disorder?”
Good Answer: Discusses mood cycling vs. emotional instability, duration of symptoms, and treatment differences.
Red Flag: No real distinction, overly simplified answer.

6⃣ “What would you do if you suspect a patient is drug-seeking?”
Good Answer: Screening tools, reviewing PDMP (if applicable), alternative treatments, team consultation.
Red Flag: Quick to dismiss the patient without a thorough assessment.

Communication & Patient Interaction

7⃣ “How would you handle a patient who is non-compliant with medication?”
Good Answer: Motivational interviewing, patient education, addressing concerns rather than forcing compliance.
Red Flag: Dismisses the patient’s concerns or gives up easily.

8⃣ “A patient becomes agitated and verbally aggressive toward you. How do you respond?”
Good Answer: De-escalation techniques, calm tone, ensuring safety, involving support staff if needed.
Red Flag: Reacts emotionally, lacks a clear de-escalation plan.

9⃣ “Tell me about a time you had to deliver difficult news to a patient.”
Good Answer: Example of empathy, clear communication, and professionalism.
Red Flag: Avoids tough conversations or lacks patient-centered thinking.

Learning Style & Adaptability

“What are your biggest strengths and weaknesses as a student?”
Good Answer: Honest self-reflection, shows willingness to improve weaknesses.
Red Flag: No weaknesses or defensiveness.

1⃣1⃣ “How do you handle constructive feedback?”
Good Answer: Open to learning, values mentorship, applies feedback in practice.
Red Flag: Defensive or argumentative.

1⃣2⃣ “How do you manage stress and avoid burnout in a high-stress field like psych?”
Good Answer: Self-care strategies, good boundaries, debriefing with colleagues.
Red Flag: No clear plan, history of quitting under pressure.

Logistics & Fit

1⃣3⃣ “What are your availability and scheduling needs?”
Good Answer: Clearly communicates availability, aligns with preceptor’s hours.
Red Flag: Unreasonable scheduling demands.

1⃣4⃣ “What are your top learning goals for this clinical rotation?”
Good Answer: Has specific goals (e.g., improve diagnostic skills, gain confidence in med management, etc.).
Red Flag: No clear goals, expects too much hand-holding.

1⃣5⃣ “Is there anything you expect from me as a preceptor?”
Good Answer: Looks for guidance, structured learning, feedback.
Red Flag: Unrealistic expectations (e.g., expecting constant supervision).

Decision-Making Guide:

Green Flags (Great Fit!)

• Has prior psych experience or at least a strong understanding of psych concepts.
• Can think critically and safely assess/treat patients.
• Professional, open to feedback, and eager to learn.
• Flexible and respects boundaries & workflow.

Red Flags (Not a Good Fit!)

• No clinical reasoning, expects to “wing it.”
• Poor understanding of psychiatric meds & diagnoses.
• Defensive, resistant to feedback, lacks professionalism.
• Unrealistic scheduling needs or excessive paperwork from their school.

Here’s a Interview Scoring Rubric to help you objectively evaluate candidates. You can rate each category on a 1-5 scale (1 = Poor, 5 = Excellent), then total the score to determine the best fit.

A Student Interview Scoring Rubric

(Score each category from 1-5, with 5 being the best. Total score at the bottom.)

Total Score: ____ / 75

Scoring Guide

60-75: Excellent fit! Highly motivated, competent, and professional.
45-59: Decent fit, but may need extra guidance. Evaluate if you have time to mentor them.
Below 45: Probably not a good fit. Consider passing.