Declaring Independence: Creating a Nurse-Run Practice
By Tanya Spoon, ARNP, DNP
In an issue focused on the value of nursing, the story of an independent nurse-run primary care practice is worth exploring and perhaps a roadmap to the future. Tanya Spoon, ARNP, DNP, founder and owner of The Manette Clinic, Bremerton, Wash., tells the story of how she established and grew her own practice. In her home state of Washington, practice laws allow her to operate the clinic without physician supervision.
I was lucky. I got a job before I graduated with a family nurse practitioner degree in 2006. I worked with an older doctor who wanted to include an NP as part of his practice. In the beginning, I had total freedom to see two or 10 people a day. It was a great way to learn how to practice primary care. Even though I had been an RN since 1996, I was reentering nursing as a novice. It was an amazing time. I felt like I had reached my goal of independence practice, and that people were really coming to see me, as the physician already had a full schedule. But health care was changing and I was becoming proficient in my practice. This meant I could see more and more patients each day. Within two years, I was treating up to 28 patients a day; my patients felt cared for even in an 8- to 10-minute appointment. I learned to quickly and confidently diagnose and treat. Everything was going well, right? Wrong. I was growing really tiered, and felt like I was on a treadmill all day. I would go in at 7:30 a.m. and leave at 7 p.m. My workouts had all but stopped, I was eating my lunch as I charted, surviving on coffee and sugar. I was doing well financially, but I knew I couldn’t keep this up. I wanted to continue to care about each patient as a unique individual and not just rush a patient through, but I felt like this is what I was doing just to keep up with pace. What started as an amazing opportunity was becoming a burden. By autumn 2014, it became clear that I had to change the way I was practicing primary care.
Finding a path
I started to research other options. The doctor who had originally hired me was nearing retirement, so my timing was important. A large hospital system was moving into our community, buying up practices and I knew I wouldn’t be a fit for the larger organization. I also knew that I wanted to remain authentic in the way I believed I should care for my patients. This is when I found Direct Primary Care (DPC), which is a care delivery and payment model. DPC is membership-based primary care, no insurance billing, just a monthly fee for unlimited primary care. I started calling different clinics that were involved in DPC. I actually found the cell phone number of a doctor in Wichita, Kan. and cold-called him. Josh Umbehr is a Kansas physician who started a clinic called Atlas MD. He answered his phone and was delighted to answer all of my questions. Another doctor in Seattle, Garrison Bliss, generously gave me two hours of phone time on a Saturday morning. I was amazed that they were as excited as I was about the prospect of my own clinic. After a series of phone calls and research, I decided this was the way I could continue as an NP. But I was wrestling with this: I would be the first DPC clinic in my community and I’m a NP. Would people come?
Challenges to overcome
I experienced some roadblocks on my journey. I started talking to people about this unique style of primary care. Most people smiled at first, then got a glazed look on their faces as I explained what I wanted to do. I would incorporate “personalized primary health care for families” as my tag line. Personalized to me would mean minimum 30-minute appointments and home visits if needed. My patients also would have my cell phone number and could call or text me at any time. I didn’t want multi-phones, and I needed a staff that was sold on this new idea. I wanted my patients to feel like they were stepping back in time, and I was excited about the possibilities of using an old fashioned way to provide care. It would mean, however, that I would keep a limited number on my patient roster and focus on taking really good care of them. This was frightening, but exactly the type of clinician I wanted to be.
The biggest roadblock was Medicare. Some of my neediest patients were Medicare beneficiaries and it was impossible to explain this idea of paying a membership fee for their primary care when they already had Medicare. Some of my patients were in memory care and I already provided home visits for them and wanted to continue. Most were on such a limited income that they would not be able to afford the membership fee. I had to make the decision to keep or give up my Medicare provider number. Many DPC providers give up their Medicare number because it simplifies things. In my community, very few places would take these patients and so I would be leaving a couple hundred Medicare patients without care. I had cared for them for eight years and the doctor I worked with had them for many years prior to that. Because of this, I decided to keep my Medicare number and those Medicare patients who wanted to stay with us at my new clinic. It made my idea of a simple membership practice a little more complicated – the clinic would have to accommodate two types of payment – but I felt like it was the right thing to do for my patient population. What I didn’t know is that the assisted living and memory care residential centers had no providers on staff; the residents are not allowed to leave the facilities, so it is difficult for them to get to care appointments. I am one of two providers in our community that make house calls and this allows me to treat these patients. What started as a roadblock is becoming a little niche for my clinic, and to top it off, these patients are getting great primary care.
During the weeks that led up to my decision, I was not only seeing 28 to 30 people a day, but also I was researching for hours about what this practice would look like, writing a business plan and telling people about the plans for my new practice. I also was trying to grasp that I wouldn’t have a paycheck for a number of months and what that meant for me and my family. In addition, I was trying to make the case to my friends and family that I wasn’t going to work myself into the ground, but would actually have a better work/life balance.
Roadblocks such as funding, location and finding a lawyer were all very nerve wracking to overcome. During the winter of 2014-2015, I was grappling with paying for my malpractice insurance, license renewal and office space – all of which used to be covered by my employer. To help finance the venture, I took on a part-time teaching job and refinanced my house. It was a very busy time.
Opening the practice
We opened in September 2015, with just over 100 patients. The staff was lean – just me and a receptionist. The office manager would start a couple months later. The construction on the space we were renting wasn’t even complete, but each day the interior started looking more like a medical office and less like a strip mall location. the local paper published a story on the clinic the week before I opened. People started calling. After four months of seeing patients we were in the black and I actually saw a small pay check. At our one-year mark, we were at 500 patients, and at the 18-month mark we are close to 800. I’ve brought in a couple of amazing NPs to help me part time and the physician I worked with before comes in 10 hours a week in his retirement.
Things are moving forward and in March 2017, we added a full-time physician who hopes to become a partner. This is definitely the next chapter and will be important for the clinic’s success.
This experience taught me that the only real roadblock was my own lack of confidence and creativity, but I overcame that hurdle. I have accomplished something truly amazing and now can give my patients – and myself – amazing care, spending time caring for and teaching patients in a unique way. And that’s a practice I can be proud of.
Tanya Spoon, ARNP, DNP is founder and owner of The Manette Clinic in Bremerton, Wash. For more information about the practice, visit the clinic’s website at www.themanetteclinic.com.