The Death of a Dream: Closing an NP Practice

Owning your own practice may be a nurse practitioner’s dream—but what happens when the dream ends? Deborah S. Flournoy, an Associate Professor of Nursing in the College of Nursing & Health Sciences at Texas A&M University in Corpus Christi, shares her story of closing a practice and offers some practical wisdom from experience.

For many nurse practitioners, having your own practice is the culmination of many years of planning and anticipation. I worked as an NP for 14 years in practices operated by others—hospitals and physicians—before I opened my own practice. During those years, I had observed which ways of doing things appeared productive and healing to me and which did not.

When the time came, having seen a need for more affordable health care that was not predicated on the assumption that every patient had health insurance, I opened a cash-only practice in the town where I resided. By eliminating the need for personnel and apparatus dedicated to insurance filing, I was able to charge about half of what other practices in the same location did for identical services. My chief goal was to be of service to the community, not to make the most money possible. I anticipated that volume would make up for the lower prices in the long run.

For about four years, our revenue grew slowly. I decided to risk all and stop teaching part-time in order to focus exclusively on my practice. This proved to be a good decision—for about one year. Then the recession hit my part of the country. Suddenly, the operation of a “cash-only” practice became an oxymoron, as many of the patients with already limited funds lost their jobs. These patients started to seek “free” care at area emergency departments, and the practice income plummeted. My revenue fell by one-half the first year and then one-half of that the next year.

In what would turn out to be my final year of practice ownership, I decided to accept a full-time position as faculty of a distance FNP program. I was practicing “on the side,” although in reality I was in my office full-time and teaching from there. I was already recognizing the difficulties of juggling my roles and responsibilities when a student in one of my classes asked what it would take for me to decide to close my practice, since I was (by this point) making no money from it.

As I pondered that question (my initial response was a quite honest “I don’t know”), I stepped onto the road toward closing my practice. From a business perspective, there was little point in keeping the practice open. However, from an emotional point of view, I had invested so much in building my dream—and, by extension, so had my family—that closing the practice seemed unthinkable.

THE DECISION

Opening a practice is a time of joy, pride, and a sense of accomplishment; closing that same practice induces a period of reflection, sadness, and even anger that circumstances did not allow continued operation. While financial considerations play a significant role in the decision to close a practice, they may not be the only, or the deciding, factor.

The decision to close a practice may take months or even years before the actual process is started. I lived with my conundrum for about a year before I made the decision to close. I was exhausted—and while I was relieved to have the burden of deciding off my shoulders, it was now time to do the work of closing a practice.

NOTIFYING YOUR STAKEHOLDERS

Once the decision to close a practice is reached, the provider/owner ceases to exist in a vacuum. There are stakeholders who need to be notified—some obvious, some less so.

I started by breaking the news to my family, the people who had supported me in opening my practice (and even helped me find and refurbish furniture for my waiting room!). Although they had been aware of my internal debate, they had not lived with the decision process as I had. Having resolved at least some of my own emotions, I now had to watch others experience many of those same feelings.

Next, I had to tell my employees of the decision. Through attrition, my staff had already shrunk to two: a receptionist and a part-time licensed vocational nurse (LVN). Like my family, they had to process their own emotions about the closure. I had anticipated that the people who worked for me, concerned about their future, might choose to accept another job before we officially closed. My LVN—who had observed the practice dwindling in the preceding two years—seemed prepared for my decision. She stuck it out with me until the end and was a huge help with the influx of patients requesting records. (My MD—required by Texas law to delegate prescriptive authority to me—had already relocated his practice and was ill, so he was content with my decision.)

Of course, the biggest stakeholders in a practice are the patients. Notifying them of the impending closure is the most important action you will take (aside from making the decision to close). Although you can place notices in the local media (newspapers, TV, radio) to announce the closure of your practice to the community, you should send a notification letter directly to your patients. It should be sent at least 60 to 90 days before the closure date—and certainly not less than 30 days in any case—giving patients adequate time to find new providers and arrange for their records to be transferred.1,2 The letter should include

  • A statement of gratitude for the patient’s business
  • The dates of the transition period
  • What is expected of the patient (eg, does he/she need to come and pick up his/her records?)
  • An explanation for the closure3

I composed a letter to be sent to all patients who had been seen within the past 18 months. In it, I thanked them for being a part of the practice and gave them 60 days’ notice of the intent to close. For many patients, this was an emotional time; many understandably worried how their health care needs would be met in the future. Some responded with sadness that I had not been able to make the practice a success.

AVOIDING “ABANDONMENT”

Ideally, a provider who wants to get out of the business should seek to sell the practice—but this is not always feasible.3,4 When closure is the best (or only) option, it is important to avoid even the appearance of abandonment.

Besides giving adequate notice of practice closure, providers must have a plan for the dispersal of patients.1 Be prepared to give recommendations for new providers. Depending on the practice location (rural or urban), options may vary.

I made a concerted effort to refer patients to new providers, with the caveat that if the patient did not feel a particular provider was a good match, he/she should seek another provider of his/her choosing. Unlike in a purchased practice, where patients “go with” the practice, patients from a closed practice may be referred to one, several, or even many other providers.5

Provisions must be made to store patient records so that they are retrievable for a specified period of time. The requirements vary by state, so consultation of the state board’s rules and regulations—and/or an attorney—is in order.3 In general, the proscribed time period is seven to 10 years for adults and seven to 10 years after the patient turns 18 for pediatric patients.2 In some states, the retention time may be as short as three years for adults.1

OTHER PRACTICAL CONSIDERATIONS

While people will be your priority as you work through the process of closing, you will have “stuff” to deal with. What will you do with the furnishings and equipment? Obviously, anything that was borrowed can be returned. Beyond that, your options are to sell (to another provider or even a patient), donate, or repurpose items.

The orthopedic exam table from my practice went to a private school for their athletic training facility. Screens went to my neighbor, a chiropractor. My preschool-aged grandsons were thrilled to be given the children’s art supplies and books that had once graced my waiting area. One of my patients bought some decorative vases and a bookcase. The painting that had been carefully chosen to pull together my waiting room now hangs in my library at home.

As the closure date approaches, the practice environment may begin to look bare as furnishings are sold or moved. One item you will want to buy, however, is a fresh ink cartridge for your copier/printer. As patients request documents, you’ll use it!

RESPONSE AND AFTERMATH

The practice may be very busy immediately following the receipt of notification letters—but don’t be fooled into thinking you have made the wrong decision. The first month after the letters went out advising of the closure, my practice was busier than it had ever been! This tapered off in the second month, though.

Most patients, once they’ve heard the news, will want prescription refills and/or their records. Some may just want to know what happened to result in the closure. Remember that to the patient, this seems like a sudden decision—no matter how long you have deliberated about it.

What surprised me most, however, was that new patients continued to present to the practice, seeking care for acute issues. While I did provide this, I made them aware from the beginning that the practice was in the process of closing and that I could not assume the responsibility of being their primary provider. I made sure to provide these patients with recommendations for other providers.

Slowly the rush will settle down, as patients start to move on to other providers. A few may drop in to see you socially. On the day I closed my practice, several patients came in just to say goodbye and wish me well.

The last things I did in my practice were turn off the lights and leave a sign on the door stating that the practice was now closed.

RECOVERY

The time needed to recover from the closure of a practice will differ. Factors include how long the practice was open and how the clinician normally deals with a setback.6 For some, relief that the pressures of ownership are over may be the predominant emotion. Having a steady, stable salary in a new position goes a long way toward making the transition easier! Although if possible, take some time between closing the practice and starting a new job.

Do not be surprised if negative emotions manifest at odd times, as feelings of sadness, regret, and even a sense of failure are worked through. Life does go on—and nurse practitioners are resilient. Find a way to use the knowledge gained from your practice in your new endeavors, whatever they may be.