Forging better ties with physicians
Education, clear communication are the cure
Wary of violating Medicare regulations and unaware of the role of private duty services, physicians may not use home care as effectively as possible for the benefit of their patients. Private duty providers can educate and forge better relationships with physicians that will ultimately benefit patients by taking a few simple measures.
Education is the first step. "Doctors have very little awareness of home care beyond catastrophic needs. There are huge areas where primary care practitioners are missing the boat," says Lawrence Bernstein, MD, chief medical officer of Longmeadow, MA-based Jewish Geriatric Services.
Physicians often overlook early warning signs of problems and don’t make a connection with how home care can help improve the situation, according to Bernstein.
"Most primary care physicians recognize only 25% to 40% of modest disfunctionalities such as gait dysfunctions, urinary incontinence and sensory deficits. For example, they may not recognize that an otherwise relatively independent patient who needs to be hoisted on to the exam table is at risk for falling in the shower and needs PT and OT," he explains.
"Or, even if she does associate a patient’s yellow undergarments with urinary incontinence, the physician may not see either the patient’s perception of the problem or the role for home care. The patient may be fearful that her family will place her in a nursing home, or she may be leery of going out for fear of urinating in public. A thorough home assessment may indicate the person needs a bedside commode or rearrangement of furniture to make it to the bathroom quicker," Bernstein adds.
After the fall
Falls are another condition that physicians fail to associate with home care, according to Bernstein. After determining the patient didn’t break any bones or suffer any disorientation, they often view a fall as just something that happened and may send the patient home with no further follow-up. Yet, "those over sixty five who experience one fall are at great risk for subsequent morbidity," Bernstein explains. And what appears as a minor fall to the physician, "may be devastating to the patient. They stay home and are less confident," he notes.
Other physicians may have Medicare homebound status and skilled need requirements so deeply ingrained in their vision of home care that they either don’t realize when a patient can benefit from private duty or they don’t offer it. However, "if patients don’t qualify for Medicare, the family will usually pay for it if they understand the need," Bernstein asserts.
Physicians may also be unaware of community resources available for patients without resources. For example, local councils on aging provide shopping and food bank services for the elderly.
Home care providers readily see how their services benefit patients. Conveying that benefit to busy physicians who may not even recognize the underlying problem, much less the home care link, is a challenge that can be overcome, according to Bernstein. Here are some suggestions:
• Use case studies.
Use case studies to present problems from a patient’s perspective and show how home care helped the situation, he suggests. For example, rather than a didactic discussion on falls, detail a real-life patient fall experience. Explain the patient’s status and feelings both before and after the fall. Describe the interventions used to make the patient more secure and less prone to future incidents.
• Be brief.
Already inundated with paperwork, physicians won’t read voluminous and highly detailed communiqués. Keep written information brief. "It doesn’t take a lot of time. You can do it in a few minutes," Bernstein says.
• Be clear.
Written communiqués should also be succinct and to the point. "Most communication [from home care providers] is useless. It’s not in a form that’s useful; it’s full of home care jargon and abbreviations and it’s far, far, far too detailed. You should state what the patient has, what you intend to do and how long it will take you. For example, The patient has had a stroke on the left side and is receiving rehab. Our goal is to have her bathe and dress independently and it’s going to take us two months to get there,’ not She’s 13% stronger on the left side and 10% weaker on the left,’" Bernstein explains.
• Consider using new forms.
Even for private pay patients, home care providers tend to use a Medicare Certificate of Medical Necessity (485) type format for clinical updates, according to Bernstein. But "they’re designed for Medicare, not for me," he says. Consider a different clinical update form, he suggests. "It can be 30 words or less. Just say, The patient’s had a CVA of the left hemisphere and she now dresses and bathes independently. Our concerns are that she frequently urinates and is dizzy when she stands up. I’ve asked her to follow up with you on these issues.’"
Spectrum Home Health Care, also located in Longmeadow, uses a one-page clinical update form for certain patients, according to Linda Donoghue, RN, MPA, CNA, CHCE, executive director. It participates in a congestive heart failure (CHF) disease management program, and sends weekly updates to physicians. The document is titled "CHF Protocol Update," and in bullet points provides the patient’s vital signs, weight, and any exacerbations of his or her disease.
• Provide resource information.
Spectrum Home Health Care not only sends all first time-referring physicians information about its services, but also those of its affiliated system, including adult day care and case management. Spectrum also sends a copy of the American Medical Association brochure "Medical Management of the Home Care Patient: Guidelines for Physicians."
Community resource information is also helpful, according to Bernstein. "It’s a teaching thing so that the physician gets a sense of what’s going on."
• Create a profile for each medical practice.
When establishing a relationship with a physician or a group practice, ask the office how, when, and what you should communicate. Every practice has a protocol about when faxes are appropriate over phone calls, for example, or when each physician is available for phone consultation, Bernstein explains.
• Establish internal communication protocols.
"One of the things that drives me crazy is when a doctor calls in and no one knows who asked to speak to him," Donoghue says.
To avoid frustrating the physician and creating a negative impression of your company, develop a protocol to respond to physician calls. Require field staff to notify their clinical managers when they’ve left a message for a return phone call, in the event that the physician calls the office rather than the staff member’s beeper or message number. Ask anyone who is expecting a return phone call from a doctor to notify the receptionist so that she can help locate the person when the call comes in, Donoghue suggests.
• Find the "it" person.
"Make sure you know who in the doctor’s office directs him and have good communications with them. Every doctor has one of those persons and when you find them, 99% of your problems are gone," advises Bonnie Whorton, MS, executive director of Home Care of Mid-Missouri in Moberly.
• Send introductions and thank-yous.
Spectrum Home Health Care sends letters of introduction to first-time referring physicians. "Thank you for the privilege of caring for [patient’s name]," it begins. The letter then identifies the primary nurse, therapist, and/or paraprofessional involved with the case. It also invites physicians to review Spectrum’s policies and procedures.
Facts about your service are helpful, but don’t overdo marketing pieces, Bernstein recommends. "Don’t provide a lot of flowery information. Just state it as succinctly as possible."
Good communication, especially when developing a new relationship, is critical. "For the first one or two patients, communicate like crazy. But don’t call the doctor just to say the patient’s OK. Provide meaningful information," Bernstein advises.
• Consider yourself a consultant.
"Think of yourself as a consultant who is teaching me about my patient," Bernstein suggests.
Editor’s note: Copies of the American Medical Association (AMA) booklet "Medical Management of the Home Care Patient: Guidelines for Physicians" are $4 each; $75 for 25. They are available from the AMA at (312) 464-5000.
• Lawrence Bernstein, MD, Chief Medical Officer, Jewish Geriatric Services, 770 Converse St., Longmeadow, MA 01106-1786. Telephone: (413) 567-6213.
• Linda Donoghue, RN, MPA, CNA, CHCE, Executive Director, Spectrum Home Health Care, 136 Dwight Road, Longmeadow, MA 01106. Telephone: (413) 567-4600.
• Bonnie Whorton, MS, Executive Director, Home Care of Mid-Missouri, 102 W. Reed, Moberly, MO 65270. Telephone: (660) 263-1517.