The Doctor’s Advocate | Third Quarter 2021
An Ounce of Prevention

Patient Relations: Anticipate and Address Challenging Situations

Richard Cahill, JD, Vice President and Associate General Counsel, The Doctors Company

Our dedicated patient safety risk managers deliver a wide range of expert services and resources to you—our member—including personal telephone consultations to help guide you through challenging situations. A recent review of our call data shows that “patient relations” and “patient termination” consistently appear as the top reasons that members request assistance. The following strategies can help prevent challenging patient situations and provide guidance if a situation occurs.

Conditions of Treatment

Develop a Conditions of Treatment agreement for each patient to review and sign at the outset of the professional association. This agreement enhances patient understanding of the requirements for initiating and continuing care with the provider.

In the agreement, identify expectations regarding patient adherence with care plans, medication regimens, specialty referrals, follow-up appointments, and financial obligations. Outline the level of behavior required toward staff, other patients, vendors, and visitors to the office; emphasize the group’s zero-tolerance policy toward unacceptable conduct (such as violence, disparaging language, and sexual harassment); and note that failure to comply with the agreement may result in termination of the relationship. Post the Conditions of Treatment on your practice website.

Patient Conduct

Nonadherent and noncompliant patient conduct (whether intentional or unintentional) has been shown to negatively affect clinical outcomes. These behaviors include failing to participate in the recommended treatment plan, canceling follow-up appointments, discontinuing therapy or medications prematurely, refusing to seek specialty referrals or obtain laboratory tests as ordered, and ignoring established office policies regarding payment and practice operations.

Uncover and Address Barriers

A patient’s failure to engage in the planned treatment process may be related to health literacy, mental competency, language or cultural barriers, or financial restraints. Effective communication can help you discover the cause of the behavior and assess the patient’s comprehension of the treatment plan. Consider the following strategies:

  • Maintain an ongoing dialogue with the patient to identify potential adherence barriers. Ask about any issues preventing the patient from following your recommendations, and work to address concerns.
  • Use language services for your limited-English-proficiency patients.
  • Determine the extent of the patient’s comprehension. Ask the patient to repeat back what was said during the informed consent process, the treatment plan discussion, or any educational session with you or your staff.
  • Establish written financial policies, and consider using payment plans to assist patients in meeting their financial responsibilities.
  • Refer patients to appropriate community resources, such as those providing transportation, in-home care, meals, or smoking cessation.

Promote Patient Engagement

Meaningful exchanges of information with patients who understand and agree to a recommended plan result in better adherence and, ultimately, in more favorable outcomes.

List the patient’s responsibilities as part of a written plan, and provide a copy to the patient. Encourage involvement by using interactive tools, such as online educational materials and checklists.

Ask patients to respond to reminder calls and notifications regarding appointments, referrals, diagnostic tests, or medication refills.

Document Behavior

Document specific nonadherent or noncompliant behavior, such as canceled or no-show appointments and failure to follow instructions. A well-documented record that reflects the patient’s responses demonstrates the provider’s attempts to develop a plan of care.

Document patient refusal. If, at some point, the provider-patient relationship is discontinued, documentation about patient refusal supports the provider’s efforts. (See our article “Informed Refusal.”)

Manage Continued Behavior

Discuss and document the patient’s understanding of the consequences of the continued behavior. If you are not able to have this discussion with the patient in person, explain the consequences in a letter. Describe the actions the patient needs to take, such as calling the office for an appointment or obtaining a diagnostic study.

Ending Patient Relationships

If it becomes necessary to end a patient relationship that is no longer therapeutic or appropriate based on patient behaviors, it is critical that the provider end the relationship in a manner that will not lead to claims of discrimination or abandonment.

Although this list is not exhaustive, it is generally appropriate to end a relationship under the following circumstances:

  • Treatment nonadherence.
  • Follow-up noncompliance.
  • Office policy nonadherence.
  • Verbal abuse.
  • Display of firearms or weapons.
  • Nonpayment.

Special Circumstances

Several situations may require additional steps or a delay in ending the patient relationship if:

  • The patient is in an acute phase of treatment.
  • The provider is the only source of medical or dental care within a reasonable driving distance.
  • The provider is the only source of specialized medical or dental care.
  • The patient is a member of a prepaid health plan.
  • The patient is pregnant. During the first trimester: End the relationship only if it is an uncomplicated pregnancy and the patient has time to find another practitioner. During the second trimester: only for uncomplicated pregnancies and only if the patient transfers to another practitioner prior to cessation of services. During the third trimester: only under extreme circumstances, such as illness of the physician. Effect a safe transition by working with the risk manager of the facility where delivery is scheduled.

Certain situations prohibit patient dismissal, including patients with:

  • Limited English proficiency or status within a protected category under federal or state legislation.
  • A disability—which cannot be the reason for termination unless the patient requires care or treatment that is outside the provider’s expertise.

Medical or dental groups may consider dismissing a patient from the entire practice. This avoids an on-call situation that might require the practitioner who ended the relationship to treat the patient.

Written Notice

If you need to dismiss a patient, formalize the termination by providing written notice you are withdrawing care and requiring the patient to find another practitioner. Mail the written notice to the patient by both first-class and certified mail with a return receipt requested. Include the following information in the notice:

Reason: Although stating a specific reason for termination is not required, it is acceptable to use the catchall phrase “inability to achieve or maintain rapport” or to assert that “the trust necessary to support the relationship no longer exists.”

Effective date: Provide the patient with a reasonable amount of time to establish a relationship with another practitioner. Although 30 days from the date of the letter is usually considered adequate, follow your state regulations. The relationship may be ended immediately if the patient or a family member has exhibited threatening behavior toward the provider or staff.

Interim care provisions: Offer interim emergency care. For emergency situations that cannot be handled in the office, refer the patient to an emergency department, or instruct the patient to call 911.

Continued care provisions: Offer referral suggestions for continued care through medical or dental societies, nearby hospital referral services, community resources, or the patient’s health plan network.

Patient records: Offer to provide a copy of the office record to the new practitioner by enclosing a HIPAA-compliant authorization to be returned to the office.

Transition of care: Indicate your willingness to speak with the patient’s new provider to help ensure a smooth transition.

Patient responsibility: Specify that the patient is personally responsible for all follow-up and continued care.

Medication refills: Explain that medications will be provided only up to the effective date that the relationship ends.

For more information, see our article “Terminating Patient Relationships” or contact your patient safety risk manager by email or phone.

New Complimentary CME

The information shared in this article can help healthcare clinicians address disruptive provider-patient relationships. Answer the five questions in our new on-demand activity, Patient Relations: Spotlight on Challenging Situations, to earn complimentary CME credit.

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.