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July/August 2011

 
Practice Perfect: Compliance & Risk Management
Four Risky Scenarios—From No-Show Patients to Next-Door Neighbors
By Leslie Burling-Phillips, Contributing Writer
Interviewing Hans Bruhn, MHS, and Elise Levine, MA, CRC, OCS
 
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Each patient encounter—or, in the case of a no-show, a nonencounter—is accompanied by its own set of clinical and legal challenges. In this issue, EyeNet considers four scenarios: 1) the patient who is noncompliant and/or doesn’t show up to appointments; 2) the patient who is a visually impaired driver; 3) the patient who has difficulty understanding you; and 4) the over-the-fence chat with a neighbor that results in a patient-physician relationship.

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Noncompliance and No-Shows

There are as many reasons for noncompliance as there are patients, but “getting to the source of the noncompliance and finding solutions to break down the barriers to care is necessary for successful patient care,” said Elise Levine, MA, CRC, OCS, practice administrator and director of clinical research at North Valley Eye Medical Group in Mission Hills, Calif.

Understand and address the reasons for noncompliance. “Our economy has had a significant impact on patients. They have lost their jobs, and many homes are in foreclosure. As a result, some patients may not be able to afford their medications or follow-up care,” said Ms. Levine. “Or, perhaps the noncompliance stems from Parkinson disease, and the patient’s hands are simply not steady enough to administer the drops.” If you can determine the reason for noncompliance, you may be able to assist these patients— for instance, by offering a payment plan or referring to community services (see “How to Help Patients Who Can’t Pay” in “Further Resources”)—but some patients simply refuse to follow your recommendations or repeatedly miss appointments.

“Beware of noncompliant patients who complain that they are not receiving the proper care,” said Hans Bruhn, MHS, senior risk management specialist at the Ophthalmic Mutual Insurance Company (OMIC). “For example, those who repeatedly fail to keep appointments without rescheduling yet maintain that they are experiencing ongoing symptoms. Similarly, patients who do not take their medication as directed, but complain that their symptoms have not improved, can also pose a liability problem.”

Have a policy for no-shows. Establish a policy for patients who fail to show up for their appointments, and adhere to it consistently. When a patient misses an appointment, someone on your staff should follow up to reschedule—particularly if the patient has ongoing clinical issues that need to be closely monitored. OMIC recommends that the treating physician look at a patient’s chart when an appointment is missed. “Ideally, a no-show list should be generated and reviewed each day to determine how pressing it is for the patient to be examined,” said Mr. Bruhn. “Send follow-up postcards or contact patients by phone to reschedule and establish a time frame in which the patient should respond. If a patient does not reply within the allocated period, the next series of communications should begin—this time with a formal letter. It is important that the patient is made aware that missed appointments do not allow the practice to provide the level of care that is needed.”

Have a policy for noncompliance. If the patient is turning up for appointments, but is not complying with your treatment recommendations, OMIC recommends the following steps:

  • Identify the noncompliance.
     
  • Try to determine the underlying reason for the patient’s noncompliance, and provide treatment recommendations.
     
  • Educate the patient about the disease process, treatment recommendations and consequences of noncompliance.
     
  • Decide whether or not to continue care if the patient refuses to comply.
     
  • Document your findings, discussion and decision.

Once you have exhausted reasonable resources, it might be time to sever the patient-physician relationship.

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Further Resources

NONCOMPLIANCE AND NO-SHOWS

  • How to Help Patients Who Can’t Pay (EyeNet, July/August 2010)
  • No-Shows and Other Acts of Noncompliance (OMIC Digest, Winter 2003)

A QUESTION OF ROAD SAFETY

  • Find your nearest Area Agency on Aging program (Go to www.n4a.org
    and select “About n4a” and then “AAAs/Title VI”)
  • Vision Requirements for Driving (Go to www.aao.org/about and select “Policy Statements”)
  • Caught in the Middle: The Eye M.D., Visually Impaired Drivers and Road Safety (EyeNet, February 2010)

THE LANGUAGE BARRIER


For EyeNet articles, go to www.eyenetmagazine.org/archives. For OMIC Digest articles before 2003, go to www.omic.com and select “Resources,” “Risk Management” and “OMIC Publications Archive.” For OMIC Digest articles from 2003 onward, go to www.omic.com and select “News” and “OMIC Digest.”

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A Question of Road Safety

Many people are reluctant to give up their car keys, despite the pleas of their friends and family. The risk for you, as a physician, is that you can become the target of a malpractice complaint for failure to advise a patient about his or her ability to drive. Depending on the state, a physician may be mandated to report patients who are unable to safely operate a motor vehicle. “Check with your state’s ophthalmological or medical society or your attorney to find out your state’s rules and regulations,” said Mr. Bruhn. “Physicians can protect themselves by documenting in the patient’s record that their concerns were discussed. Patients should also be referred to the local DMV for a vision assessment that will determine if their vision is within the parameters to have an active license.”

Ms. Levine also suggested that you “refer these patients to your local Area Agency on Aging (www.n4a.org), which can provide assistance such as finding transportation services in your community. It is a simple gesture, but a practical solution, for patients who are losing their independence. For seniors who may be facing multiple issues, it’s a great place to start to find resources in the community.”

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The Language Barrier

Whether you’re giving instructions to a patient who speaks Farsi or taking a medical history from a deaf patient, you must be wary of any potential barriers to comprehension.

Take advantages of foreign-language services. Under Title VI of the Civil Rights Act, a physician who participates in Medicare or Medicaid should make a reasonable effort to accommodate patients who have limited English proficiency by providing an interpreter at no cost to the patients. “We always advocate using a professional translating service if you suspect that there is a language problem, but the reality is that it is an expensive endeavor and is time-consuming to coordinate,” said Mr. Bruhn. Some insurance plans provide interpreting services. As an alternative, check with local hospitals, which often offer free translation assistance, or consult with websites that provide online translation services. OMIC and the Academy both provide materials in Spanish.

Make sure nothing is lost in translation. “You have to be careful when someone is interpreting for a patient, particularly a family member who may not be well versed in medical terminology,” said Mr. Bruhn. “Although you have the benefit of another person in the room to help clarify the situation and communicate, you should ask the patient questions, acting through the interpreter, to confirm the information conveyed is correct.”

Don’t assume that a hearing-impaired patient is fluent in written English. “American sign language is not expressed in the same syntax as English,” said Ms. Levine. “Just as if you were to translate Spanish into English, the sentence structure changes. Merely writing down your instructions may not be effective, which can be critical if you are discussing surgical consent, postoperative instructions or medication directions.”

Make sure patients give their “informed” consent. “Without comprehension, it can be argued that consent was not really obtained—even with a patient’s signature on the form,” said Mr. Bruhn. “It is also important for the ophthalmologist to document comprehension concerns, such as the patient’s literacy, cognitive ability, language and medications that may affect the patient’s ability to give consent for a procedure.”

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Informal Requests for Advice

Requests for medical advice from friends, family, staff—and even strangers—are commonplace for physicians. Unfortunately, what may begin as a brief exchange could have serious implications if the “patient’s” symptoms worsen or complications arise. “Failing to treat family, friends and staff as you would a ‘regular’ patient is a frequent mistake made by physicians,” said Mr. Bruhn. “Any time you give advice, you should write it down, start a medical chart, follow up and observe the same confidentiality rules that you would for a patient who sees you in your office. And never give advice without documenting the encounter and suggesting that the individual come to your office to see you or make an appointment with his or her regular eye care provider.”

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Learn More in Orlando

On Sunday, Oct. 23, at the Academy’s Annual Meeting, two events focus on driving: a symposium—Safety Behind the Wheel: Should Miss Daisy Be Driving? (12:45 to 1:45 p.m., event code “Sym04”); and an instruction course—Vision, Aging and Driving (2 to 3 p.m., event code “215”).

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