Have you ever wondered why your PT buddy down the road can get referrals from the orthopedic surgeon and you can't? Aside from the conspiracy theories about big medicine trying to keep us down, can you think of any other reason? I've got a hunch it has something to do with the fact that your PT buddy accepts the patient, creates a standard plan of care that's understandable to the world of medicine, and then releases the patient when that plan reaches its natural conclusion. That sounds like a pretty easy way to secure your practice's future, and all it takes is planning and documenting your care in a way that's understandable outside of chiropractic. It does not mean giving up the philosophy and practice of wellness care, as that falls outside a targeted diagnostic-based treatment plan.
We know, after our discussion last month [www.chiroweb.com/archives/25/07/18.html], that this proposal isn't so easy for many chiropractic practices, since we really don't even know where to begin when creating a plan of care. I outlined my opinion of why we're in this predicament, but didn't have the space to detail how clinicians may overcome it. This is where I get to make good on my promise and follow up last month's bad news with the good news.
The good news is that you can achieve better, more efficient patient management. All it takes is learning the ingredients to create a proper plan of care and applying that method to every one of your patient interactions. While that sounds like a big task, it doesn't have to be under the new model of the digital clinic. It's a proposition that will save you money and could boost your bottom line, and I'm going to show you what it could look like.
Bad News Redux
Our current performance with patient plan of care could be summed up in one word: deficient. This deficiency is based on a mistaken definition that's found throughout the profession. I began defining a plan of care last month by stating what it isn't. It isn't listing how many weeks you'll see your patient before re-examination, and it isn't recording how many times they will visit. It includes those components, but isn't defined by them.
I defined a proper plan of care as one in which you predict patient outcomes or have a methodology to measure those outcomes, and justify your involvement with the patient over the course of your plan. It has a time frame and lists visits, but it also has why, what, by whom and for how long written all over it. Most importantly, it's modifiable in case of changes in patient presentation and the arrival of expected or unexpected outcomes. For example, are there complicating factors that may delay recovery? What body region complaint or which diagnosis is a specific treatment designed to help? Are there specific goals associated with the treatment, and how will you judge the success of the treatment?
I also quoted a bit from the Department of Health and Human Services' report from the Office of Inspector General (OIG) on chiropractic and Medicare. I shared the alarming statistic found by the OIG that only 28 percent of chiropractic services were provided with a written plan of care, and only a nominal number of that percentage was actually done with any accuracy. In other words, we aren't meeting legal requirements, and the government, which is paying us millions of dollars to meet those requirements, knows about it. This means Congress and third-party payers also know about it.
What the PT Does Right
So, back to your PT buddy. It's no secret that in certain states, PTs and DCs are looking at each other askew, due to some turf wars. Forget about that for a moment. There's also a kind of inside joke among chiropractors that PT modalities aren't as effective as chiropractic care, but forget about that one, too. Forget everything you know about physical therapy, but add this one small gem: Whether the modalities work or not, and whether the patient improves or not, PTs still receive referrals from health care professionals in their community because they have a plan of care that is communicated in a way the referral source understands. This results in more referrals.
Doing It in Your Practice
Theorizing a definition of a plan of care and applying that model in practice is where most of us are left scratching our heads. That's why, in spite of the fact that we think we're superior, your average PT is going to reap more referrals from the medical community than your average DC. Let's see if we can't assemble a theoretical plan of care and walk through each of the components.
First, let's look at the condition, or the what: For the sake of discussion, let's call it sciatica. From first visit on, once that patient consents to care, you already have an idea in your head of how long it's going to take to get that patient well. Even if your philosophy doesn't emphasize diagnosis and the pathophysiology of disease, you still have a functional goal in mind and a time frame. A written plan of care begins here by simply writing down that goal and the estimated time it will take to reach it.
Next, the how: How are you going to get to the goal and see if you can match your prediction? What's your chiropractic protocol for sciatica? Will you use Activator adjusting, Gonstead side-posture, or another low-force technique? Which option offers the best outcome? What could be contraindicated? Include these choices in the plan of care. What about other considerations, such as relief via therapy modalities - nutrition, massage therapy or therapuetic exercises? Put these in the plan as well. Will the patient need to make lifestyle changes? Is so, these recommendations go in the plan as well. What about objective findings to mark progress, such as thermographic imaging to document sciatic involvement and measure changes in patient presentation over time? They also go in the plan. Assessment of ADLs, with specific descriptions to quantify the level of performance of the activity, is also essential. What about subjective measures? Will the patient mark a body diagram they present in the office? Document all of these strategies in the plan. Better yet, simply click a mouse on your electronic health record and document these details instantaneously.
Finally, the who and when: Remember, you're the doctor, so if the patient wants to get better under your care, both who and when are essentially your call. Be bold, set a deadline and include everyone who's going to help you accomplish it, including other DCs in your practice, CAs, PTs, or whoever is involved in the care.
Put all of these ingredients together and you've got a game plan, a set of milestones for the patient. It's documented, which means the patient knows about it, other providers know about it, and you've legally acknowledged your intent to plan and measure the patient's progress. In addition, you've just done something that many of your colleagues can't find the time to do. This will distinguish you in the community you serve.
The Digital Clinic's Plan of Care
How do we enact this plan? Of course, the answer is to move beyond the old model of clinic management, in which work was delegated from the top down and was confined to pen and paper. In the old model, one person created the plan and one person modified it, which didn't allow for multidisciplinary input to the patient's management, aside from brief documentation in the note. All too often, it meant no plan at all; only lists of segments adjusted.
Of course, the plan still includes space for marking segments adjusted, but they're set within the context of a complete digital note engineered for a documented plan of care. We're not talking about a 3x4 plan on a tablet, but rather who, what, when and where and for how long - all reproducible within minutes in a record that's understandable, even outside of chiropractic. The mobile and instantaneous nature of a digital note supplies automatic information about that plan and its modifications to other providers associated with the patient's treatment, with the ability to update their participation as needed, all in real time.
Listing all of the benefits of this shift in management would probably be a whole column by itself, so I'll hit a few key points here:
- This is the only sustainable way to effectively manage an interdisciplinary practice that eliminates miscommunication between providers. It improves record-keeping and patient management, even in those cases in which the patient is under coordinated care.
- It eliminates redundancy in staff functions, which saves money.
- It eliminates non-billable visits resulting from provider miscommunication about the plan of care.
- It creates an opportunity to achieve true management of the patient, in which objective and subjective evidence are reviewed with the patient, and progress is actively documented and acknowledged - as it should be.
- It saves time for the patient.
- You get a professional patient plan that's above third-party standards and is immediately understandable to the patient's internist, general practitioner, etc., which could allow greater opportunity for referrals and a chance to elevate your profession.
- If your ideal patient has progressed to post-condition and wellness care, closing the plan provides an opportunity to educate them about preventative care when legally released from condition-based care and accept them into your wellness model. It creates a system for communicating with the patient's other providers on a diagnosis - model basis while maintaining your wellness model ideal.
Ultimately, the greatest benefit is that our patients can finally get what they deserve: to get well under a detailed plan of care, not under an ad hoc or one-size-fits-all arrangement that leaves them at risk of falling through the cracks. After all, it's our patients' time and money at stake. If we truly want to reach 80 percent or more of the population, it is simply not going to happen with what we've been doing. The facts don't lie. We're stuck at only 10 percent or so of the U.S. population choosing chiropractic care. This can increase to 80 percent if we embrace the referral sources that are already seeing the 80 percent. They will refer when they see professional documentation that demonstrates results and a sensible plan of care that has a method of measuring the outcome with an expected end point. If paperless patient management can help the patient and doctor make the most of both, that's one more reason for all of us to start embracing a proper plan of care and the digital clinic of the future.
