Capturing compliance opportunities every patient visit (Sponsored by Nestlé Purina)

When a client brought her 14-year-old dog to the veterinarian for a preventive care exam, she asked about arthritis because Hondo moves slower on stairs and has less energy. The doctor found Hondo's hips were tender upon manipulation. Hondo also had Grade 3 dental disease. The dog received an exam, a senior wellness screening, vaccinations, heartworm and tick-borne infection tests, an intestinal parasite test, and a refill of 12 months of heartworm preventive. The client said she'd consider a nonsteroidal anti-inflammatory drug for Hondo's arthritis after getting senior screening results.

While compliance seems acceptable, a deeper look into the medical record revealed missed opportunities. Hondo's vaccinations for Bordetella and leptospirosis were overdue. The owner feeds Kirkland adult dog food from Costco. Why didn't the technician or doctor discuss the benefits of a joint-management diet? Although the client bought heartworm preventive medication, she declined flea control products. A dental treatment plan should have been presented.

Missing preventive care opportunities not only fails patients, it hurts the financial health of your practice. Patient visits have seriously declined during the past two years, with a net 17% decrease.1 When patients visit, they are often ill. Veterinarians say they are seeing patients that needed care one to two weeks earlier. Delaying care often drives costs higher, and fewer treatment options may be available.

While you cannot predict when pets will become sick or injured, you can anticipate when they will need preventive care. Exams, diagnostic procedures, vaccinations, therapeutic diets, and parasite preventives are renewable wellness services that generate 38% of revenue.2

Just as you refill medications, think about which wellness services need refills, too. Changing your approach to preventive care can provide better patient care, increase client satisfaction, and generate ongoing revenue.

Here are strategies that you can implement immediately:

1. Search for other pets in the family that are due for veterinary care. When clients call to schedule exams, check the reminder status of all pets in the same family. Research shows 41% of dog owners have cats and 53% of cat owners have more than one cat.3 In 2010, 70% of cats and 60% of dogs age 3 and older did not visit a veterinarian.4

When a client calls to schedule her dog's exam, ask about cats that may be at home. If a cat is overdue for preventive care, ask the client to schedule an appointment now. Say, "Wendy, let's schedule your dog's wellness exam. I also see that your cat, Opus, is overdue for preventive care. Changes in your cat's health can occur quickly. That's why we recommend a preventive care exam at least once a year. The doctor will assess which vaccines, preventives, and diagnostic tests your cat needs to stay healthy. Catching changes early before they become serious often means they will be easier and less expensive to treat. You can bring Opus along with your dog to the same appointment. Let's schedule their appointments this week. Which day of the week works best for you?"

If you don't know whether the client has a cat, say, "Thank you for calling to schedule your dog's preventive care exam. Many of our clients also own cats, and we want to ensure the entire pet family is protected. Do you have any cats at home, including outdoor cats?"

Most practices are seeing fewer cats. Cats make up 39% of the patient population in hospitals, yet they are 55% of the pet population. Dogs are 45% of the pet population and 59% of veterinary patients.1

2. Screen patient records for compliance the day before patients' exams. Receptionists can review charts for tomorrow's appointments, using a checklist to note areas out of compliance. This checklist lets technicians and doctors have a plan before the exam door swings to ensure every compliance opportunity gets captured.

Compliance Checklist

Which core and non-core vaccinations are due? When were the last parasite preventives dispensed? Is the client sharing a box of preventives between pets? Look for the date of the last preventive purchase, products sold, and number of doses prescribed. Is the patient on a long-term drug that requires monitoring? Is the pet due for diagnostic tests, including heartworm and tick-borne infection tests, intestinal parasite screening, and wellness blood work and urinalysis?

3. Make appointment confirmation calls. When receptionists call clients one or two days before exams, they can encourage compliance by letting clients know what to bring. Tell dog owners, "This is Wendy calling from Your Veterinary Hospital to confirm your dog's appointment with Dr. Your Name tomorrow at 10 a.m. Please remember to bring a teaspoon-sized stool sample that's fresh within four hours, as well as any medications and supplements you're currently giving your dog. If you have questions or need to reschedule, please call us at 555-555-5555."

Tell cat owners, "This is Wendy calling from Your Veterinary Hospital to confirm your cat's appointment with Dr. Your Name tomorrow at 10 a.m. Please bring a teaspoon-sized stool sample from the litter box that's fresh within four hours. It's okay if litter is on the stool sample. A helpful tip is to scoop your litter boxes tonight, and then it will be easy to spot a fresh stool sample in the morning to bring with you. We will screen your cat for multiple intestinal parasites, including those that can be passed from pets to people. Also bring any medications and supplements that you're currently giving your cat. If you have questions or need to reschedule, please call us at 555-555-5555."

These scripts significantly increase compliance for intestinal parasite testing. Asking clients to bring medications and supplements helps you identify "extra" doses of preventives that were never given as well as self-prescribed drugs.

4. Use the check-in report in your practice-management software. Print or view this onepage summary before each exam. Depending on your software, the report highlights reminder status, flagging overdue services and products. A summary of the last medical history taken also appears if it was entered.

Because the client's address, e-mail address, and phone numbers are listed, have pet owners confirm all contact information at check-in. Highlight missing information, such as e-mail addresses, so clients can provide updates. Research shows 30% of people change their e-mail addresses annually, and the average person has three e-mail accounts.5

How you ask for clients' e-mail addresses matters. Do not say, "Can I get your e-mail address?" Instead, use benefit statements that will have clients volunteering their e-mail addresses.

Say, "Our hospital is going green and sending more reminders by e-mail. We also want to be able to quickly notify you about any pet health alerts such as a rabies outbreak in the county or a pet food recall. You can access Jake's reminders and request prescription refills through our website. Which e-mail address would be the best for you to receive Jake's reminders?"

Likewise, confirm clients' cell phone numbers because one in four homes has only cell phones.6 Calling clients' cell phone numbers is the most efficient communication because mobile phones are with consumers 98% of the time.6

5. Ask clients about medication and food refills as they check in. To reduce wait time at checkout, have receptionists ask pet owners as they check in, "What medication and food refills can we get for you today?" This statement is stronger than "Do you need any heartworm preventives or food today?" Then the receptionist can alert a technician, who can begin filling the medication. If the client requests a large bag of food, you've got the entire exam time to retrieve it. This strategy will help you increase compliance and sales for therapeutic diets and heartworm and flea and tick preventives.

6. Involve technicians in exams. Assistants or technicians begin the exam by taking a brief patient history and reviewing which services and products are due today. Tell the client, "For your preventive care visit, we will do a nose-to-tail exam, vaccinations, heartworm and tickborne infection testing, and intestinal parasite screening. We will refill 12 months of parasite preventives. Is there anything else you want to discuss with the doctor?"

If clients ask, "How much will this cost?" prepare a treatment plan. Don't let clients decline care before seeing the doctor. Say, "Let's have the veterinarian perform your pet's exam first, and then he can prioritize which services and products your pet needs."

Client compliance is 50% with only the doctor in the exam room, while it is 80% with a veterinarian and a staff member present.7 Why the 30% jump? The client hears the same message more than once, gaining compliance through repetition. The assistant can hold the pet during the exam, letting the veterinarian and client have a focused conversation without the pet as a distraction. With an extra set of hands in the exam room, the doctor can be a better communicator and the client can be a better listener.

7. Take a great patient history. How you phrase questions can teach clients about the importance of preventive care. The technician would ask, "What dental care do you provide for your pet at home?" If the client does not already do something, start a conversation about Purina Veterinary Diets DH, teeth brushing, oral rinses, gels, chews, drinking water additives, and other home-care options. Using the phrase "What do you do?" emphasizes that the client should be providing oral care at home, compared with "Do you brush your pet's teeth?" which elicits a yes-or-no answer and sounds optional.

Develop a history questionnaire so assistants ask clients the same questions at every wellness exam. This ensures continuity of care and increases compliance. For paperless practices, create a template in your practice-management software. If you have paper records, try a laminated sheet with dry- or wet-erase markers and note abnormalities in the chart.

A written history form keeps you focused when it gets busy, avoiding default questions such as "Any problems?" "Any coughing, sneezing, vomiting, or diarrhea?" or "Fleas, ticks, lumps, or bumps?" Using a written history questionnaire ensures consistency among staff, whether it's an employee's first day or 20th year with the hospital.

8. Stress year-round parasite prevention. Compliance studies conducted by Communication Solutions for Veterinarians in 2010 and 2011 found that less than 40% of dog owners are following a standard of care for year-round heartworm prevention (Table 1). Among feline patients, only 10% receive heartworm preventives and 13% receive flea control.

TABLE 1

Help clients understand their pets' risk in your neighborhood. Post prevalence maps in exam rooms. IDEXX Laboratories shares data by state and ZIP code for canine tickborne disease on www.dogsandticks.com and data for feline leukemia, feline immunodeficiency virus, and feline heartworm infection on www.kittytest.com. The Companion Animal Parasite Council's website (www.capcvet.org) offers incidence maps for intestinal parasites, heartworm infection, and tick-borne disease by state, county, and species.

9. Be passionate about poop! Use the term "intestinal parasite test" rather than "fecal test." Intestinal parasite test more accurately describes the diagnostic test and educates clients about the need for regular screening. Avoid medical jargon such as "zoonotic disease." Instead say "parasites that can be passed from pets to people."

Testing is equally important for indoor cats because 15% of potting soil contains roundworms.8 Cockroaches, mice, crickets, and flies can carry roundworm eggs. Cats are natural hunters and could become infected through their prey.9 The Companion Animal Parasite Council offers brochures on intestinal parasite testing in both dogs and cats at www.capcvet.org.

To improve compliance, try a three-step approach:

Step 1: Make confirmation calls to remind clients to bring pets' stool samples for testing.

Step 2: If the owner forgot poop, collect a sample during the exam. Tell the client, "I'm taking Sophie to the treatment area where we'll collect a stool sample for her intestinal parasite test. We will screen for multiple intestinal parasites, including those that can be passed from pets to people." Avoid saying "I'm taking Sophie to the back," which may make some clients anxious to be separated from their pets. "Treatment area" is more professional.

Step 3: Can't collect enough for a diagnostic sample? Offer the client a prepaid intestinal parasite test with a collection cup. Put a prescription label on the cup and have the code generate a callback one week later to remind the client to drop off a stool sample. Say, "We were unable to collect a sample from Sophie, so I'm sending you home with this prepaid collection cup. Just drop off her stool sample at your convenience, and we'll call you with test results. We'll also call you as a courtesy reminder if you haven't returned her sample within seven days."

10. Schedule medical progress exams at checkout. If puppies, kittens, or sick patients need follow-up care, schedule medical progress exams first, and then have clients pay last. This order has two advantages:

• It prevents pet owners' hesitation to schedule followup care sometimes caused by sticker shock.

• Appointment reminders can be printed on receipts.

Only 4% of practices always schedule medical progress exams at checkout, while 35% do so often, and 49% sometimes do.1 Compliance is highest at checkout, so tell clients with puppies, "Your puppy will need his next exam, vaccinations, deworming, and intestinal parasite test in three weeks. That would be (date). Does this same time work for you?" Suggesting a specific date for followup care will encourage the client to book the appointment now. This technique is called suggestive selling and is stronger than, "Do you want to make your next appointment?"

If the client doesn't schedule the next visit at checkout, enter a callback in your practice-management software. Call the client one week before services are due, so she has time to fit the appointment into her schedule.

Likewise, sick patient followup exams should be scheduled at checkout. Let's say you diagnose a dog's ear infection, demonstrate cleaning and treatment, and instruct the client to treat the infection for 10 to 14 days. You want to examine the patient at the end of treatment. Most clients will follow your instructions for the first three days. Then the dog quits shaking his head, so the client stops treatment. A few weeks later, the ear infection recurs and may even be worse. The client blames you or claims the medication did not work.

Could wellness plans be a compliance solution?

Tell the client the specific date when follow-up care is needed. Use benefit statements to emphasize

the importance of returning. Say, "I will see your dog again on (date). Ear infections can be painful and develop into a serious condition unless treated and re-examined to make sure the infection is gone. The receptionist will schedule a medical progress exam for Jake on (date)."

Use the term "medical progress exam" instead of "recheck." From a client's perspective, "recheck" sounds free and optional. Upgrade your terminology to show value for your professional services and the need for follow-up care. The fee for a medical progress exam is typically 75% of your exam fee. If you charge $55 for an exam, a medical progress exam would be $41.25.

11. Use callbacks to ensure treatment continues at home. For this ear patient, enter a medical callback at Day 3 and Day 10. Besides checking on treatment, the staff member can schedule the medical progress exam if an appointment was not made at checkout.

Here's a callback script: "Have you been able to clean your dog's ears daily and use the ointment? Has your dog stopped shaking his head? That means the medicine is starting to work. Be sure to finish the entire 10 days of treatment. Stopping treatment could cause the ear infection to return and worsen. Finishing treatment is just as important as when your physician prescribes 10 days of antibiotics when you are sick. Sometimes people stop taking antibiotics when they feel better, but you really need the full 10 days of therapy. The same is true for ear infections in dogs."

Just as you perform callbacks for sick pets, elevate the medical need of a diet change. Communicate treatment recommendations in a way that makes compliance stick. By "stick," I mean that your treatment plan is understood and followed — having lasting impact and changing clients' behaviors. Only 19% of dogs and 18% of cats are in compliance with therapeutic diets.7 A University of Minnesota study found that a renal diet extends the lives of dogs and cats with kidney disease.10

Whenever a diet change is made, a staff member should call the client two or three days later and check on the food transition. Say, "This is Wendy with Your Veterinary Hospital. Dr. Your Name asked me to call to confirm that you're making the transition from Ollie's previous food to the new therapeutic diet, Purina Veterinary Diets NF, for kidney disease. When switching foods, you should be mixing the two foods, gradually increasing the proportion of NF over one week and reducing the amount of the previous food. Have you begun the transition to get Ollie on his new kidney diet? Is he eating it? Eating this diet is the cornerstone of Dr. Your Name's treatment plan and will help us better manage Ollie's kidney disease. Research shows cats with kidney disease can live twice as long after diagnosis if they eat a therapeutic diet. I will give you a courtesy reminder to refill Ollie's food, which should be in three weeks. Would you like me to contact you by e-mail or phone?"

Using the doctor's name brings authority to the call. Remind the client that her cat has kidney disease, a serious condition that requires ongoing care. Explaining that the therapeutic diet is a cornerstone of the veterinarian's treatment plan communicates the need for change. The benefit statement of "can live twice as long" motivates the client to follow the doctor's advice.

Just as medications need refills, so do therapeutic diets. If you know the cat will eat the bag or case of food within four weeks, call the client in three weeks as a courtesy reminder. You don't need to call the client every time she will need to buy food, just the first refill to ensure long-term compliance. Because it typically takes 21 days to change a habit, the diet change will have gained "stickiness" by the first refill.

Also use callbacks, online resources, and social media for weight-management coaching. When a client commits to a weight-management program, teams need to perform medical callbacks to show their commitment as well. In the exam room, explain that a staff member will call to check on progress. Say, "Your dog weighs 70 lb today. This extra weight could lead to serious and expensive health consequences such as heart disease, arthritis, and diabetes. Even losing 10% of his weight will have immediate health benefits. We'll create a plan today for your dog to lose 7 lb. We'll use a combination of Purina Veterinary Diets OM, healthy treats, and walks. Once a month, we'll call to remind you to stop by with your dog for a weight check. It takes just a few seconds to measure your dog's weight, and we will record it in your pet's medical record. You'll be amazed at the changes in your dog's health and attitude!" Weight checks let you fine-tune feeding recommendations, ensuring that pets get the correct amount of food to achieve targeted weight loss.

Post a "trusted links" section on your practice website. Send clients to obesity resources such as Purina's websites at www.projectpetslimdown.com and www.facebook.com/FightingPetObesity. Clients can get tips, reminders, tracking tools, and coupons.

Communicate about obesity with images that help clients stick to a weight-loss plan for pets. Today, 82% of pet owners consider obesity to be a problem.11 A 2011 study by the Association for Pet Obesity Prevention found 55% of dogs and 53% of cats are overweight or obese.12

12. Present invoices to show value for preventive care. Use confident body language and sales-reinforcement techniques. Let's say a client visits with Mason, a 3-year-old Newfoundland, for preventive care. As she nears the checkout counter, stand to greet her, smile, and make eye contact. Read the list of services and products off the computer screen, and then state the total. Besides showing value, this allows the client to add items such as preventives, medication refills, and food. Say, "Today Mason had a comprehensive exam, heartworm, tick-borne infection, and intestinal parasite tests, and vaccinations to protect him from canine distemper, adenovirus, parainfluenza, parvovirus, rabies, and respiratory disease. You have Mason's parasite preventives and Purina Veterinary Diets OM diet for weight loss. Does Mason need any other medication refills today?" After the client responds, say, "Your total is $____. Which payment method are you using today?"

This approach shares service first, price last. Asking the client's preferred payment method subtly indicates that payment is due when services are provided. For new clients, add which types of payments you take, such as, "We accept cash, checks, and all major credit cards." Once the transaction is complete, hand the receipt to the client along with a smile that communicates, "We appreciate your business."

13. Check every reminder at checkout. Remember, wellness services and products generate 38% of revenue.2 Verify that all preventive care reminders and callbacks are correctly entered. If the pet was ill, what reminders or callbacks need to be entered? Were any long-term drugs prescribed for the first time? If so, are drug-monitoring reminders entered? Are other pets in the same family due for services?

Accurate reminders drive repeat visits to your hospital. When you focus on compliance, it's a winwin-win for everyone. Patients get preventive care. Clients save money. Practice revenue is healthy. Which strategies will your team implement?

Wendy S. Myers

Communication Solutions for Veterinarians

Denver, Colorado

References

1. National Commission on Veterinary Economic Issues, Brakke Consulting, Bayer Animal Health. 2011 Bayer Veterinary Care Usage Study.

2. Myers WS. Understanding the reminder cycle and need for follow-up calls. In How to conduct effective reminder calls & callbacks. Denver, Colo.: Communication Solutions for Veterinarians Inc., 2009;9.

3. U.S. pet ownership and demographics sourcebook. Schaumburg, Ill.: American Veterinary Medical Association, 2007;1-27.

4. Data on file, VetInsite Analytics, 2011.

5. Fox S. Today's best e-mail publishing strategies. In e-Riches 2.0: Next-generation marketing strategies for making millions online. New York, N.Y.: AMACOM, 2009;55.

6. National Center for Health Studies, 2009. Available at: http://www.cbsnews.com/stories/2010/05/12/tech/main6476743.shtml .

7. The path to high-quality care: Practical tips for improving compliance. AAHA study, 2003;62-63.

8. Vet Rec 2006;158(2):217.

9. Lappin MR. General concepts in zoonotic disease control. Vet Clin North Am Small Anim Pract 2005;35(1):1-20.

10. Ross S, Osbourne C, Polzin D, et al. Clinical evaluation of effects of dietary modification in cats with spontaneous chronic renal failure, in Proceedings. ACVIM Vet Med Forum 2005.

11. Ward E. Obesity in dogs and cats is on the rise in the U.S. Vet Econ March 2010. Available at: http://veterinarybusiness.dvm360.com/vetec/article/articleDetail.jsp?id=661954. Accessed December 5, 2011.

12. Association for Pet Obesity Prevention. Fat pets getting fatter according to latest survey. Available at: www.petobesityprevention.com/fat-pets-getting-fatter-according-to-latestsurvey. Accessed February 6, 2011.