Common sense approaches encourage patient care recommendations

July 1, 2003

Article

Ms. Sue Schmidt provides you with the tools to build a stronger compliance ratio for your practice.

Statisticians and consultants struggle to measure lost hospital income ranging from uncharged services to excessive discounting. Rather than bemoaning a poor economy and flat hospital revenues, why not establish protocols that enhance likelihood of pet owner follow-through on your care recommendations? Let's narrow your action plan by first assuming your clients trust your advice and have the best of intentions for pursuing your recommendations. Many times, clients do not comply with suggested follow-up services, diagnostics and future vaccination series, simply because they forget.

Don't make the mistake of falling into the negativity trap by believing clients purposely avoid follow-up care. Like everyone else these days, responsible pet owners have complicated schedules and active lifestyles. Deferring action reflects oversight more often than neglect. Your practice management challenge is to increase the odds in favor of timely client compliance through courteous staff assistance.

How often have clients told your receptionist they couldn't schedule recheck appointments because they didn't have their calendar with them? How many clients say they will call later to schedule the appointment and never do? What about the client who opts to wait a few days before having a blood test, X-ray or other diagnostic test performed on her pet? Or, the client who apparently ignores a routine reminder notice, but comes in months later for a specific problem with her pet?

Is your staff aware of how they can effectively handle such situations? This article addresses these different, common situations that reflect client short-circuits. We offer protocol solutions that encourage client compliance with suggested treatments.

Nailing a recheck appointment

In the first frequent occurrence, a doctor or technician has made a solid recommendation for follow-up care. The client is advised to schedule a follow-up visit for a recheck examination, a second series of boosters or laboratory testing. The client does not have her calendar or appointment planner with her, so she says she will call later to schedule the appointment. This client means well, but forgets to call.

Table 1. CLIENT REMINDER AND CALL BACK LOG

Do not file the patient chart when the client leaves the practice; otherwise, the client and pet will be overlooked unless the client eventually calls to establish the second appointment. To assist the client and assure proper treatment of the pet, institute a tickler reminder system in your computer or by using a daily planner log. Call the client in approximately five days, if she has not already called to schedule the appointment.

In many cases, you will experience a grateful client who will arrange an appointment time and will apologize for forgetting to call. In the least, the client will appreciate the fact that an employee called to inquire about the pet's status.

Waiting on a diagnosis

The second typical scenario involves a client who wants to wait a few days before incurring the added expense of an X-ray, blood work or some other diagnostic procedure in case the pet improves on its own.

Do current hospital procedures direct an employee to call the client in two to three days to see how the pet is doing? Or is the chart filed, assuming the client will probably call if the pet shows no improvement?

We strongly recommend the former procedure. A telephone call to inquire about the pet's condition does not need to be completed by a veterinarian. Instead, assign a receptionist (or preferably a technician) to handle the task. Even though your hospital procedure manual may require telephone calls to such clients, do you know for a fact that they have been completed? Identify a second individual, possibly a staff veterinarian, for perpetual review of the completed callback lists to supervise the completion of this important task. A standard form or checklist to maintain the tickler system and periodic self-audit of compliance helps enforce timely, ongoing completion of phone calls (Table1, p. 24).

Ignored reminder system

The third event is the client who receives a reminder notice but fails to act. Six weeks, six months or perhaps a year later, the client appears with the pet because of illness or injury. We assume the practice's reminder system is up to date and every effort was made to contact the client several times before giving up. Practices always experience a certain proportion of the client base that is on temporary leave of absence. When the client self-reactivates, an effective receptionist checks the record to ascertain what reminders are delinquent. This requires a two-pronged approach: Well-developed staff habits of reviewing the record for delinquent procedures, and a well-educated staff that knows current, baseline prevention and wellness care for each species and patient age group.

Anytime a client presents an animal for a perceived problem, a great opportunity presents itself to ascertain and resolve all delinquent reminders. An even greater responsibility is identifying those services for which reminders do not exist, but are important to the preventive healthcare of the pet.

Putting ideas into action

Although these suggestions sound like a lot of extra work and time, a well-organized practice can efficiently manage tickler systems that are easily handled by attentive and caring employees.

The first implementation step is to establish a tickler system or daily planner. The most obvious option is through the existing practice management software program. All programs designed for veterinary practices incorporate extensive options for recall and reminder dates.

As in all situations involving a computer system, the results are only as good as the input. Employee training and follow-through to establish ticklers and follow through later on report creation and client callback are crucial.

A receptionist must establish and document ticklers or reminder postings each time a client says she will call back in a few days to establish the appointment for the specific doctor recommendation.

The receptionist inputs the appropriate data to the computer system, or uses a handwritten methodology for the following information:

Client name

Telephone number

Pet name

Reason for follow-up visit

Due date for call

What about the client who is compliant and does call to establish the follow-up appointment? At the time of the telephone call, the client will allude to the reason for the appointments, specifically that it is based on doctor advice. The astute receptionist then retrieves the client record and deletes the future telephone follow-up tickler. The action is a quick one, as the reminder is only a few days in the future.

Occasionally, a receptionist may forget to delete the pending follow-up phone call from the tickler system. Before making tickler telephone calls for the day, we recommend the receptionist check the computer system for pending appointments to assure no duplication of effort.

After the first week into a new system of callbacks, telephone calls will start to be made daily. Assign one individual per day, preferably a receptionist, to make the follow-up telephone calls to clients based on the tickler or daily planner sheet of clients who failed to schedule a follow-up appointment. Allow the assigned receptionist a 15-minute time slot for relief from her front desk phone-answering assignment to deal strictly with callbacks assigned for that day.

A specific employee assignment reduces the likelihood of missed follow-through due to confusion. Management's responsibility is to request a daily report of all successful calls completed and outcome. Eliminate the situation of two or three employees pointing at each other, saying they thought someone else completed the calls. Hold one specific person responsible for completing calls and ensure thorough follow-through.

Technical details

Technicians should be responsible for client recalls about patient status, where diagnostic tests or more complex treatment plans were deferred at the client's election. Technicians are better equipped to handle technical questions that might arise from client conversations about pets with ailments or injuries. The technician can initiate the conversation with a script such as:

"Mrs. Smith, we are calling to see how Fifi is progressing. Is her limp better, or do you wish to go ahead and schedule an X-ray? We're sure you don't want her to get worse, or to delay a treatment that will help improve her condition."

Communicating the correct information during these follow-up calls requires adequate patient records with timely doctor notes of recommended follow-up care. Be aware and make provisions for the fact that a technician may need to spend more time with recalls, because a specific patient problem exists. As with receptionist callbacks, we recommend assigning one specific technician per day to complete all assigned telephone calls. In larger multi-doctor practices, a specific technician per doctor may be assigned: an assistant who is most familiar with that doctor's outstanding cases.

No answer

As with any employee making a client telephone call, the probability of reaching an answering machine or voicemail is high. In both instances, the receptionist or technician should leave a detailed and clearly-stated message including employee name, practice identification, telephone number and the reason for the call. Periodically review employee technique. Garbled, rapid-fire messages will result in client confusion, not appreciation. Get into the habit of slowly repeating the telephone number at the end of the message, so that the client does not have to review the message again. Such courtesies go a long way in improving client response to callbacks.

When the message is left in voicemail or on the client's answering machine, the receptionist or technician should then move the tickler forward 48 hours. Another call is made in the event the client does not respond to the first message.

When you should stop calling the client who does not respond to messages is individualized, based on your knowledge of that client. If possible, update the client's computer record to assist other employees to know how to best handle such calls in the future, or the best time of day to reach the client.

Do not call more than two times to leave messages unless you know the client very well, and his or her schedule. More messages might be left in special situations when the client is known to be very busy, travels a lot, or does not respond in a timely fashion to reminders or calls. The number of callbacks a receptionist or technician should make in any specific situation is a judgment call. If an employee is not familiar with the client or is unsure, making two calls is adequate.

When the client returns the call, whoever takes the call can establish the appointment or transfer to the pertinent technician if necessary. The employee should then delete the future tickler for follow-through.

Unresponsive clients

In the last situation posed, a client fails to respond to a reminder notice sent, and reappears at some future point after leave of absence. To recoup missed services through poor client compliance, carefully review each and every patient file as it is pulled. Check the patient record as well as the automated reminder system for any delinquent reminders.

Proactively think about the patient's current status because of age or other risk factors to determine for what routine services the animal is due. Patients at most risk for further missed wellness care are those that are presented by the client for illness or injury. Since the presenting reason is for other than routine prevention or wellness care, such necessary procedures may be overlooked unless employees are well trained and proactive about informing the client of such necessary services.

Once such delinquent care is identified, the receptionist must make recommendations to the client at the point of check-in or admission for care. In the situation of an ill patient, preventative care, such as vaccines, may be appropriately deferred until later dates in accord with the attending doctor's decision. In other situations, the doctor, once alerted to the fact of overdue wellness care, can help the client bring the patient back up to date.

Record review

Patient charts can be reviewed the day before appointments to highlight any missing services in anticipation of the bustle that occurs during normal appointment hours. Establish a protocol for regular patient chart reviews before the frenetic activity that normally occurs during early morning or late afternoon appointment schedules. Otherwise, the probability of ongoing missed opportunities for improved client compliance will continue.

Periodically review the reminder system to ascertain that all reminders are current. Quarterly housekeeping reviews are excellent procedures. Often, a new client (whether walk-in or scheduled) may be missing essential patient history that results in a lack of future reminders.

Keep in mind the Golden Rule of the three Rs: Recall, Reminder and Re-appointment. One of the three should exist to assure follow-through with each and every client and pet.

An astute reception staff will quickly interview each client at the initiation of check-in to keep the patient record system as up to date as possible. Ask about any address changes, or pet ownership status changes. Ask each client whether new pets have been added to the household. Any pet's appointment visit is a good opportunity to inquire about other household members and establish records accordingly with a reminder tickler attached.

Act in a proactive, enthusiastic and helpful fashion. Client compliance failures are usually due to oversight, not purposeful negligence. A cheerful support staff that expresses true interest in the pets' welfare and client convenience can greatly enhance client compliance with solid doctor recommendations and the practice's preventive care philosophy.