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1/ 2/ 2019

Taming the Tiger

Managing the Difficult Dental Patient

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At the conclusion of this program, you should be able to:

Objectives

Identify factors that may contribute to problematic or noncompliant patient behaviors Identify proactive steps for reducing the escalation of problematic or noncompliant patient behaviors Discuss the role of technology in patient engagement Discuss strategies for effectively handling new or established patient visits when patients are difficult and/ or noncompliant S ummarize the process for discharging a patient from the practice

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What the media say

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What the researchers say

When dealing with difficult patients: Clinicians are 42% more likely to wrongly diagnose a complex medical issue Clinicians are 6% more likely to wrongly diagnose a simple medical issue

Source: Schmidt, H. G., et al. (2016, March). Do patients’ disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment. BMJ Quality & Safety. Retrieved from http://qualitysafety.bmj.com/content/early/2016/02/09/bmjqs-2015-004109

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What claims data says about risk factors

Primarily inadequate patient assessment, most often involving a narrow diagnostic focus

Risk factors are broad areas of concern that may have contributed to allegations, injuries,

• r initiation of claims.

71% 43% 37% 24% 20%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Clinical Judgment Technical Skill Communication Documentation Behavior-Related

Percentage of Claim Volume

Inadequate informed consent process; failure to properly educate patients about follow-up instructions and medication regimens Insufficient documentation of clinical findings/ rationale for treatment Primarily patient noncompliance with treatment regimens; also involves patient dissatisfaction with care

Source: MedPro Group closed claims data, 2005−2014 (all specialties); totals do not equal 100% because more than

• ne factor may be coded per claim.

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How Can a Difficult Encounter Affect Patient Care?

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Components of a difficult clinical encounter

Source: Hull, S. K., & Broquet, K. (2007, June). How to manage difficult patient encounters. Family Practice Management. Retrieved from http://www.aafp.org/fpm/2007/0600/p30.html

Healthcare Team

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Situational issues

Transportation Financial Complex healthcare system Location Office policies Environmental Cultural

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Provider/ staff issues

Fatigued Dogmatic Fearful Distracted Condescending Unprofessional Defensive Frustrated Angry

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Triggers

“Doctors tend to think they are immune from the ‘emotional pull’ of clinical encounters, and often deny their judgment is influenced, noted researchers from the Institute for Medical Education Research in the Netherlands. ‘The fact is that difficult patients trigger reactions that may intrude with reasoning, adversely affect judgment and cause error.’” — Modern Healthcare

Source: Rice, S. (2016, March 14). Blog: 'Difficult' patients more likely to be misdiagnosed. Vital Signs Blog, Modern

• Healthcare. Retrieved from http://www.modernhealthcare.com/article/20160314/BLOG/160319965

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Effects of provider/ staff behaviors

Billing errors Appointment mistakes Miscommunication Impatience Apathy Frustration Documentation errors Loss of objectivity Employee dissatisfaction

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Patient issues

Complex health issues Substance abuse Family issues Psychiatric issues Financial/job issues Expectations Fear/confusion Past experiences Health literacy

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Difficult patients — warning signs

Unrealistic demands Escalating behavior “Frequent flyer” behavior Frequent requests for refunds/waivers Angry/aggressive Repetitive complaints without clear clinical significance Noncompliant behavior

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Case study — the difficult patient

The Noncompliant Patient: John B

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Noncompliant patients

Noncompliance might be due to: Lack of understanding Choice Noncompliant patients might: Miss appointments Not pay bills Also be difficult patients Be fearful Be dealing with other social factors

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Putting it all together

Fatigue Emotional issues Psychiatric issues Cultural issues Family issues Behavioral characteristics Substance abuse Environment Complex health issues Complex health system Distractions Expectations Location Financial issues Health literacy Past experiences

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Addressing known situational issues

Environmental Office policies Staffing deficiencies Staffing issues

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Guidelines and Policies

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Recommended guidelines

Administrative

• Appointment

cancellation/ no shows

• Fees and

refunds/ waivers

• Financial
• bligations

Patient Care

• Prescription

refills

• Mutual

respect

• Visit follow-

up (“no shows” or lab results) General

• Complaint

handling

• Termination
• f the

relationship

• Behavior

contracting

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Patient responsibilities

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Setting expectations early

Does your practice brochure/ welcome packet include the following information? Yes No

Directions to your facility

 

Office hours

 

Phone numbers (regular and after-hours)

 

Website and social media information

 

Mission/vision/philosophy

 

Provider biographies

 

Brief excepts from guidelines/policies

 

Patients’ rights and responsibilities

 

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Complaint Process

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Turning negative feedback into positive results

“Your most unhappy customers are your greatest source of learning.” — Bill Gates

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Patient complaint avenues

Phone/email Social media State medical

• r dental

licensing board State attorney general’s office Small claims court Federal Trade Commission HHS Office for Civil Rights (HIPAA violations) Better Business Bureau Lawsuits

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Complaint–litigation cycle

Complaint No resolution Claim Litigation Public & staff effect

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Proactive complaint management

Does your practice have protocols for identifying and responding to patient complaints? Do staff receive education about managing complaints? Has your practice assigned someone to handle and respond to patient complaints? Does your practice promptly respond to complaints before claims are filed? Does your practice proactively evaluate and update processes to improve patient satisfaction? Does your practice trend complaints to identify top priorities?

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Handling complaints

Consider environmental safety Determine whether an interpreter is needed Practice before meeting with the patient and/or family Verify your understanding of their concerns Let the patient speak without interruption Respectfully use the patient’s name when speaking to him/her Demonstrate your understanding of their concern with empathy Avoid rationalizing Don’t point fingers Under promise and

• ver deliver

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Limited Health Literacy

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Case Study

The patient was a 29 year old male with limited English proficiency who developed throat pain and was prescribed amoxicillin and clavulanic acid by a physician. One day later, he went to the ED with continued pain, and was discharged with a prescription for pain medication and penicillin. The patient’s family told the patient to stop taking the amoxicillin and clavulanic acid, and to take the penicillin only. Four days later, the patient went to a dentist who diagnosed him with severe gingival inflammation, heavy plaque, and calculus on two teeth. The patient’s medication history in the chart was blank, and there is no indication that an interpreter was

• ffered or utilized. Extractions were performed. At the follow up visit,

complications were identified, and an immediate consult with an oral surgeon was recommended.

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Case Study

Because the patient stated he had no money, the dentist prescribed penicillin and pain medication and referred him to a community health

• center. Later that day, the dentist’s staff called the patient, who reported

that he felt better and had not seen another provider. That evening, the patient was discovered deceased at his home. An autopsy determined that he had died of sepsis. This case was settled in the midrange, with defense costs also in the midrange.

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What is health literacy?

Source: Institute of Medicine. (2004). Health literacy: A prescription to end confusion. National Academies Press. Retrieved from http://www.nap.edu/catalog/10883/health-literacy-a-prescription-to-end-confusion

Health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” — Institute of Medicine

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Resources to address health literacy

“Saves Lives. Saves Time. Saves Money.” — NIH

www.cms.gov/Outreach-and- Education/Outreach/WrittenMaterials Toolkit/index.html?redirect= /written materialstoolkit/

https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear- communication/health-literacy

www.cdc.gov/healthliteracy/index.html

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Teach-back

Teach-back toolkit: http://www.teachbacktraining.org/

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https://www.cdc.gov/healthliteracy/pdf/Simply_Put.pdf

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I nformed refusal

MedPro Resource Informed Refusal: A Review (www.server5.medpro.com/ document s/ 11006/ 16730/ Informed_Refusal_A_Review.pdf)

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Patient Engagement Through Technology

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The time is here

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Mobile devices Virtual assistants/ e-visits Text/ email Health-related gaming/ apps Crowdsourcing Remote monitoring S

• cial media

Digital resources are continuously changing

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13% 23% 28% 40% 63% 0% 20% 40% 60% 80% Electronic Alerts Monitor Health Condition Measure Fitness Share Data With Doctor Made Changes Based on Data

Rates of conferring with doctors via email, texting, or video have doubled in the last 2 years and are expected to continue to rise.

Age of digitization

Source: Monegain, B. (2015, October 15). Deloitte: Consumers using more healthcare technology. Healthcare IT

• News. Retrieved from http://www.healthcareitnews.com/news/deloitte-consumers-using-more-healthcare-tech

Use of Technology to Improve Health

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The need for caution

Source: Conn, J. (2015, November 28). Easy on those apps: Mobile medical apps gain support, but many lack clinical

• evidence. Modern Healthcare. Retrieved from http://www.modernhealthcare.com/article/20151128/MAGAZINE/311289981

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https:/ / healthit.ahrq.gov/ health-it-tools-and-resources

Development, selection, and evaluation of I T tools

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286553/ http://mhealth.jmir.org/2015/1/e27/

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Measure Your Success

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Agency for Healthcare Research and Quality

http://www.ahrq.gov/cahps/index.html

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Sample patient satisfaction survey

Poor Fair Very Good Excellent Length of time between appointment request and actual appointment

   

Length of time waiting at the office

   

Cleanliness and comfort of the waiting room

   

Friendliness, politeness, and helpfulness of the provider and office staff

   

Thoroughness and competency of the provider

   

Adequate time to ask questions and voice concerns

   

Rating for overall visit

   

Please rate the following with respect to your visit today.

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Using your EHR system to measure quality

EHR systems offer healthcare organizations an

• pportunity to bring quality

improvement into focus through development of well-defined processes that utilize EHRs' data capabilities and functions.

www.medpro.com/rm-guidelines

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Staff Education & Training

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Areas to cover

Customer service Practice guidelines/ policies Complaint process Hostile/ aggressive patients

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Conduct periodic drills on managing patient complaints and behavioral issues.

Don’t forget — practice makes . . . better

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Proactive Strategies

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Screening

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Case study — the difficult patient

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Strategies following decision-making

Accept

• Be clear about boundaries, limitations,

and expectations.

• Stick to the plan.
• Document thoroughly.

Decline

• Do not charge for visit.
• Tell the patient you cannot meet their

needs.

• Advise the patient to find another doctor.

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Case Study

The patient was a 32 year old female with a medical history of cancer, including treatment in a hyperbaric chamber. S he had had # 29 and 30 inj ured in an auto accident, and presented to Dr. W, the MedPro-insured general dentist, for treatment. After evaluation, it was determined that RCT would be needed, which was accomplished by an endodontist. S he returned to Dr. W and the teeth were prepped for crowns, however, she did not show up for the crown placement. Five months later, she called Dr. W’s office, saying she was in pain and requesting pain medication and an antibiotic. S he would not schedule an appointment. The medications were prescribed and refilled one time (without an appointment). Two months later, she called again with the same complaints, received the same medications (including one refill), and was seen two weeks later. At that visit, it was decided to remove #30 because of the degree of decay. The extraction was scheduled for ten days later. On the day of the extraction, she was advised that the tooth might break because it had been weakened by the RCT and placement of a post. S he decided to proceed with the extraction.

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Case Study

Part of the root tip did break off during the extraction, and the patient was referred to an OMFS for further treatment. The patient chose to not see the OMFS

• r have further treatment

for the retained root tip (despite Dr. W’s recommendation to do so). Two weeks later, she called Dr. W’s office complaining that she was in pain. Antibiotics and pain medication were prescribed, and she was again advised to contact the OMFS ’s office. Two months later, she was seen in Dr. W’s office for continuing pain at #30 and was once more prescribed antibiotics and pain medication, along with an admonition to see the OMFS . Two weeks later, she picked up her xrays from Dr. W’s office, saying the OMFS wanted to see them. S he was given the original of her xrays. The practice had no further contact with the patient until they received the legal complaint. During discovery, it was learned that, in addition to the retained root tip, the patient’s j aw had been fractured in the course of the extraction. The case was settled in the low range, with defense costs in the high range.

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Strategies for Managing the Relationship

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Challenging patients

www.hospitalrecruiting.com/blog/3060/tips-for-dealing-with-difficult-patients/

The noncompliant patient The angry patient The know-it-all patient The needy patient

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Back to the basics

“Nobody cares how much you know, until they know how much you care.” — President Theodore Roosevelt

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No means no

Source: Spickerman, F . (2004, February). The fine art of refusal. Family Practice Management. Retrieved from http://www.aafp.org/fpm/2004/0200/p80.html

Realize that “no” hurts. Try the toddler principle. Take responsibility for “won’t” versus “can’t.” Be firm yet calm. Use the “broken record” technique. Work up a contract. Show faith.

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Case Study

The patient was a 53 year old female patient with no relevant medical history

• ther than being on Boniva for osteoporosis. S

he was referred to Dr. W (MedPro- insured periodontist) in late year 1 for consultation regarding advanced

• periodontitis. S

he was evaluated to have a guarded prognosis and underwent root planing and deep scaling, as well as one area of gum grafting. The patient was put

• n an every three month cleaning plan, to alternate between Dr. W and Dr. D (her

primary care dentist). Her subsequent treatment with Dr. W went as follows: Y ear 3: seen by Dr. W for first follow up, hygiene noted to be poor Y ear 6: worsening periodontitis; root planing and deep scaling Y ear 7: “ deep pockets” throughout her mouth; upper right and left molars in j eopardy; surgery recommended but declined Y ears 7-9: several cleanings by Dr. W Y ear 9 -10: bleeding throughout mouth; surgery recommended but declined

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Case Study

Y ear 11: advanced bone loss; poor prognosis for #1, 2, 4, 5 Y ear 12: complaints of swelling at #14; cleaning and antibiotic: upper molars no longer salvageable Y ear 13: recommended extraction of three teeth; declined Y ear 15: extraction of #2, 3, 14, 15, 16, implants placed at #3 and 14; infection at #14 and it was removed; patient told to discontinue Boniva. Y ear 16: infection in #13 and referred for RCT; general improvement throughout first quarter of year; no further contact The patient sued Dr. W for malpractice in June of Y ear 16. The case was tried to a defense verdict, with defense costs in the midrange.

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Behavior Contracting

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Behavior contracts

• Patterns of inappropriate behavior
• Manipulative behavior
• Continued noncompliance
• Financial barriers
• Drug-seeking or addictive behaviors

Using a behavior contract might be beneficial when working with patients who have:

A behavior contract also might be beneficial when dealing with families or caregivers who have challenging behavior.

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Before the behavior contract

Is the relationship worth preserving? Is the patient acutely ill? Is the behavior ongoing, or was it an isolated incident? Can the problematic behavior(s) be changed? Is the person who has the problematic behavior the patient or a family member/significant other? Do certain factors — such as intellectual immaturity, health illiteracy, or comorbidity — inhibit the patient from understanding that the behavior is hindering an effective relationship? What measures have been taken so far to correct the behavior?

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Before the behavior contract (continued)

Is the problematic behavior objectively documented in the patient’s medical record as it occurs? Does the documentation avoid disparaging remarks and subjective statements? Are quotes used when possible? Are you willing to follow through with the terms of the contract if it is violated (e.g., terminate the relationship)? Has a threat of harm or actual harm occurred to you or your staff? If yes, implementing a behavior contract may not be appropriate. You may want to consider terminating the provider–patient relationship.

MedPro Resource Behavior Cont ract s (www.server5.medpro.com/ document s/ 11006/ 16738/ Behavior+Cont ract s+Guideline_10-2013.pdf)

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Prescription drug compliance monitoring

http://www.pdmpassist.org/content/state-profiles http://www.cdc.gov/phlp/publications/topic/prescription.html

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The Nuclear Option: Termination of the Doctor-Patient Relationship

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Professional organization opinion

Physicians have an obligation to support continuity

• f care for their patients. While physicians have the
• ption of withdrawing from a case, they cannot do

so without giving notice to the patient, the relatives, or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured. The American Dental Association does not have an official position related to termination of patient relationships; however, the American Medical Association offers a good starting point.

http://www.ama-assn.org//ama/pub/physician-resources/medical-ethics/code- medical-ethics/opinion8115.page

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Terminating the provider–patient relationship

Consistent with practice policies Sufficient and

• bjective

documentation that supports the decision Phase of treatment

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Written notice elements

Focus on long-term benefits for all Use a professional tone Providing a reason for discharge is not required Offer emergency care for stated period (e.g., 30 days) specifying when offer expires Offer to send copy of medical record to new provider; include medical record release form Indicate need for follow-up and necessary timing; list potential risks if patient does not follow through MedPro Resource Terminating a Provider−Patient Relationship (www.medpro.com/ documents/ 10502/ 359074/ Terminating+the+Provider-Patient +Relationship+Guideline.pdf)

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Administrative considerations

Note: Some managed care organizations require

additional steps before discharge. Send letter by (a) certified mail with return receipt requested and (b) by first class mail Retain letter in the patient’s record with signed receipt Notify staff to place patient’s name on “no schedule” list

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What if the patient terminates the relationship? “This is to confirm that you have terminated the relationship with . . .”

Confirm with letter Certified with return receipt requested and first class mail

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Be aware that terminations may require a longer transition period in certain situations, such as (a) in rural areas, and (b) if the clinician is the sole specialist in the region. Offer the patient resources for finding a new provider. Resources might include insurance companies, medical societies, etc. Whenever possible, avoid referral to a specific provider. Check managed care contracts for possible requirements.

Additional considerations

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Termination can be challenging

Second chances often lead to the patient believing his/her negative behaviors can continue without consequence. Once the decision is made, stick to it. Make sure the process is well thought out and the right choice for each situation.

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What would you do?

Patient

• 41-year-old female presenting to dentist for routine visit; complaints about

pain and concerns about smile/appearance.

Case overview

• The patient has had episodic care over her 10 years with the dental
• practice. She usually brushes daily, has never flossed, has been irregular

with her prophylactic treatments, and is a smoker. You have consistently advised her that she must improve her oral hygiene (with careful documentation in the patient record); however, she has not heeded any of your recommendations. Periodontal probing has shown a gradual but consistent worsening of pocket depths, to the point where bone loss has begun to occur. She refuses your referral to a periodontist, instead limiting your treatment to keeping her out of pain and keeping her “smile nice.”

Approach

• Behavior contract, informed refusal, or terminate?

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Not all patients are a good fit for your practice. S creen and choose carefully. Noncompliant patients are a challenge to the practice. Identify issues (situational, provider/staff, and patient) and develop plans to address them accordingly. Patients might be difficult for a variety of reasons. Listening to and trying to understand the patient’s situation may improve provider–patient interactions. Consider using alternative approaches (i.e., technology) to meet the needs

• f your patient populations.

Document all attempts to address noncompliance and/or difficult behavior . Terminate the relationship only as a last resort, unless threats are involved.

Summary

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Thank you!

Questions?

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The information contained herein and presented by the speaker is based on sources believed to be accurate at the time they were referenced. The speaker has made a reasonable effort to ensure the accuracy of the information presented; however no warranty or representation is made as to such accuracy. The speaker is not engaged in rendering legal or other professional services. If legal advice or other expert legal assistance is required, the services of an attorney or other competent legal professional should be sought.

Disclaimer