Patient Relations: Anticipate and Address Challenging Situations

Our dedicated patient safety risk managers deliver a wide range of expert services and resources, including telephone consultations to guide members through challenging situations. Questions about “patient relations” and “patient termination” consistently appear as the top reasons that members request assistance. The following strategies can help prevent challenging patient situations and provide guidance if a situation arises.

Conditions of Treatment

Develop a Conditions of Treatment agreement for each patient to review and sign at the outset of the professional association. This type of agreement enhances patient understanding of the requirements for initiating and continuing care with the practitioner.

In the agreement, identify expectations regarding patient adherence with care plans, medication regimens, specialty referrals, follow-up appointments, and financial obligations. Outline the level of behavior required toward staff, other patients, vendors, and visitors to the office; emphasize the group’s zero-tolerance policy toward unacceptable conduct (such as violence, disparaging language, and sexual harassment); and note that failure to comply with the agreement may result in termination of the relationship. Post the Conditions of Treatment on your practice website. (For more information on this topic, see our article “Set Expectations for New Patients With a Conditions of Treatment Agreement.”)

Patient Conduct

Noncompliant and nonadherent patient conduct (whether intentional or unintentional) has been shown to negatively affect clinical outcomes. Negative behaviors include failing to participate in the recommended treatment plan, canceling follow-up appointments, discontinuing therapy or medications prematurely, refusing to seek specialty referrals or obtain laboratory tests as ordered, and ignoring established office policies regarding payment and practice operations.

Uncover and Address Barriers

A patient’s failure to engage in the planned treatment process may be related to health literacy, mental competency, language or cultural barriers, or financial restraints. Effective communication can help you discover the cause of the behavior and assess the patient’s comprehension of the treatment plan. Consider the following strategies:

• Maintain an ongoing dialogue with the patient to identify potential adherence barriers. Ask about any issues preventing the patient from following your recommendations, and work to address concerns.
• Use language services for your limited English proficiency (LEP) patients.
• Determine the extent of the patient’s comprehension. Ask the patient to repeat back what was said during the informed consent process, the treatment plan discussion, or any educational session with you or your staff.
• Establish written financial policies, and consider using payment plans to assist patients in meeting their financial responsibilities.
• Refer patients to appropriate community resources, such as those providing transportation, in-home care, meals, or smoking cessation.

Promote Patient Engagement

Meaningful exchanges of information with patients who understand and agree to a recommended plan result in better adherence and, ultimately, in more favorable outcomes.

List the patient’s responsibilities as part of a written plan, and provide a copy to the patient. Encourage involvement by using interactive tools, such as online educational materials and checklists.

Ask patients to respond to reminder calls and notifications regarding appointments, referrals, diagnostic tests, or medication refills.

Document Behavior

Document specific nonadherent or noncompliant behavior, such as canceled or no-show appointments and failure to follow instructions. A well-documented record that reflects the patient’s responses demonstrates the practitioner’s attempts to develop a plan of care.

Document patient refusal. If, at some point, the practitioner-patient relationship is discontinued, documentation about patient refusal supports the practitioner’s efforts. (See our article “Informed Refusal.”)

Manage Continued Behavior

Discuss and document the patient’s understanding of the consequences of the continued behavior. If you are not able to have this discussion with the patient in person, explain the consequences in a letter. Describe the actions the patient needs to take, such as calling the office for an appointment or obtaining a diagnostic study.

Ending Patient Relationships

If it becomes necessary to end a patient relationship that is no longer therapeutic or appropriate based on patient behaviors, it is critical that the practitioner end the relationship in a manner that will not lead to claims of discrimination or abandonment.

Although this list is not exhaustive, it is generally appropriate to end a relationship under the following circumstances:

• Treatment nonadherence.
• Follow-up noncompliance.
• Office policy noncompliance.
• Verbal abuse.
• Display of firearms or weapons.
• Nonpayment.

Special Circumstances

Several situations may require additional steps or a delay in ending the patient relationship if:

• The patient is in an acute phase of treatment.
• The practitioner is the only source of medical or dental care within a reasonable driving distance.
• The practitioner is the only source of specialized medical or dental care.
• The patient is a member of a prepaid health plan.
• The patient is pregnant. During the first trimester: End the relationship only if it is an uncomplicated pregnancy and the patient has time to find another practitioner. During the second trimester: only for uncomplicated pregnancies and only if the patient transfers to another practitioner prior to cessation of services. During the third trimester: only under extreme circumstances, such as illness of the physician. Effect a safe transition by working with the new practitioner and risk manager of the facility where delivery is scheduled.

Certain situations prohibit patient dismissal, including patients who have:

• LEP or status within a protected category under federal or state legislation.
• A disability—which cannot be the reason for termination unless the patient requires care or treatment that is outside the practitioner’s expertise.

Medical or dental groups may consider dismissing a patient from the entire practice to avoid an on-call situation that might require the practitioner who ended the relationship to treat the patient.

Written Notice

If you need to dismiss a patient, formalize the termination by providing written notice that you are withdrawing care and the patient must find another practitioner. Mail the written notice to the patient by both first-class and certified mail with a return receipt requested. (Both types of mailing are required in some states.) To promote optimal continuity of care, you may reassure the patient that you will be available to confer with the new provider. Include the following information in the notice:

Reason: Although stating a specific reason for termination is not required, it is acceptable to use the catchall phrase “inability to achieve or maintain rapport necessary to promote the trust critical to support an effective clinical relationship,” state that “the therapeutic practitioner-patient relationship no longer exists,” or assert that “the trust necessary to support the relationship has eroded beyond repair.” If the reason for ending the relationship is patient noncompliance/nonadherence, you may state it briefly and succinctly as well, along with your attempts to obtain patient compliance.

Effective date: Specify the effective date for ending the relationship and provide the patient with a reasonable amount of time to establish a relationship with another practitioner. Although 30 days from the date of the letter is usually considered adequate, follow your state regulations. The relationship may be ended immediately if the patient or a family member has exhibited threatening behavior toward the practitioner or staff. The relationship may be ended immediately under the following circumstances:

• The patient has ended the relationship. (Acknowledge this in writing with a letter from the practice.)
• The patient or a family member has threatened the practitioner or staff with violence or has exhibited threatening behavior.
• The patient participates in drug diversion, theft, or other criminal activity involving the practice.
• The patient exhibits inappropriate behavior or sexual misconduct toward the practitioner or staff.

Interim care provisions: Offer interim emergency care prior to the effective date. For emergency situations that cannot be appropriately handled in the office, refer the patient to an emergency department or instruct the patient to call 911.

Continued care provisions: Offer referral suggestions for continued care through medical or dental societies, nearby hospital referral services, community resources, or the patient’s health plan network. Do not recommend another healthcare practitioner specifically by name.

Patient records: Offer to provide a copy of the office record to the new practitioner by enclosing a HIPAA-compliant authorization (to be returned to the office with the name and address of the new practitioner and the patient’s signature). One exception is a psychiatric record, which may be offered as a summary in many jurisdictions in lieu of a full copy of the medical record.

Transition of care: Indicate your willingness to speak with the patient’s new practitioner to help ensure a smooth transition and continuity of care.

Patient responsibility: Specify that the patient is personally responsible for all follow-up and continued medical or dental care.

Medication refills: Explain that medications will be provided only up to the effective date that the relationship ends.

For more information, see our article “Terminating Patient Relationships” or contact your patient safety risk manager by email or phone.