July 2009

Practice Tactics: Treatment protocols

Documented care plans can dramatically improve both your bottom line and your patients’ outcomes. Talk about a win-win.

Hand drawing empty diagram

iStockphoto.com/Brian A. Jackson

Creating a consistent, comprehensive and systematic process for treating lower extremity ailments improves patient outcomes and can also improve the financial performance of your practice, often by a considerable degree. Depending on patient volume and current practice behaviors, adopting comprehensive treatment guidelines can generate between $40,000 and $50,000 of incremental revenue for a solo practice. The advantages may seem obvious, but in clinical practice, such processes are not very common. While many clinicians claim to have either rudimentary or detailed treatment protocols in place in their practices, a review of practice data might suggest otherwise. Like personal and professional goals, comprehensive treatment protocols need to be written down and adhered to in order for maximum benefits to be realized.

Many practitioners shy away from this approach to care, disdaining “cookie cutter medicine” and claiming that it does not properly acknowledge the uniqueness and variability of patients. In fact, a properly designed treatment protocol is not prescriptive. It allows for clinical judgments to be made and assists clinicians in the decision making process. And it ensures that those clinical judgments are made in the context of a comprehensive and systematic blueprint for assessing and treating common conditions in a practice setting, which results in greater consistency.

Optimizing outcomes
There are numerous reasons why treatment protocols help to improve patient outcomes. In many different clinical and institutional settings, they have been shown to be both efficacious and cost effective by reducing the length of hospital stays and identifying complications early enough to minimize their deleterious effects. Properly crafted protocols help to identify “best practices” for a given diagnosis and create a well-defined set of standards of care. Capturing this information in a document and properly disseminating it to the entire clinical and administrative team provides a single framework for solving patient problems and facilitates a patient-focused approach to care. Because every member of the clinical team, whether inside or outside the practice, understands the assessment and treatment approaches and objectives, the variability that typically arises in a practice can be minimized or eliminated.

The institutionalization of protocols in a private practice setting can also improve the financial health of the enterprise. All staff members need to be thoroughly trained on the care plan details and each team member’s role in implementing them. This is not limited to just the clinical team. Billing, reception and other administrative functions will also become more predictable as a result of having a well defined plan for certain types of patients. In turn, the organization becomes anticipatory rather than reactionary in support of the clinical and administrative aspects of the operation. When your staff can stay one step ahead of you and be prepared for what is coming next, they will function more efficiently.

Maximizing compliance with the care plan depends on proper presentation. When patients understand the entire assessment and therapeutic landscape, they are more encouraged to complete their therapy as directed by the practitioner. If a patient drops out of the practice after only one or two visits for a condition that requires more time to properly treat, it is often because the presentation was incomplete or ineffectual. Protocols help to create fluidity in patient communications and will usually improve patient acceptance.

Disciplined adherence to treatment protocols and running all of the appropriate diagnostic tests and assessments can lead to valuable sources of practice revenue. This is not to suggest that revenue generation should be why testing modalities are added. Only the most accepted testing standards should find their way into your protocols. However, a review of practice data frequently reveals that even appropriate testing is often performed inconsistently. These inconsistencies can stem from a variety of non-clinical issues, including reimbursement, staffing and patient scheduling. By creating greater consistency in appropriate testing, the practice will be able to capture more revenue attendant to those modalities.

Getting started: Five steps
For those practitioners who have not yet created protocols for their practices, there are five primary steps to follow:

  • Determining the diagnosis
  • Review of best practices
  • Create the flow chart / decision tree
  • Communications throughout practice
  • Periodic review

Not every condition treated in your practice will warrant the time and energy required to create a detailed treatment protocol. Start by identifying up to three key conditions. Several criteria are involved. The first is the frequency of a particular diagnosis. Try to select high-volume conditions so that the benefits of an organized, systematic approach to care will be most meaningful to the practice. If you treat a large number of heel pain patients, but hardly any wound care, it  makes the most sense to concentrate on a comprehensive heel pain protocol. In addition to frequency, the condition should have a high degree of variability. To determine this, evaluate the medical charts by reviewing the previous 25 patients with that particular diagnosis and determine the uniformity or variability of care. Again, focus your efforts on a diagnosis that has the greatest impact on your practice. Finally, practitioners should have a keen interest in and aptitude for the selected conditions.

Now it’s time to gather information. Remember a comprehensive treatment protocol is an algorithm predicated upon best practices and the state of the art. If you are treating that metaphorical heel pain patient the same way as when you started practicing 20 years ago,  it’s time to take another look. Your professional association or any educational institution may already have clinical pathways established for the diagnoses that you have selected. A comprehensive literature review and consultation with noted authorities is also recommended. Finally, consider vendors as a resource to identify new products or technologies that are applicable to the diagnoses in question.

After gathering all of the information, compare and contrast your current approach to assessment and treatment with those identified in the literature search, institutional clinical pathways, or other sources. Decide what should be added to or deleted from your current approach. Try to rise above the normal human response to change, which is to avoid it. If the benefits are to be realized, changes are going to be necessary. Most clinicians who have gone through this process have reported that initial discomfort  ultimately gave way to unquestioned satisfaction with regard to more comprehensive care and considerable improvements in financial performance.

Let it flow
After making the decisions regarding best practices, develop a flow chart that identifies exactly what will happen to each patient during each step of the protocol. This needs to be broken into “with improvement” and “without improvement” branches. For example, if part of the pain management approach for our heel pain patient includes a series of injections over the course of several visits, you may decide that 0 percent improvement after the first injection indicates a need to stop the series immediately and send the patient for an MRI to rule out a ligament tear. It is important to include all dispensable items in the protocol, including DME and over-the-counter remedies. This will ensure that proper authorizations are done and proper billing is achieved, which in turn will maximize appropriate revenue opportunities.

Now that the hard work is done, it is time to share the integration and implementation burden with every member of the practice team. Every member of your staff should be completely familiar with the aspects of the treatment protocols that are relevant to his or her job description. Patient scheduling, billing and documentation, treatment room preparation, test preparation, dispensing, and chair-side assisting tasks should all be reviewed and assigned in consideration of a patient’s diagnosis and stage of treatment. With so many aspects of the patient encounter being properly anticipated, practitioner productivity will increase. Some practitioners use an exception sheet for their medical assistants, which identifies variances from the typical protocols. For example, a protocol for treatment of heel pain might dictate that a patient automatically be scheduled for a unilateral X-ray taken from a specific view on the initial visit. On the exception form, the doctor might request additional views or possibly order a diagnostic ultrasound examination instead.

The final step is to develop a timeline for periodic review and a method for documenting effectiveness. Because protocols are intended to reflect the best approaches to assessment and treatment, appropriate attention must be paid to changes taking place in your field of care. As new technologies are developed, or new treatment approaches are shown to be effective, your practice protocols should be modified to pass on these advances to your patients. It is equally important that an objective system for outcome measurement be embedded into the practice protocols. In many clinical settings, this key process is either absent or not completely objective. A lack of patient complaints, for example, should never be the only measure of clinical success. Objective treatment objectives should be established, and patients’ progress should be measured against those objectives to determine whether protocol changes have improved outcomes. Analog pain scales, improvement in gait parameters, or other measurable endpoints should be considered. Remember, if you can’t measure it, you can’t manage it.

Compliance self-assessment
If you have gone to the trouble of creating comprehensive protocol documents, it is valuable to be able to determine your own level of compliance with your plans. You may be surprised by the inconsistency with which your practice adheres to its own guidelines. Achieving the maximum benefit of providing systematic care requires disciplined implementation of each protocol.

To evaluate your own compliance, select one of the more common diagnoses for which you have developed a protocol document. Identify the basic approaches to the initial assessment and diagnosis development, listing each test or procedure. Next, detail the various treatment modalities, both initial and ongoing through to discharge. If additional tests are required to determine progress or to document treatment endpoints, identify those as well. Finally, determine the number of patient encounters included in your care plan.

Randomly pull the charts of 25 patients who were diagnosed with the condition you are evaluating and have completed their treatment regimen. If, for example, your protocol for heel pain included x-rays, biomechanical evaluation, strapping and injections during the first visit, you would identify how many of the 25 patients received each of those procedures or tests. Continue this review for each  part of the protocol and score your percentage of compliance for each procedure. If, in the above example, only 20 patients were x-rayed, your score on that particular procedure would have been 80%. While there are no specific benchmarks for these behaviors, an initial target should be in excess of 70%. If you are consistently below this level, thought should be given to altering the protocol.

There are many reasons why caregivers deviate from an original care map. A properly constructed treatment protocol provides complete freedom for clinical judgments to be made. The reality, however, is that often testing or treatment decisions are altered by non-clinical variables such as reimbursement, judgments about a patient’s willingness or ability to pay for services, schedule conflicts, poor patient presentations, and organizational shortcuts. These factors can compromise outcomes and undermine the financial performance of practices.

Strength in documentation
In this very challenging and changing health care environment, reducing variability and disorganization, documenting effectiveness, and maximizing financial performance will be increasingly important. Additionally, there is a medicolegal benefit to having a systematic approach to patient care: If the decision making process is consistent and well documented, it is much more difficult to assail your approach. Malpractice insurers are in total agreement with this fundamental approach to practice.

So, for all of the right reasons, better outcomes, improved financial performance of the practice and a more defensible approach to patient care, documented practice protocols are an increasingly important management tool for practitioners.

Jason Kraus is executive vice president of Langer Biomechanics and former partner in the practice consulting firm SOS Healthcare Management Solutions.

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