Urgent message: Call-backs within 24 to 48 hours of discharge can identify potential complications, ensure that instructions are followed, and reinforce a positive visit experience.
ALAN A. AYERS, MBA, MAcc, Experity
Introduction
Urgent care centers provide immediate medical attention to patients who feel their symptoms are too pressing to wait for an appointment with their primary care physician, but not serious enough to warrant a visit to the emergency room (ER). With extended night/weekend hours, high-visibility locations, and ondemand service via a walk-in model,urgent care is also a retail delivery channel for health care. As a result, urgent care centers must have adequate training, procedures, and equipment to assess, diagnose, stabilize or treat conditions ranging from cuts and sprains to back pain, fever, skin conditions, sinus congestion, stomach discomfort, and breathing difficulties—among others.
For many patients, urgent care is a provider of “first resort”—their entry point to the health care system—so what may be described as the therapeutic journey begins in the center and has to be put on the right path upon dis- charge when the patient is no longer under a provider’s observation. “Clinical quality” includes timely follow-up of findings and tests and, when appropriate, referral to a higher-acuity facility, a qualified specialist or a primary care physician for longitudinal care.
Anticipating Failure in Patient Communication
When an urgent care provider explains to the patient his or her observations, diagnosis, proposed treatment and follow-up requirements, the supposition is that the patient has understood those remarks and will comply accordingly. Medical professionals, however, have learned through experience that even when patients “hear” what the doctor has said in simple words, a large percentage will still fail to comprehend the details of the physician’s discharge instructions. A patient’s failure to understand next steps can result in adverse outcomes. It is not acceptable for a patient to put a prescription in his or her pocket, wave good-bye to the receptionist and walk out the door. This may be convenient and time-saving but it’s neither a good nor safe practice.
Before a patient leaves the center, a knowledgeable and responsible provider should:
- determine that the patient truly understands the clinical findings and the instructions for follow-up or self-care, and intends to follow them;
- assess whether, if the patient received a prescrip- tion, he or she intends to get it filled whether the cost of the drug is affordable;
- arrange for follow-up with a specialist or primary care provider if necessary, including forwarding the chart to the patient’s personal physician (verify it’s the same one named by the patient at registration); and
- detail where the patient should go if his or her condition worsens, including back to the urgent care center or straight to the hospital
In addition, the patient should be told upon dis- charge that it is the center’s procedure to telephone a day or two after the visit to determine all is going well with the therapeutic journey:
- the patient should be told that the center will call to follow up;
- the patient should be asked what number and what time to call;
- but never asked whether the center should
Making the Case for Follow-up Telephone Calls
Although many physicians insist theirs is a profession and not a business, if money is received in exchange for a service, then a business transaction has taken place. It can be a well or an ill conducted business, but a business it is. Profitability in urgent care is driven by volume, therefore, to capture repeat patient visits and spur positive word of mouth, urgent care centers need to ensure that patients are satisfied with their experience and outcomes.
Patient satisfaction is not merely a “smile and be nice” set of behaviors. It’s a philosophy that is founded in the concept that the patient’s experience of care is important and ultimately translates into greater compliance with the provider’s instructions. The follow-up steps are thus:
- Important: a follow-up (unexpected or not) is evidence of a patient-centered
- Effective: when an unexpected follow-up occurs, it’s impressive and reinforces a positive patient
- Engaging: a follow-up demonstrates a connection and a continuing concern and reinforces patient compliance with medical
- Revealing: a follow-up opens communications in both
- Differentiating: a follow-up puts a center ahead of its competition, especially when competitors are too busy to “care.”
- Inexpensive: most follow-up steps are relatively simple and don’t have a big price tag attached. Satisfied patients return, they refer and they are bonded to the practice through an established relationship.
The fact that urgent care is a business does not take “care” out of the picture. So although patients will be pleased that the clinic appears to be concerned for their welfare when it calls, the caller should, in fact, “care” that the patient is or is not improving. Calling and feigning “care” is worse than not calling at all.
Murphy’s Law
The cliché is that if something can go wrong, sooner or later it will go wrong. Wise urgent care operators do not fool themselves into believing that Murphy’s Law does not apply to their centers—instead, they set up damage control mechanisms for the inevitable. Often, providers are rushed to see patients and errors in diagnosis, treatment, medication, and documentation can result. Diagnostic errors are a leading cause of malpractice claims against outpatient facilities such as urgent care centers.2 The follow-up call is the damage control mechanism for a diagnosis of a severe condition that was not recognized at the time of the visit. Unless the patient is checked again by phone, he or she may not seek further care.
As a risk reduction strategy, follow-up phone calls3:
- Promptly recognize a change in patient condition
- Uncover patients’ concerns before formal complaints occur
- Give the center’s staff prompt feedback on their performance
- Minimize complaints, claims, lawsuits, and payouts
Because the calls provide accurate and timely patient satisfaction data, they can be used to improve the center’s patient satisfaction scores, provide a roadmap for improving center performance, and enhance the center’s reputation in the community.
Policies and Procedures for Follow-up Calls
As Table 1 illustrates, follow-up calls are generally made 2 days after the patient visit, with the exception of patients who have been referred for acute care. The treating provider should set the timeframe for callbacks by indicating in the chart at discharge: “how many days to f/u.” Any patients with a potential for misdiagnosis or for complication should be called the next day, or possibly even later the same day. And so should the mother of a child with a fever. But a sutured finger or a mild flu can wait 2 or 3 days because the condition may not immediately improve, resulting in premature complaints regarding outcome and an unnecessary return trip to the center if a call to the patient is made the next day.
Generally follow-up calls are made by a nurse, medical assistant, or well-trained member of the office staff except in cases of referral or when lab/test results need to be reviewed by the medical provider. Engaging the staff in callbacks works well when providers work “shifts” and are not present in the center every day. Although a patient may be flattered if he or she receives the personal attention of the doctor,4 that is not always possible although undeniably a call from the provider is preferable to that of a member of staff. Because most urgent care centers experience ebb and flow in patient volume, callbacks are something that can keep the center team productive during slow periods (typically mid-afternoon in most centers).
A patient follow-up call is not a social visit over the phone. Yes, it must be conducted in a pleasant manner and leave the patient feeling that he or she has a friend in the clinic. But the caller must be a knowledgeable person, attuned to hints of all not being quite as “rosy” as the patient bravely states, fully conversant with all the potential complications of the condition, and knowing always that the diagnosis may be incorrect.
During a patient callback, the caller might review the patient’s dis- charge instructions, ensure the patient is taking his or her medication as prescribed, inquire about pain control, and inquire whether the patient has received or scheduled follow-up care. Often, in addition to reviewing instructions, the caller asks the patient to describe the care and medication the patient has received since discharge. The caller may also schedule a follow-up exam and encourage the patient to make a list of questions to ask upon returning to the center.5
The patient’s chart should not be restored to filing until the follow-up call has been made. If the clinic is “paper- less,” then a program must be devised within the electron- ic medical record system to ensure no call is neglected.
Documenting Follow-up Calls
Among lawyers’ many axioms is, “If it wasn’t written down it didn’t happen.” Ludicrous as that may seem to non-lawyers, there will be little support in court for the doctor who says, “I know I called him, but I forgot to make a note of it.”
Any medical advice provided to a patient by telephone is entered in the patient’s record and appropriately signed or initialed, including medical advice provided and the names of individuals who provided such instructions. The method of record will depend on the office system, essentially to what extent it is “paperless.” But there must be a record of every phone call, and it is as well to have a checklist, as illustrated in Table 2.
At a minimum, the checklist should have a date and time stamp (always preferable to a potentially forged entry); name of person making the call; name of person responding if not the patient; a statement about the patient’s progress; a statement about future intentions; a statement about advice given; and duration of call (or time signed off).
Conclusion
Calling patients within 24 to 48 hours of discharge allows the urgent care provider to follow-up on how they are doing. Not only can callbacks identify potentially life-threatening complications that require immediate medical attention, they can also ensure that patients understand the discharge instructions they were given, seek care with the appropriate referral providers, and have an opportunity to ask any questions. From a business perspective, follow-up calls increase patient satisfaction, reinforce a positive visit experience, and spur repeat business and word of mouth. Overall, callbacks are an inexpensive but high- impact way that urgent care centers ensure safe, quality care for their patients.
References
- http://www.healthcaresuccess.com/articles/forgotten-followup.html
- http://www.medicalattorneyny.com/Medical-Malpractice/Urgent-Care-Errors.aspx
- http://www.emergencyexcellence.com/discharge-phonecalls.html
- http://www.healthcaresuccess.com/articles/forgotten-followup.html
- http://cheyenneregional.org/cheyenne-regional-medical-center-recognized-at-national- conference-for-patient-call-back-results/
