Plan of Care for the Digital Clinic, Part 1 - Chiropractic Practice Management

Plan of Care for the Digital Clinic, Part 1
March 26, 2007
By Steven Kraus,DC
Dynamic Chiropractic

Would you spend thousands of dollars on a clinic expansion without seeing a detailed rendering? All you have is the contractorÌs word that youÌre going to get the space you need and that it will look the way you want. As far as the projectÌs time frame, ÏThat all depends,Ó says the contractor. ÏWeÌll work on it for the next six weeks and then see how it goes.Ó

If youÌre like me, you wouldnÌt invest that much time, energy or money on a project with so many unknowns. You just donÌt get that kind of work done without demanding a plan from the professional in charge.

Ironically, while we would never subject ourselves to this lack of planning, this kind of investment in time, energy and money without a plan is exactly what our patients do every day in our offices. They do it every time we define our plan of care as: ÏThree times a week for the next month, and then weÌll see how it goes from there.Ó Even though a plan of care for our patients is just good, sound chiropractic Ò and a legal necessity if we have Medicare patients Ò many of us donÌt even know where to begin when it comes to creating that plan. And it shows. Medicare is starting to figure it out and so are our patients.

IÌd like to tell you how digital documentation, true electronic health records and digital efficiency can reform the way your practice meets this legal demand by prompting you to manage the patient better than you do now. It might sound like a challenge, but it actually will save you money, and it could boost your bottom line. Of course, your patients will be impressed as well, and really, itÌs what they deserve.

But perhaps IÌm getting ahead of myself. LetÌs get back to the reality in a majority of chiropractic clinics and hash out why thereÌs a deficiency in treatment plans Ò and how I could dare say such a thing. Once you understand where researchers of documentation and data flow like me are coming from, you will understand why I can see such a disastrous documentation climate, but still envision a bright future.

Two Problem Realities

There are two unfortunate realities occurring in many practices today: one, a proper plan of care isnÌt being made because, two, a deficient concept of a plan of care is being perpetuated in our profession. First off, I canÌt say for certain whatÌs going on in every clinic, but if the 2005 report from the Office of the Inspector General (OIG) of the Department of Health and Human Services accurately depicts whatÌs happening in our profession, many of us arenÌt fulfilling legal obligations Ò very explicit legal obligations.

The report reads: ÏJust 28 percent of chiropractic services were provided as part of a written plan of care, and only 23 percent of those plans included specific treatment goals and objective measures to evaluate progress towards those goals. ÷ The absence of specific goals was a strong indicator of unnecessary care.Ó1

To pare it down to what matters most, approximately 72 percent of chiropractors in the Medicare program arenÌt actually writing down what they intend to achieve with their patients. And of the minority that does, perhaps two out of 10 will actually include the necessary ingredients to a care plan, such as simple goals. Now, read that last line from the report again, and understand what the government is saying. IÌll reword it for them: ÏIf you canÌt take the time to write down goals for your patientÌs improvement, then you must not have any in mind, and therefore your care will be defined as unnecessary, and weÌll refuse to pay you. If it isnÌt in writing, then it doesnÌt exist.Ó

These very blunt words have gotten a lot of us active in trying to figure out where weÌve gone wrong as a profession. ThereÌs no room here to detail the responses from our official educational and political bodies. Suffice it to say, and as IÌve said in previous columns, things are going to have to change if theyÌre going to get better, and I know IÌm personally not waiting around to see where the chips fall. My whole interest in digital clinic management and what I do as a clinician has largely been in response to the need for better documentation in chiropractic practice, which began long before this OIG report. While itÌs a proverbial smoking gun that indicts our deficient documentation, the report only confirmed for us documentation junkies what we really knew all along: We, as a profession, just donÌt have a proper concept of what a plan of care is or whatÌs required of us for documentation that will withstand third-party inspection.

What a Plan of Care IsnÌt

Listing how many weeks you will see a patient before a re-examination is not a plan of care. That may be what you learned in student clinic, but Medicare and other third-party entities arenÌt basing their standards on what your clinic doctor told you. Neither is a plan of care as your practice management guru defines it to be. Not every patient who walks through the door is going to have a level of functional severity or objective findings to substantiate giving them a three-by-12-visit schedule. If every new patient you see is getting the same treatment plan, then according to third-party standards, theyÌd all better be presenting with the exact same complaint.

A time frame is only a prediction of how long a patient will need to regain whatever it is theyÌre seeking under your care. In fact, it may be changed on a week-to-week basis, based on your experience, outcomes data, and information obtained from the visit-to-visit encounters. If a time frame is all a treatment plan includes, it becomes easy to understand how a modification of that plan becomes difficult. Modifications are based on goals and objective observations; the kind of things you write down. Modifying without references to previous predictions becomes a kind of subjective exercise thatÌs very confusing to the patient and hard to track on paper. It becomes too easy for the patient and third-party payer to imagine youÌre stretching things out in your own best interest rather than because of patient need.

Also, a plan of care isnÌt how many visits the patient will come into your office. ItÌs how many times they are going to receive a certain chiropractic modality (e.g., flexion-distraction) for their presenting condition, based on your protocol of choice. It also includes any other therapy given by any other provider in your facility, and when, where and why that decision is being made. In addition to stating goals for the patient, a plan of care also should be a detailed game plan of how those goals are going to be achieved and how they will be evaluated.

What a Plan Should Be

Essentially, a plan is a road map of where you predict patient outcomes and how you justify your involvement with the patient. ItÌs your declaration of intent, one that you say deserves reconsideration every time the patient substantially improves or makes a turn for the worse. ItÌs your proof that you want whatÌs best for the patient and identifies the standard youÌll use to determine if they are responding to care in an expected way. ItÌs your record that you are as good as you say you are and that chiropractic is as effective as you say it is.

A plan of care isnÌt just in our heads prompting us to clue our patients in when we think theyÌre noncooperative. It exists in the world of flesh and blood, pen and paper, or as I prefer, binary code. ItÌs been recorded, so according to third-party standards, it exists and cannot be a basis for which weÌll be denied payments. ItÌs evidence of your patientÌs progress and a tool to educate your patient about the objective ways in which chiropractic care has been effective for them, and how it could be effective for their friends and family as well.

A Plan Could Be Digital

So, how do you feel now? Are you excited about the possibility of what a plan of care could be? Or are you resisting these suggestions because you believe IÌm overstating the problem, or because you think what I suggest is impossible when, as it is, we barely spend half our time in direct patient care? If you think IÌm overstating the problem, I canÌt help you. WeÌll just see how the future unfolds.

If you think my ideas are worthy, but impractical, then IÌve got another aspect on what a plan of care is not. A plan of care is not limited by paper. To steal a phrase from a previous column, itÌs not limited by pen-and-paper physics. If the whole of your resistance to goal-setting and objective measures for each and every patient is that itÌs impossible under our current model, then I would say youÌre right. But the model is changing. Pen and paper are obsolete. What we can do now in seconds used to take minutes, and that goes for plan of care as much as anything else IÌve addressed in this venue, including authorization-of-care forms and improving informed consent.

This time, IÌve talked about the bad news when it comes to chiropractic practice and creating a patient plan of care. In my next column, IÌll get to the good news. WhatÌs the good news? ItÌs about how the digital clinic can help us do what seems to be impossible: manage our patients more effectively so we can get the most out of every clinic interaction. ItÌs already happening in those few, but efficient, digital clinics of the future.

Reference

1. Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis. Department of Health and Human Services, Office of the Inspector General, June 2005. OEI-09-02-00530, p.11.