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Click to edit Master title Taming the Tiger style Click to edit Master subtitle style Managing the Difficult Dental Patient 1/ 2/ 2019 0

Objectives At the conclusion of this program, you should be able to: 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 1

What the media say 2

What the researchers say Clinicians are 42% more likely to wrongly diagnose a complex medical issue When dealing with difficult patients: 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 3 randomised experiment. BMJ Quality & Safety. Retrieved from http://qualitysafety.bmj.com/content/early/2016/02/09/bmjqs-2015-004109

What claims data says about risk factors Risk factors are broad areas of concern that may have contributed to allegations, injuries, or initiation of claims. Primarily inadequate patient assessment, most often Inadequate informed consent involving a narrow diagnostic focus process; failure to properly educate patients about follow-up 80% Primarily patient instructions and medication noncompliance with regimens 70% treatment regimens; Percentage of Claim Volume 71% also involves patient dissatisfaction with 60% Insufficient care documentation of clinical 50% findings/ rationale for treatment 40% 43% 37% 30% 20% 24% 20% 10% 0% Clinical Judgment Technical Skill Communication Documentation Behavior-Related Source: MedPro Group closed claims data, 2005 − 2014 (all specialties); totals do not equal 100% because more than 4 one factor may be coded per claim.

How Can a Difficult Encounter Affect Patient Care? 5

Components of a difficult clinical encounter Healthcare Team Source: Hull, S. K., & Broquet, K. (2007, June). How to manage difficult patient encounters. Family Practice Management. 6 Retrieved from http://www.aafp.org/fpm/2007/0600/p30.html

Situational issues Cultural Environmental Office policies Location Complex healthcare system Financial Transportation 7

Provider/ staff issues Fatigued Dogmatic Fearful Distracted Condescending Unprofessional Defensive Frustrated Angry 8

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

Effects of provider/ staff behaviors Billing errors Appointment mistakes Miscommunication Impatience Apathy Frustration Documentation errors Loss of objectivity Employee dissatisfaction 10

Patient issues Complex health issues Substance abuse Family issues Psychiatric issues Financial/job issues Expectations Fear/confusion Past experiences Health literacy 11

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 12

Case study — the difficult patient The Noncompliant Patient: John B 13

Noncompliant patients Noncompliance might be due to: Lack of understanding Choice Miss appointments Not pay bills Noncompliant patients Also be difficult might: patients Be fearful Be dealing with other social factors 14

Putting it all together Emotional Psychiatric Fatigue Cultural issues issues issues Behavioral Substance Family issues Environment characteristics abuse Complex health Complex health Distractions Expectations issues system Past Location Financial issues Health literacy experiences 15

Addressing known situational issues Environmental Office policies Staffing deficiencies Staffing issues 16

Guidelines and Policies 17

Recommended guidelines Administrative Patient Care General • Appointment • Prescription • Complaint cancellation/ refills handling no shows • Mutual • Termination • Fees and respect of the refunds/ relationship • Visit follow- waivers up (“no • Behavior • Financial shows” or contracting obligations lab results) 18

Patient responsibilities 19

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 20

Complaint Process 21

Turning negative feedback into positive results “Your most unhappy customers are your greatest source of learning.” — Bill Gates 22

Patient complaint avenues State medical Phone/email Social media or dental licensing board State attorney Small claims Federal Trade general’s office court Commission HHS Office for Better Civil Rights Business Lawsuits (HIPAA Bureau violations) 23

Complaint–litigation cycle Complaint Public & No staff resolution effect Litigation Claim 24

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? 25

Handling complaints Consider Avoid rationalizing Don’t point fingers environmental safety Demonstrate your Determine whether understanding of Under promise and an interpreter is their concern with over deliver needed empathy Practice before Respectfully use meeting with the the patient’s name patient and/or when speaking to family him/her Verify your Let the patient understanding of speak without their concerns interruption 26

Limited Health Literacy 27

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 offered or utilized. Extractions were performed. At the follow up visit, complications were identified, and an immediate consult with an oral surgeon was recommended. 28

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. 29

What is health literacy? 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 Source: Institute of Medicine. (2004). Health literacy: A prescription to end confusion. National Academies Press. 30 Retrieved from http://www.nap.edu/catalog/10883/health-literacy-a-prescription-to-end-confusion

Resources to address health literacy “Saves Lives. Saves Time. Saves Money.” — NIH https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear- communication/health-literacy www.cms.gov/Outreach-and- www.cdc.gov/healthliteracy/index.html Education/Outreach/WrittenMaterials Toolkit/index.html?redirect= /written materialstoolkit/ 31

Teach-back Teach-back toolkit: http://www.teachbacktraining.org/ 32

https://www.cdc.gov/healthliteracy/pdf/Simply_Put.pdf 33