New Patients: Rules of Engagement

[BigSib]

I was only 3 months into practice and already had a heavy patient load seeing 20-25 outpatients per day. Before clinic I am hospitalist or newborn rounder in the morning one week every 2-4 wks and see some nursing home patients 1-2 mornings monthly. My typical schedule is Mon-Wed 9am-515pm and Thu 7-7pm (actual work /charting hours). I'm at the hospital or NH at 630-7 on the weeks I'm covering there. I take phone calls on Tues evenings and it's usually only 1-2 calls. It's all reasonably managable but starting to get hectic at clinic trying to see so many people who are usually pretty complex. Subsequently we're starting to cut back significantly on who we're taking on for new patients. I'm curious to know what kind of processes you have for accepting new patients (e.g., application, review of current chart, simple phone conversation with the nurse/staff).

I use the following strike out criteria for accepting all new patients:
- Any person who calls and asks if I prescribe a particular medication like marijuana, an opioid, or other features of doctor shopping
- Multiple previous PCPs
- Having a PCP in our system and switching here requires a review as to the reasons why.
- Discharged from a practice within our health system for any reason.
- Having a problem or medication list that is several pages long.
- Having a countless number of ED visits.
- Having a specialist for every body system already.
- Having another primary doctor through the VA or an out of state specialty center like Mayo and just wanting to use us as an urgent care.
- Any new patient who was scheduled to establish care and missed the first appointment cannot be rescheduled.

I still pick up a good number who do meet the criteria above if someone calls me about them (urgent care doc, caregiver, ect) or if I care for them in the ED or hospital and I think it's going to work out. All family members of established patients are free to join. I get a ton of referrals from the ED and cherry pick the easy patients for my staff to call, but I also have them call all of the addicts and alcoholics because I'm into that.

I strive for efficiency and effectiveness so we have a lot of processes setup to maintain this as much as possible. I spend a good 5 min reviewing my expectations of their interacting with the clinic as what kind of services we provide (e.g., suturing, XR, Ekg, etc) at the first visit.
- Established patients are discharged after 3 No Shows or late appointments and multiple fair warnings.
- We confirm appointments 24-48 hrs beforehand. Patients are instructed to come 15 min early and if they're 6+ min late for their appointment it's a No Show.
- Those who keep rescheduling their appointment the same day are limited in doing so after we catch onto this behavior.
- Everyone is strongly encouraged to use the patient portal to reduce phone calls.

Last apt is at 445 and we're nearly always done at 5pm.

I guess I want some kind of reassurance that this all sounds reasonable. At times I feel like a hard ass but most of the providers in my group are not accepting any patients and, being in an area of need, there's not many options for people around here right now.

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[FrustratedFamDoc]

Very reasonable. I have all new patients fill out a demographics form and will accept/deny from there. I accept probably 90% a chance but am clear right off the bat about what I do and don't do and what my expectations are. Poor attitude and in general being a complete jerk with no hopes of self help is a non-starter. Similarly, it's not my fault some doc 20 years ago got you hooked on irresponsible medications. If every visit is a nerve pill/pain medicine fight, there are other docs in the area that can better accommodate your wants.

 

[deleted87716]

All very reasonable, and much like we do. I don't do the "application" thing, although some offices in my group do. Personally, I'd find it insulting.

 

[septoplasty]

That's a great practice/set of rules. Goal setting, and obvious discipline is a good way to establish ground rules imo, some people will think this is a hard approach like you said, but majority of the people who are at least a wee bit self-motivated to do the right things for their help will follow and abide by this.

Any way you can share the details of the application itself? Would like to have something like this in stock/modify for my needs for future opportunities.

 

[VA Hopeful Dr]

All very reasonable, and much like we do. I don't do the "application" thing, although some offices in my group do. Personally, I'd find it insulting.

That's always been my thought as well. The only pre-screening of any sort that I've ever done is to make it clear that I don't prescribe controlled substances chronically. It's up to the patients to decide if they still want to show up.

 

[Shinken]

- Having another primary doctor through the VA or an out of state specialty center like Mayo and just wanting to use us as an urgent care.

It's all reasonable, except the point above. I usually don't mind the patients that want to use me as an urgent care while having a VA physician. It's an easy, quick level 3 visit at least, without the hassle of any "by the way, since I'm here for a cold, my sugars have been high...".

Also, your week is very similar to mine when I started practice. However, I quickly burned out and stopped doing hospital and NH visits. Keep the pace while you can, but don't be afraid to cut back. Your health and well-being are more important.

 

[deleted87716]

If they want to go to urgent care, they should go to urgent care. I've accepted a few patients over the years who continue to get all of their chronic care at the VA, and I've regretted it every time. They're invariably a big, hairy mess, and I can never get records from the VA. They're the furthest thing from an "easy, quick 99213" that you can imagine, unless you're into undercoding.

 

[Shinken]

Well, my experience has been different. Regardless, the OP can't go wrong by not taking those patients.

 

[Bacchus]

If they want to go to urgent care, they should go to urgent care. I've accepted a few patients over the years who continue to get all of their chronic care at the VA, and I've regretted it every time. They're invariably a big, hairy mess, and I can never get records from the VA. They're the furthest thing from an "easy, quick 99213" that you can imagine, unless you're into undercoding.

True. And when I do get records, it’s the entire medical record which each request.

Being the metric, quality, etc. guy, trying to hit milestones while having someone else in control of orders drives me ****ing bonkers.

 

[deleted87716]

Being the metric, quality, etc. guy, trying to hit milestones while having someone else in control of orders drives me ****ing bonkers.

That, too. Nobody needs more than one PCP.

 

[DoubleBogey]

I would love to setup a screening process like this, but unfortunately my employer doesn’t allow it. So, I setup a “goals of care” discussion regarding chronic pain meds, which some follow titration of opioids/controlled subastances to reasonable levels or they just leave and find another doctor in the area. The ones who stay I can say I have developed a great relationship with, but certainly the others are a struggle that drain everyone.

If I could screen, I would do exactly what you’re doing with the addition of:
BZ + opioid gets a call from staff prior to visit indicating that I will not be rx’ing these meds and if they still want to see me great; opioid doses > 30mme the same; same with sleep aids. The pts on large doses of mood stabilizers must have a psych rx’ing; and an allx list > 5 meds would be a caution flag.
No show to new appt would be an auto dismissal.

I would have a hard time turning away vets, but hey, to each their own.

Wish I learned Spanish because using the translator/bat phone chews up time and becomes very challenging in pts who are chronically ill and very poor self awareness/health IQ.

 

[FrustratedFamDoc]

I would have a hard time turning away vets, but hey, to each their own.

I turn no vets away, ever but agree with the sentiment that it is typically a pretty big cluster. Most end up seeing me almost exclusively so it's not that bad.

 

[BigSib]

I turn no vets away, ever but agree with the sentiment that it is typically a pretty big cluster. Most end up seeing me almost exclusively so it's not that bad.

Only turning those away who specifically express they're just here for urgent needs. That one is hard to pick up on before they show up in the office. Most of them are just getting Medicare and are happy to branch out from the VA system. A lot of those have a ton of specialty access and end up getting their yearly labs and such there.

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[TableMD]

Ill see anyone but I do not believe in doing anything that makes me uncomfortable.

The more the office has a structured policy for new patients, the more the physicians will be protected. An example of this is no narcotics/benzos w/o prior records.

In regards to benzos, i am only comfortable with prn doses in someone actively emgaged in productive therapy with a psychologist. If they arent willing to work, then I am happy to see/support them, but will not prescribe.

Opiods: my philosophy is that they harm 90%, help 10% and that the patient has an obligation to prove that they are in the %10 category through adherance to a regimen of psychiatric outreach, exercise/rehab and a willingness to engage in community relationships (volunteering, working as able), nutrition (weight loss), etc. if they are a pain catasthophizer, then a psychologist must be part of the treatment.

Thats my approach, so by having nonsubjective metrics, I try to reduce the stress that can occur with some of these encounters

 

[simpler2]

The providers in my system who try to pre-manage expectations and use similar criteria to create barriers for patient access also have the worst productivity numbers for our system. Those of us with the highest quality and productivity stats just see whoever and whatever gets scheduled. I personally see attempts at controlling patient/problem access futile and frequently counterproductive. Keep in mind I view practice with the lens of a community clinic provider working in a FQHC system.

 

[deleted87716]

Keep in mind I view practice with the lens of a community clinic provider working in a FQHC system.

Yeah, you're pretty much screwed.

 

[DoubleBogey]

The providers in my system who try to pre-manage expectations and use similar criteria to create barriers for patient access also have the worst productivity numbers for our system. Those of us with the highest quality and productivity stats just see whoever and whatever gets scheduled. I personally see attempts at controlling patient/problem access futile and frequently counterproductive. Keep in mind I view practice with the lens of a community clinic provider working in a FQHC system.

If I have a new patient who is being prescribed >120 MME per month (which I won’t continue) or on methadone (which I don’t prescribe) - this should trigger a conversation of expectations prior to the visit to avoid and unnecessary visit. Sure, I could see them and say I’m not prescribing these meds/taking responsibility for them and bill for the encounter, but that’s just wasting the pt’s time. I’m not going to have the proverbially, or literal, gun pointed to my head to prescribe something I’m not comfortable with, especially when this is my livelihood AND we are seeing more and more DEA involvement regarding to high MME prescribing. Just not worth it

 

[smq123]

If I have a new patient who is being prescribed >120 MME per month (which I won’t continue) or on methadone (which I don’t prescribe) - this should trigger a conversation of expectations prior to the visit to avoid and unnecessary visit. Sure, I could see them and say I’m not prescribing these meds/taking responsibility for them and bill for the encounter, but that’s just wasting the pt’s time. I’m not going to have the proverbially, or literal, gun pointed to my head to prescribe something I’m not comfortable with, especially when this is my livelihood AND we are seeing more and more DEA involvement regarding to high MME prescribing. Just not worth it

I'm also assuming that your practice can afford to hire people that are a) reasonably competent or b) can be trained to some semblance of competence. FQHCs don't always have that luxury. Many of our staff have zero experience working in a healthcare office before working for us. So while the phone room staff may be told "our doctors do not prescribe suboxone, methadone, benzos, or opiates at the first visit," they may either forget or not recognize when a patient is asking for a controlled substance.

In an FQHC setting, it truly is often easier to just see the patient than argue at all. The less complicated you make things for staff, the happier everyone is.

 

[TableMD]

In an FQHC setting, it truly is often easier to just see the patient than argue at all. The less complicated you make things for staff, the happier everyone is.

I never think its a waste of time for a physician to disagree with an in place med regimen, since often these patients are hustled through without a real eval. Usually these patients are leaving a pill mill shut down by the Feds, state licensing board etc, so its always fair to ask “ if you were happy with your prior physician’s plan, why are you seeing me?”

“Well uh hes no longer able to practice medicine....”

“Well there you go...Has this worked, are you able to work on these meds, doing well in the community, leave your house (other than med refills?).”

In a situation like what you are dealing with, keeping the doors open to underserved patients is an important victory itself and I would be happy with a somewhat speedy rooming process and would do the med eval/expectations myself. You going to work and doing what you do is important.

Its part of the previous physicians job to tee these folks up with a safe tranfer of care plan, so them showing up on q4 Norco and q6 ativan q12 adderall with sleep apnea and an a1c of 12 and smelling of MJ while demanding refills on all the above is not fair to you, to make you scramble to fix it all in 15 to 30 minutes. I would prescribe with a wean to avoid withdrawal from the benzos with close follow up and advise that I did not create the situation but I am happy to try to medically atabilize within my skillset and prescribing scope, and adhere to the goal of 50 mme.

Everyone has a story and these are often sad and neglected souls.

 

[smq123]

I never think its a waste of time for a physician to disagree with an in place med regimen, since often these patients are hustled through without a real eval. Usually these patients are leaving a pill mill shut down by the Feds, state licensing board etc, so its always fair to ask “ if you were happy with your prior physician’s plan, why are you seeing me?”

Yes, indeed. I have been practicing in Florida for the past 5 years. It's always fun to request the patient's previous records, and have them sent to you from the local Sheriff's office - because that's where they went when the previous PCP was busted.

Its part of the previous physicians job to tee these folks up with a safe tranfer of care plan, so them showing up on q4 Norco and q6 ativan q12 adderall with sleep apnea and an a1c of 12 and smelling of MJ while demanding refills on all the above is not fair to you, to make you scramble to fix it all in 15 to 30 minutes. I would prescribe with a wean to avoid withdrawal from the benzos with close follow up and advise that I did not create the situation but I am happy to try to medically atabilize within my skillset and prescribing scope, and adhere to the goal of 50 mme.

<shrug> Most of these patients were coming from doctors who have no experience prescribing these types of medications. One was a plastic surgeon who had lost his hospital privileges, so he was doing pain management to "pay the bills." Another came from a semi-retired orthopedic surgeon. Another came from an EM physician who had decided to open his own medical spa. Many have come from doctors who did not finish their residency, and have been forced to see whatever patients they can in order to keep their homemade clinics open. At this point, I don't really care about "fairness," I'm just surprised that their incompetence hasn't killed anyone yet.

I don't even bother trying to get them to a "goal" of any sort. My CMO does not allow any chronic pain medication management, so these patients are free to go elsewhere if they're not willing to wean down to zero.

Everyone has a story and these are often sad and neglected souls.

Eh....kind of. Some of them, sure. Some of them were legitimately led astray by incompetent doctors, or by doctors who were inexperienced but meant well. But those were the minority, in my experience. Many of them will explicitly admit that they chose these doctors or clinics because they had a reputation for giving out pain meds without asking many questions. Some of these patients have poor pain tolerance due to years of drug abuse, or just low "resilience" in general. Physical therapy and weight loss are slow, and time consuming. Pain pills are fast and offer relief right away.

 

[TableMD]

makes sense, kinda laughed when I saw that you are from Florida (I grew up in Miami)....neat discussion.

 

[smq123]

makes sense, kinda laughed when I saw that you are from Florida (I grew up in Miami)....neat discussion.

Miami has actually been a relief compared to the Gulf Coast. Pasco County had (has?) a terrible narcotics/drug problem, and once their pill mill got shut down, they'd go to Tampa, St. Pete, and Clearwater. Many of the Hispanic patients in Miami are skeptical of any medication - annoying when it comes to their diabetes and HTN, but wonderful when it comes to pain. Many will gladly take Robaxin or Voltaren gel and skip the Percocet once you mention the horrible "addiction" word.

 

[VenusinFurs]

man, this makes me wish I had any sort of control in who I see