Edinburgh/Trafalgar Family Health Centers, Inc.
POLICYCODE: AD 1.13
Reviewed/RevisedDate: 12/21/09 /
Next Review Date: 12/11
/Approved by:
/ Date:Date: / Effective Date: 12/12/07Edinburgh/Trafalgar Family Health Center
/12/11/09
Board of Directors
disCHARGING PATIENTS
PURPOSE:The purpose of this policy is to define the reasons for discontinuing the provision of patient services to established E/TFHC patients/consumers (i.e., “discharging” patients).
Rationale: The Mission Statement of the Edinburgh/Trafalgar Family Health Centers, Inc., (E/TFHC), specifically directs the organization to not only improve the health status of patients and communities, it also directs the E/TFHC to focus its efforts on serving those in need: “... with a particular evidence on helping the medically underserved and vulnerable residents.” The Indiana State Department of Health (ISDH) and the Health Resources & Services Administration (HRSA), (both governmental funding agencies), require Community Health Centers (CHCs) and Federally Qualified Health Centers (FQHCs) to serve consumers “... regardless of their ability to pay.” The ISDH and HRSA also require funded health centers to provide “affordable health care” as evidenced by offering a Sliding Fee Scale based on Federal Poverty Guidelines. At the same time, both agencies charge CHCs and FQHCs to distinguish between the concepts of “ability to pay” and “willingness to pay” when addressing the payment process with consumers. Finally, the ISDH, HRSA and the E/TFHC’s Board of Directors fully acknowledge that, in the provider - patient relationship, patients need to be actively committed and fully cooperative, (i.e., “compliant”) in order for the best service outcomes to occur.
With this information in mind, along with the E/TFHC staff’s appreciation that consumers occasionally have legitimate difficulty complying with reasonable expectations, limits must be set. Thus, whenever a consumer repeatedly demonstrates an inability/unwillingness to adhere to the expectations associated with being a Health Center patient, especially when such actions impede a provider’s ability to deliver effective medical care or interfere with the E/TFHC’s ability to serve patients as efficiently as possible, the process of discharging a patient should be initiated.
SCOPE:The entire E/TFHC organization
POLICY STATEMENT: This policy is intended to provide guidelines to the E/TFHC’s administrative and clinical staff for those situations when consumers do not appropriately cooperate and is interrelated with the following E/TFHC policies: AD 1.12 (“Patient Attendance”) and PC 11.01, (“Prescribing Controlled Substances”). In other words, when patients do not respond to the guidelines and expectations of the E/TFHC when it comes to their relationship with the organization as a whole and the clinical team in particular. Such instances include, but are not limited, to the following:
1.Attendance Compliance:
a.patients keeping scheduled appointments at E/TFHC;
b.patients arriving on time for appointments;
c.patients calling ahead when late in order to determine if they can still be seen;
d.patients following established guidelines for canceling scheduled appointments;
e.patients routinely updating personal addresses, telephone numbers and current health insurance carrier when requested;
2.Clinical/Medical Compliance:
a.patients following their provider’s directives re: actions needed to address a medical condition;
b.patients following through with appointments made with referral sources - - i.e., imaging, mammograms, medical specialists, etc.; and
c.patients adhering their provider’s directions when consuming prescribed medications;
d.when applicable, patients adhering to the expectations outlined in a Controlled Substances Agreement.
3.Behavioral Compliance:
a.patients adhering to the facility guidelines related to noise, not damaging the facility or its equipment, not entering restricted areas, etc.; and
b.patients not behaving or interacting in a threatening, argumentative, rude or hostile manner. with staff, providers and other patients.
PROCEDURE:
1.Criteria/Circumstances for Discharging Patients:
a.Attendance Non-compliance (“no-shows”).
1)Definition: Please refer to E/TFHC Policy AD 1.12 “Patient Attendance,” to review the criteria used to determine this form of non-compliance.
2)Procedure: If a patient who fails to show-up for a scheduled appointment, or, fails to contact the Health Center within two (2) hours of a scheduled appointment in order to cancel an appointment, (i.e., “no shows”), the following actions will occur:
a)For individuals who are established patients at the E/TFHC, the missed appointment will be noted the in their medical record.
b)The same day of the missed appointment, the front office staff will notify the clinical provider involved of the missed appointment.
c)The provider will review the patient’s chart and the stated purpose of the appointment and determine:
-if the patient should be contacted by phone to reschedule, and - whether or not to send the patient a “missed appointment” letter.
d)Patients who miss an appointment and do not call to cancel the visit will be
mailed a letter pointing out the missed appointment plus a copy of the patient attendance policy. The following sequence of letters will be used for missed appointments:
- First Missed Appointment: / The Practice Supervisor where the patient receives services will send the patient a reminder letter and a copy of the attendance policy.- Second Missed Appointment: / The Practice Supervisor will send a second reminder letter. A copy of the letter will be placed in the patient’s medical record.
- Third Missed Appointment: / If a patient misses three (3) appointments within a six (6) month period, he/she may be discharged from the E/TFHC. The Practice Supervisor will follow the procedures outlined in E/TFHC Policy AD 1.13 (“Discharging Patients”).
b.Clinical/Medical Non-compliance
1)Definition: Whenever a patient repeatedly fails to follow a provider’s directives regarding the actions he/she needs to take in order to address a medical condition, such behavior is called “non-compliance.” When a patient is non- compliant, his/her behavior harms the provider - patient relationship because the provider realizes the patient is not fully cooperating with the healing process, thereby reducing or eliminating the likelihood of success. This behavior is especially serious when the patient has a potentially life-damaging and/or life- threatening illness (e.g., high blood pressure). On such occasions, when a Health Center provider realizes he/she cannot adequately treat a patient due to non-compliance, the provider may initiate the discharge process. It is at the provider’s discretion to determine when to begin the discharge process for non- compliance.
The other form of clinical/medical non-compliance involves the improper use of a controlled substance(s) by a patient that has been prescribed by an E/TFHC provider. Please refer to E/TFHC Policy PC 11.01 “Prescribing Controlled Substances” to review the procedure used to address this form of clinical non-compliance.
2)Procedure:
a) First Notice: When a patient fails to follow his/her provider’s directives for addressing a medical condition, the provider will complete a Patient Discharge Request form and submit it to the site Practice Supervisor. The Practice Supervisor will review the form with the provider and send the appropriate form letter to the patient, signed by both the provider and the Practice Supervisor, that:
- outlines the provider’s specific directives and recommendations,
- describes the area(s) of non-compliance, and
- requests that the patient follow those directives and recommendations.
A copy of this letter will be placed in the patient’smedical record.
b)Second Notice. Once the activities outlined in item 2) a) above have occurred, if the patient fails to follow his/her provider’s requests again, the patient will be mailed a second form letter, signed by the provider and the Practice Supervisor, that:
- outlines the provider’s specific directives and recommendations,
- describes the area(s) of non-compliance,
- requests that the patient follow those directives and recommendations, and
- notes that further non-compliance may result in the Health Center deciding it can no longer effectively serve the patient.
Once again, a copy of this letter will be placed in the patient’s medical record.
c)Should a patient fail to respond to the aforementioned notices described in both 2) a) and 2) b), the provider may initiate the discharge process outlined in section 2. (“Guidelines for Discharging Patients”) below.
c.Behavioral Non-compliance
1)Definition: When a patient, a patient’s family member or an acquaintance behaves within the Health Center in a manner that is disruptive, abusive or threatening in a verbal or physical manner to anyone, especially a staff member, a Quality Care Report will be completed on the incident and submitted to the Director of Quality & Disease Management.
2)Procedure:
a)A Quality Care Report will be completed on the incident and submitted to the Director of Quality & Disease Management.
b)First Notice. Upon receipt of the Quality of Care Report, the Quality Director will share a copy of the report with the site Practice Supervisor. Both administrators will investigate the matter and, if indicated, send the patient a notice (i.e., registered letter) that:
- identifies the individual whose behavior was inappropriate, (if it was not
the patient),
- describes the unacceptable actions/behavior,
- requests a change in behavior, and
- indicates that a repeated display of such behavior could lead to the
patient being suspended or discharged from the Health Center.
This letter will also include an invitation for the patient to meet with the Quality Director to discuss the matter in person. A copy of this letter
will be placed in the patient’s medical record.
d)Discharge Notice. If a second behavioral incident occurs, the Practice Supervisor will send the patient a certified letter that :
- describes the unacceptable actions/behavior that occurred,
- notifies the patient that he/she has been discharged from the E/TFHC,
- informs the patient that his/her provider will be available only for urgent care, and
- needs for thirty (30) days following the date of the letter.
Upon initiating this step, the Practice Supervisor will follow steps outlined section 2.b. of this policy.
2.Guidelines for Discharging Patients:
a.Discharge Requests. All requests to discharge patients for non-compliance in any of the three previously identified categories: patient attendance, clinical or behavioral must be
submitted in writing and forwarded to the Practice Supervisor or Office Coordinator where the patient receives services. The Practice Supervisor will investigate the request and execute the appropriate procedure(s) listed below.
If the circumstances of a case are particularly complex, the Practice Supervisor, at her/ his discretion, may forward the request to the E/TFHC’s Director of Quality and Disease Management for additional review and feedback. In such instances, the Quality Director will also investigate the matter. Collectively, those administrators will determine the course-of-action to take:
1)If the request has merit based upon the content of this policy, both the Practice Supervisor and the Quality Director will sign the request and the Practice Supervisor will execute the actions listed below.
2)If the request is denied, the following administrative staff will meet with the Quality Director and the Practice Supervisor to determine a course-of-action for the patient-in-question:
a)Attendance Non-compliance: Executive Director
b)Clinical Non-Compliance: Medical Director + attending Provider
c)Behavioral Non-Compliance: Executive Director
b.Steps in Notifying/Discharging Patients.Based upon the circumstances of the request, the following steps should occur when notifying a patient of being discharged:
1)The appropriate written notice (i.e., letter) will be generated and forwarded to the patient via registered mail (i.e., requiring a return signature upon receipt).
2)A copy of the letter should be filed in the patient’s chart.
3)If the patient has been sent a discharge letter, the following actions will occur:
a) The patient’s “discharged” status will be recorded in the patient’s medical record (Medmate) under area “f8” of the patient demographic screen as well as the effective date and the reason for discontinuing services.
b)All future non-emergent appointments will be cancelled.
c)A memo or e-mail will be sent to the Practice Supervisors or Office Coordinator’s at every E/TFHC clinical site regarding the patient’s status (please refer to item 3.a. below).
d)Receipt of the Post Office’s signed notice will be filed noted in under area “f8” of the patient demographic screen - - i.e., the date the notice was received.
e)If the notice is returned without signature by the Post Office, the unopened letter and envelope will be filed in the patient’s medical record.
f)If the patient contacts the office at a later date, after confirming the identity of the patient, he/she will be verbally informed of his/her discharge. In addition, a second copy of the discharge letter will be sent via registered mail.
g)All discharged patients will have direct clinical services discontinued as of the date of the notification letter and patients’ clinical practitioners only will provide urgent care services, if needed, for up to thirty (30) days of the date of the notification letter. The E/TFHC’s Executive Director must approve any exceptions to this procedure.
3.Additional Considerations:
a.Once a patient has been discharged from one E/TFHC service location, he/she will be considered to have been discharged from all E/TFHC locations.
b.If a patient has been discharged from the E/TFHC for non-compliance as outlined in this policy, and he/she requests to become an active patient again, he/she MUST meet with the Practice Supervisor of the Health Center involved before being reinstated. In such instances, the Practice Supervisor will, prior to meeting with the patient, meet with the patient’s most recent provider, the E/TFHC Medical Director and the Executive Director to review the request and make a determination regarding the request. Prior to the patient becoming “active” again, the patient, in writing, must agree to a contract that outlines the E/TFHC’s expectations and contingencies for remaining an active patient going forward.
REFERENCES:RELATED POLICIES/FORMS: / AD 1.12 (Patient Attendance); PC 11.01 (Prescribing Controlled Substances)
REGULATORY / ACCREDITATION STANDARDS ADDRESSED:
REVIEWED BY:
KEYWORDS: / discharging patients, discontinuing clinical services; non-compliance;
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/PATIENT DISCHARGE REQUEST
Patient Name: Pt. No:
Within the next five (5) business days, please take the following action with the above-named patient
Action / Reason(s)Send First Notification (letter re: items, 1, 2 or 3)
Send Second Notification (letter re: items 1 or 3)
Send Letter re: Discontinuation of Pain Management Tx.
Send Letter re: Discharge from E/TFHC. / 1. Non-Compliance: Patient Attendance guidelines
2. Non-Compliance: Behavioral
3. Non-Compliance: Clinical/Medical
4. Non-Compliance: Controlled Substances Agreement
5. Other (please explain below)
DETAILS
I. DESCRIPTION of SITUATION: (if needed)
Staff MemberSiteDate
------
Reviewed By:
Practice SupervisorSiteDate
Reviewed By:
Director of Quality & Disease ManagementSiteDate
Action(s) TakenRequest Approved. First / Second Letter re: sent on:
Request Approved. Discontinuation of Pain Management Tx Letter sent on:
Request Reviewed and Forwarded to Director of Quality & Disease Management on:
Request Approved. Discharge Letter sent on:
[Note: Please use back of form to note additional information; please attach any pertinent documentation]
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