Family-Oriented Primary Care in the Real World : Practical Considerations for Comprehensive Care

NUNANONG RODCHEUY

5/7/2016

Introduction

– Translating a family-oriented approach from theory into daily clinical practice presents a variety of broad pragmatic challenges

– In this chapter, we will provide very specific, family-oriented suggestions that take into account the reality of today’s healthcare environment

A Family-Oriented Image

– First impressions are important

– The practice name should contain the word family

– A practice logo that represents the family

A Family-Oriented Image

– Promotional material about the practice should emphasize its family orientation and services for families of all types

– Staff should support and encourage a family-oriented approach

Enrollment of Patients and Families– A genogram should be obtained on all families at the

time of their first visit

– Even when all members of the family do not have the same clinician, sufficient information about the entire family can be obtained at registration to construct a basic genogram

Enrollment of Patients and Families– The entire family should be enrolled together with an

initial joint visit whenever possible

– This provides a time-efficient way to gather background health information about the family and to construct a routine genogram

Enrollment of Patients and Families– This type of first visit gives the strong impression that will

appreciate the entire family’s participation in healthcare

– The initial visit to the clinician often is by an individual patient

– Important information about other family members can be obtained by appropriate family-oriented questions

Physical Layout

– The physical layout of the medical office should be designed or adapted to accommodate families

– The waiting room should be able to accommodate families with all age members, including small children and disabled elderly

– Examination rooms should be large enough to accommodate families

Physical Layout

Range of Available Services

– A family-oriented medical practice should offer the services that a family most often needs

– The practice should offer pregnancy and pediatric services when possible

– Social work and nutritional services should be offered

Range of Available Services

– The family-oriented clinician needs to have a list of telephone and internet resources for services not provided in the practice

Range of Available Services

– A clinician can rent out space in the office, either when open or closed, to organizations that offer other related services to patients and families

– Larger multi-clinician practices may want to organize their own family-oriented groups focused on such specific areas

Incorporating a Family Therapist into a Medical Practice

– The most successful referrals occur when the family therapist practices under the same roof as the clinician

– Patients and families often prefer counseling sessions at the clinician’s office, rather than going to a therapist’s office or to a mental health center

Incorporating a Family Therapist into a Medical Practice

– Models of collaborative family health care

– The therapist has a private practice in the same building as the clinician

– The therapist may rent space within the clinicians office, but conduct a private practice that is financially independent

– A family clinician and family therapist see patients together as a team

Incorporating a Family Therapist into a Medical Practice

– Close communication is integral to comprehensive care

– The therapist should receive a referral note and should have access to the medical record containing the genogram

– The clinician must be careful not to release the mental health notes to other clinicians or insurance companies, unless the patient specifically permits their release in addition to the medical records

Record Keeping

– The charts of all members of the household ideally should be filed together or electronically linked

– There should be easy access to family information

– Front : A separate family card

– Back : Family problems or family assessments

Record Keeping

– Advantages– No need to be duplicated genogram for each family member’s chart

– Any family member can update the information at the time of visit

– Relationships

– Detection of patterns of healthcare utilization, which may reflect family stress or dysfunction

– Identify member’s health problem and risk factor

– Easier to conduct family research

Confidentiality

– A family member often requests information about another family member’s health care

– The clinician must be particularly careful about confidentiality of information

– The clinician should not provide information about an adult family member without that person’s consent

Confidentiality

– It is important to determine the difference between a patient’s request for legitimate confidentiality and colluding with a patient or family member about a secret that may fuel individual and family dysfunction

– The clinician should never provide information about an adult patient to another family member except when the patient has given explicit permission

Confidentiality

– The clinician can use his or her influence to advise the patient or family to disclose any important information

– Consider referral to a psychotherapist to manage any serious fallout if the information is likely to be provocative

Confidentiality

– There are situations where it may be unethical not to encourage the family to be involved in the management of a health problem

– There may be situations where the clinician should strongly urge the patient to involve or inform the family

Working with Other Professionals– Anytime more than two parties are involved with an

issue, triangulation is a possibility

– The primary care clinician is at risk for triangulation in multiple ways, either with other members of the healthcare team or with the patient’s family

Working with Other Professionals– Key strategies to avoid triangulation are communicating

clearly and avoiding taking sides, while maintaining patient advocacy

– The primary care clinician may be tempted to overfunction for the patient and speak for them

– The clinician can be helpful by offering to be present during a potentially difficult interchange

Working with Other Professionals– Dr. S. avoided triangulation by providing education and

facilitating direct interaction between Ms. Fernandez and the school

– When there is conflict, the clinician may need to communicate directly with the other parties before making any judgment: There are always to sides to a conflict

Working with Other Professionals– The clinician should avoid being drawn into the role of

decision maker, unless the decision is clearly a medical one

– The clinician should instead bring all relevant parties together and facilitate a process in which the group can discuss the problem

– The best solution occurs when all parties can agree to support the outcome

Home Visits

– Home visits or house calls

– Home visits should be a regular part of the practice

– They offer an opportunity to see the patient and family in their own natural setting and can provide valuable information about how the patient is functioning and how the family is adapting to the health problem

Home Visits

– House calls may be the best form of intervention during a family crisis

– Home visits are particularly important for– Frail elderly

– Homebound elderly

– Postpartum patient

Home Visits

– A very quick way to become known in a community

– For multiproblem or chaotic families, making a home visit sometimes may be the only way to assemble the entire family for a meeting

– A home visit also may provide insights into the problems that the family is facing

Billing and Finances

– A common concern about a family-oriented approach to medical care is that it takes too much time to implement and is not financially feasible

– Which pays itself back in the long run with reduced visits

– Family conferences do take additional time, and that time should be billed at the same rate as other visits

– The billing procedure needs to be flexible enough to take account of the family’s income and insurance

Termination of the Clinician–Patient Relationship– The clinician must make every effort to address the

problems and to seek creative solutions. Even so, “irreconcilable differences” may exist

– It is generally the patient who initiates a change and seeks out another clinician to provide care

– It is crucial to find out why

Termination of the Clinician–Patient Relationship– People are usually quite pleased that the clinician took

the time to call

– They are eventually relieved and relish an opportunity to discuss the situation

– With some patients, clinicians may want to be cautious about allowing them to return to the practice

Termination of the Clinician–Patient Relationship– It is rare for a clinician to discharge a patient from his or

her practice

– It is a possibility that when recognized may help both parties attend to improving the relationship

– A patient who realizes that he or she may be discharged from the practice may work harder to maintain responsible and mature relationships with his or her healthcare providers

Conclusion

– The practice of family-oriented primary care is time-efficient, cost-effective, and, perhaps most importantly, care-effective

– A family-oriented approach allows us to know our patients as people

– With today’s focus on speed and the bottom line, there is no substitute for the satisfaction derived from this human connection