It’s 2 a.m., and a long term care facility resident has a fever and stomach pain. What happens next says a great deal about the relationship between facility staff and the attending physician.
As the aging population grows and more physicians follow their community-based patients into assisted living and nursing facilities, administrators, nurses, and others must find ways to successfully establish and maintain relationships with clinicians who may have little experience working in the long term care continuum. At the same time, physicians must learn the unique policies, protocols, personnel, and communications systems of facilities that vary in size, type, and demographics.
Fortunately for everyone, the answer to these challenges may be in reach and based on common sense. With strong communication, a culture that promotes teamwork and open discourse, consistent and ongoing education and training, and clear policies and procedures, positive relationships can result, and quality care is the ultimate outcome.
Scope Of The Problem
In one recent study reported in the Journal of Patient Safety, nearly 400 nurses identified several barriers to effective nurse-physician communication in long term care. These included lack of physician openness to communication, logistical challenges, lack of professionalism, and language barriers. Authors Tija J, Mazor K, Field T, et al., identified two specific barriers—feeling hurried by physicians and an inability to reach doctors promptly. In the same study, qualitative interviews suggested overwhelmingly that nurses need to be brief and have current, accurate clinical information when communicating with physicians and that physicians need to be better listeners.
Josh Allen, RN, chief executive officer (CEO) of California-based Caring Compliance Group, which specializes in assisted living staff training and education, says, “A common complaint I hear from nurses is that they can’t reach physicians in a timely manner.” This is especially challenging in assisted living, he says, because, “We don’t have standing orders, so we need new physician orders for everything. When you have to reach out for approval on everything, it can be frustrating when a physician can’t be reached.”
It can help to develop an as-needed (PRN) authorization form to enable commonly used medications such as Tylenol to be available when residents need them. “With every resident in the building, we’ll get commonly prescribed PRN orders as appropriate and keep them on file,” Allen says.
One challenge to good nurse-physician communications is that physicians might have different expectations. For example, according to Charles Cefalu, MD, CMD, a multifacility medical director in New Orleans, some physicians don’t want to be called for nonacute changes of condition. Others want more constant communication.
As Karyn Leible, MD, CMD, chief clinical officer at Pinon Management, Lakewood, Colo., says, “I want to know if a patient is experiencing a decline over a period of days before he or she is admitted to the hospital.”
These disconnects can be addressed to some degree, says Cefalu, by training team members on how and when they should contact physicians. At the same time, facilities should address with physicians up-front how they want to be contacted when there is a problem.
Facilities also need to let physicians know what is expected of them and when and why staff will need to contact them.
Successful Models, Innovative Ideas
A successful model for good facility-physician relationships includes overall collaboration and mutual respect and trust, says Robert Bales, administrator of the John J. Hainkel, Jr., Home and Rehabilitation Center in New Orleans. His facility has implemented several successful measures to maximize physician-nurse relationships.
For example, he says, “We use a monthly Performance Improvement Committee meeting that is physician-led and chaired by the medical director. We focus on patient care concerns specifically and don’t let the group get sidetracked by other issues. If there is a new protocol, such as one for wound care, we make sure to get physician input as we develop them.”
It is important to get physicians involved in such committees so that they feel connected to the facility and have an opportunity to get to know all the players. “We attempt to get attendings [attending physicians] involved on committees, and we rely on their expertise,” says Cefalu. “We ask them what their interests are and get them involved accordingly. Getting their input on new programs, policies, and so on is important.”
Cefalu suggests getting physicians involved on formularies so that they can have input on medications and other products on the lists. “Things like this—that reduce unnecessary work and paperwork—save the physicians time. When you do things that make their lives easier and make it more pleasant for them to come to the facility, they appreciate it. And they think and act more like active team members,” he says.
Another way to involve physicians and improve relationships is to create educational and communication opportunities that are convenient. Cefalu suggests, “Have a ‘dine and dash’ and invite physicians in to educate them about a new policy, protocol, or product or to have them sign records.” He explains, “It can be challenging to get physicians to complete and sign medical records, especially when you have a lot of attendings. Having something like this makes it a little easier and more palatable.”
Making physicians’ lives easier can score points with them. For example, billing and coding for long term care can be a challenge, especially for physicians who are new to this care setting. Helping them and their staffs understand these issues can strengthen partnerships.
“As part of the medical staff meeting, you could have their billing people come in and update them on coding issues. This would help [physicians] a great deal, and they likely will be very appreciative,” Cefalu says.
It also can help some physicians realize that long term care actually can be a profitable care setting for them. “Billing codes have increased 5 to 7 percent per year in recent years, and overhead is very low,” Cefalu says. However, he adds, “The downside is that these patients require a great deal of care. Of course, physicians can utilize nurse practitioners to help provide this care.”
It also is helpful to make sure physicians get the information they need about patients—when possible, without asking. For instance, says Cefalu, “Offer to provide attendings with the face sheet of the admission form for their patients when they come into the facility. You can arrange to fax it automatically so that they have it before their first visit.”
How To Contain Quantity Of Calls
One complaint physicians often have is the number of phone calls they receive. So the Hainkel Center has a “problem book” at the nursing station that lists nonacute problems. Physicians can elect to use this book instead of getting phone calls about these issues.
When they come to the facilities, physicians can check for any problems or issues related to their patients. “This can prevent the physician from getting calls two to three times a day about nonemergent problems. However, for this book to work, physicians must commit to coming into the facility once or twice a week consistently,” Cefalu says.
Bales and his team also developed a protocol for communicating with physicians after hours, which also helps reduce unnecessary calls. The AMDA also has such a document, which addresses about 100 conditions and what information will be necessary when contacting a physician (see box).
“Such protocols help make sure that nurses know precisely what information physicians will expect when they call about a patient problem. This ultimately makes the nursing staff feel more comfortable and confident when they make these calls; physicians are happy because they only get calls that are necessary, and they get all the information they need to make decisions,” says Cefalu.
To help reduce the call volume to physicians, Bales also suggests differentiating between common, recurring problems and isolated incidents. Either type of problem must be addressed promptly, but a problem that suggests a trend or a common situation requires special attention and a long-term solution. “After you’ve addressed something, go back and see how it’s going. Check to see if everyone is satisfied with the resolution,” says Bales. He adds, “The main thing is to close the loop and get feedback.”
Build Mutual Respect
Of course, it also is important to have a culture where physicians and nursing staff have mutual trust and respect. “We have created a culture where physicians rely heavily on nurses’ input, and this yields the best results,” says Bales. “It is important to have a person-centered culture where people understand the importance of communication and people feel comfortable bringing up concerns without fears of retaliation.”
To help, his leadership team creates lists of potentially problematic issues and discusses them regularly with unit managers, including medical staff.
When everyone has the residents’ best interests at heart and team members respect each other, says Bales, resolving issues actually can be easy and stress-free. For example, he recalls a situation where a new physician was ordering numerous STAT lab tests, which are very costly. “We sat down with the physician and said, ‘We may have missed this in the orientation, but we have a daily lab service,’” Bales recalls. The physician cooperated, and it solidified a positive relationship with the nursing staff.
Facilities can help physicians by making sure that nursing and other staff have the skill sets to do their jobs and care for patients. “Physicians have to feel confident that staff can handle the complexity of patient care in the facility, and you need to have sound systems for hiring and training staff,” Bales says. “We are fortunate to have a medical director who enjoys teaching staff. This is a big plus for us.”
Bales stresses the need to meet with physicians occasionally outside of the noise and distractions of the facility. “Whether it’s a conversation over breakfast or a cup of coffee in a nearby park, it gives them a chance to address their issues and concerns and talk about what the facility can do for them,” he says.
It is essential for everyone to realize that respect and concern are a two-way street. “Staff have a tough job, and they appreciate a pat on the back sometimes. It means a lot to them to have physicians who see them as colleagues and respect the work they do,” Bales says.
Assisted Living Challenges
Relationships with attendings can be more challenging in assisted living (AL) communities, where staffing, size, rules, and regulations may vary considerably. “There isn’t a requirement for medical care oversight as there is in nursing homes,” notes Leible.
However, physicians who are new to the setting may not know this. They may assume that AL communities provide services similar to those found in nursing facilities. This can cause frustration and damage relationships.
AL facilities need to realize the benefit of good relationships with attendings, says Dan Haimowitz, MD, CMD, a multifacility medical director and AL attending physician in Pennsylvania. “If the AL facility really interacts with the physician, asks what he or she needs, establishes good contact patterns, and is able to get to know him or her, this can make a big difference,” he says.
There is no requirement for attendings to see their residents onsite at the AL facility. “Some attendings go to the AL community, which benefits everyone, but some never go. If they don’t, they may not know what the facility is like, who staff are and what skills they have, and what services they can provide,” says Haimowitz. However, he adds that even when physicians go onsite, they may not get the information they need.
“You may or may not get a good story about what is going on with the patient. Depending on when you go, you may or may not talk to a nurse, and the caregivers may or may not have the information the physician needs.”
Nonetheless, Haimowitz notes that it is easier and less costly for residents to be seen onsite. He adds that it can benefit the physician as well. “If a physician starts going to the AL, he or she may get more patients. It can lead to more business and become a good source of income,” he says.
While physicians shouldn’t compare AL communities to nursing facilities, they can take some ideas from skilled nursing and translate them to AL. “Physicians can spearhead such ideas as reduction of antipsychotic use in AL,” says Haimowitz. “These facilities may be able to take some sort of disease-state management programs and focus on concerns such as falls, wound care, and incontinence. Working with physicians on such programs can help practitioners understand the AL facility better and create collaborative relationships between physicians and staff.”
Residences should make sure that all attendings understand what AL can provide. “When the physician understands what the facility is trying to do, he or she is more likely to work with them to reach goals. Facilities need to help physicians understand the uniqueness of this setting. They have to work harder to establish relationships with attendings,” says Haimowitz.
Because few AL residences have a medical director and most have limited nursing staffs, off-hours communication can be difficult. “Aides may not know about assessments or have training. At the same time, they may not have access to charts and other information. This makes for a multitude of communication problems,” says Haimowitz.
Policies vary from community to community, and this can cause confusion and misunderstandings.
When Physicians Are Unresponsive
Staff need training about communication, including what to tell physicians and when to contact them. At the same time, the physician needs to understand the importance of responding to calls from the facility promptly.
Pat Giorgio, MPS, president and CEO of Evergreen Estates, a retirement community in Cedar Rapids, Iowa, says, “We need to make sure that our staff are very professional and that they have the information physicians need when they ask for it. Nothing is more cringe-worthy than when there is a fall and you don’t have the vital signs to report to the physician. We need to make sure that documentation is concise and complete. We can’t waste the attending’s time.”
Since AL settings generally don’t have physician medical directors, staff can’t count on such a person to intercede when there is a problem.
“If you start to see care issues and/or can’t get the attending to respond to calls, you have to find a way to address it,” says Leible. “Before you do anything, you need to reach out to the physician and try to find a mutually agreeable solution. If the situation continues, you may decide to discuss this with the family. If the issue is lack of response, you need to be prepared to offer specific examples of when the physician was unavailable.”
Haimowitz agrees. “If a physician chronically doesn’t return phone calls or complete paperwork, a facility leader can go to him or her and talk in a friendly way about what the facility needs and how they can work together more effectively,” he says. “Ask what the physician needs from your facility and what his or her concerns are.”
Ultimately, facilities can give residents the opportunity to choose a new physician, and they can suggest practitioners with a proven AL track record. However, they can’t force a resident to make such a change, and they should attempt to work with the nonresponsive physician before discussing a possible change with the resident or family members.
It is important to realize, says Haimowitz, that the resident may not even know that the physician is being unresponsive. “How the physician interacts with staff may not be obvious to the resident, who may not realize that their doctor isn’t returning calls, signing forms, or completing paperwork.”
It is helpful to discuss with new residents what the facility will need from their physicians and why a good relationship is important, he says. “It’s a slippery slope to discuss the physician with residents and families,” Haimowitz cautions. “You have to avoid looking like you’re playing favorites or bad-mouthing any physician.”
One challenge, says Giorgio, is that “many attendings seem to prefer faxes to face-to-face interactions, and this can be problematic, especially when faxes go unanswered or require further clarification. We feel like the physicians who ‘really get it’ will come to the facility. Those who are willing to come out have a better grasp of what AL is and what resident needs are.”
Be Proactive
Giorgio reaches out to physicians on a regular basis. “When we get a referral from a physician, we send him or her a formal thank you with a brochure, a coffee mug, and coffee. It lets them know we appreciate them, and it tells them about our philosophy of care and what services we provide. We try to build relationships this way,” she says.
Giorgio suggests that AL communities not forget about the physician’s own nursing staff. “You really need to make sure you have a relationship with the attending’s nurses. You need to explain what you do and who you are. Offer your support and willingness to provide additional guidance as needed,” she says, adding, “Don’t hesitate to take an active role in educating nurses about assisted living.”
Some facilities send out information packages to new physicians that detail what they are, what services they provide, and what they expect from the relationship. This can be helpful, but there is no guarantee that physicians will read the package even if they receive it.
Another option is to arrange a personal meeting with the physician when he or she first comes to the facility. For example, the registered nurse can show the physician around, introduce him or her to various staff, and talk about the resident’s needs, how to share information, and what the practitioner should do if he or she has questions or concerns.
“When an attending comes to the community, you need to be very welcoming. One physician said that nothing is worse than when he comes to the AL facility and no one can give him the information or support he needs,” Giorgio says. “Staff greeting visitors need to understand the importance of the attending and of finding the nurse to meet the physician.
“My experience is that physicians are more inclined to listen to what another physician tells them. Facilities can ask experienced attendings to talk with other physicians and to educate their peers about assisted living through various meetings and presentations.”
Still Tech-Challenged?
While some might think that technology is an easy answer for improving relationships and communication with attendings, it isn’t quite that simple. “Use of technology for long term care communication is still in its infancy, although it will be huge down the road,” says Kevin O’Neil, MD, CMD, FACP, medical director of Brookdale Senior Living, Brentwood, Tenn. “Few [assisted living facilities] have the technology to share information with hospitals or attendings. Hopefully, that will change in the future.”
In the meantime, there are several challenges to be overcome. For example, there are many different software products available.
“Some places have great technology that physicians can access from anywhere and use to submit orders directly from their offices or homes, but other places have different—and often incompatible—systems. That is why so many physicians are hesitant to invest in technology products,” says O’Neil.
In the meantime, he says, “We use e-mails, texting, and other means of communicating with physicians. We find that e-mail communication is a good way for the physician to interact with us. Additionally, we’ve offered some Web-based education for physicians.”
As long term care settings attract more physicians to the fold, technology becomes more consistent and readily available, and staff have access to protocols and other tools, physician-facility relationships can only improve in the coming years.
However, the changes won’t come easily. As Leible says, “Everyone has to put aside their egos and preconceived notions and focus on the common goal of providing great care for residents.”
Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.