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Physical Therapy Outcomes & Marketing Blog

Self-Discharge_Not_into_you

You can’t solve a problem you won’t acknowledge. I know this, because I too am human and I too care deeply about the work I put into the world. I have been working as a former-counselor in the field of physical therapy for over ten years now. I have had continuing education students call me crying for test answers because they got a “B.” I’ve seen seasoned therapists quit a program they have spent thousands of dollars on because they couldn’t handle constructive feedback. I have had clinic owners call me, desperate to find an outcomes report that puts them in a favorable light, rather than face the fact that they are not above average.

An incomplete plan of care means either a prospective patient didn’t buy into the concept of physical therapy that your practice pitched, or they were with you for a while but drifted off. Both are rejections and both sting.

We tell ourselves, “They weren’t committed,” or “They got better.” Let’s look at those.  

Possible Reasons for Patient Self-Discharge

They Weren’t Committed

Tequila Birthday CakeCommitment isn’t a switch you can flip. Commitment is earned. Do you have any idea how many back massages and fifths of fancy tequila I got from my boyfriend before I agreed to start dating him? Of course, he knew what he was getting into because he was high off my expert road trip-planning abilities and my questionable sense of humor. We have both had to bring certain things to the table to make a successful relationship.

What are you bringing to the table? Do you have a process at your practice (front office and practitioners) for communicating what physical therapy is and what the expectations are for the patient’s involvement?  Do you as the therapist use reflective listening to verify their understanding of their contribution to the improvement of their musculoskeletal health? Do you work in collaboration with the patient to develop a realistic home/work program and verify their commitment to it? When the patient does not make a follow-up appointment, do you have a follow-up protocol that utilizes both front office and clinical staff to re-engage the patient?

If you answered yes to all of these and you still lose the patient, then you are correct. This patient is not engaged. This is not the relationship for you. They are not ready for therapy. You have an opportunity to send them a very positive, encouraging message to please contact you when they are ready.

If you did not answer yes to all of them, then you cannot assume that the patient is not committed. You can assume that you have opportunities to retain patients using patient engagement techniques.

They Got Better

I am never going to be able to retire. How do I know this? I track the performance of my retirement accounts against how much money my checking account hemorrhages every time the weekend hits (Thursday is the start of the weekend, right?).

So, you think your patient got better. How do you know this? Are you tracking outcomes? Are you taking a detailed look at your CareConnections Self-Discharge Report

If you can see that your patients are making clinically significant change in function and pain, then yes, they got better. This still begs the question, why aren’t they completing your plan of care? Are you ending visits with statements like, “If you don’t feel better, then make another appointment?”

The discharge visit is incredibly undervalued. As humans, we are subject to context. You and your patient have a different interaction when you know it’s the last visit. Here’s what might happen at an official discharge:

  1. The patient gets the message that they have succeeded! That’s the message they will pass along with any word-of-mouth advertising.
  2. The patient gets your t-shirt, water bottle, other promotional material to promote their success and yours.
  3. You ask them to refer friends and family.
  4. You advise them on when to make another appointment (Don’t wait until you can’t walk please!).
  5. You ask them to leave a Google or Facebook review.
  6. You request that they let their doctor know how much better they are.
  7. You ask for a testimonial for your website.

Many clinics I see have half or more of their patients leaving without this official discharge process. This is not only lost functional improvement for the patient, but lost revenue from those final visits and from missed opportunities to generate more business.

Hope is Not a Strategy: Your Patients are Unsatisfied!

I must assume that many practitioners hope their patients are happy. They cross their fingers and then focus on the positive aspects of the Patient Satisfaction report. If there are low scores for Satisfaction with Treatment Progress, they focus on the Care/Compassion scores and write off the treatment progress to home program non-compliance.

Can I add a huge confounding variable? The therapeutic alliance. Here’s a result I see time and time again on patient satisfaction reports: Net Promotor Score (how likely you are to recommend this therapist to others) in the 90-100% range. Satisfaction with Treatment Progress in the 60-70% range. What’s going on here?

Your patients love you. You love them. No one wants to talk about hard truths. You don’t want to correct their unrealistic expectations and they don’t want to tell you they don’t feel better and that if they could exercise every day they would be doing it already. You can guess where they stuck your HEP.

In the past year, I have looked at over 100 patient satisfaction reports and seen this trend in all but one or two. This is a thing people!

Patient Satisfaction Overview Report Excerpt
It’s like when I would come home to my ex-boyfriend’s keys hanging out of the front door. And then walk in and see every kitchen cabinet open and all the chairs pulled out (apparently, he couldn’t sit in just one), not to mention the back-door wide open in the heat of summer. He had such an intense case of ADHD that this was not an unusual occurrence. I would pretend to be forgiving, because I would like to see myself that way. Except I am WAY too uptight for that. So, I would be that crazy person who screams, “I’m FINE!!!!” Then, under the rug everything got swept until one of us self-discharged from the relationship.

If a patient needs to change their habits and lifestyle to improve their condition, then shouldn’t that become a part of a shared plan of care that you build together? The therapists I’ve seen have prescribed home exercise programs and then hoped that their patients did at least a third to a quarter of what they prescribed. In my experience, I have only had minimal follow-up on whether I have been doing my HEP or how well it fits into my life.

As a rehab therapist, you are asking people to either change a habit or adopt a new one. Have you read about how incredibly hard this is? Do you have an idea of what you’re asking of your patients? Here’s my hands-down favorite resource

We have an obesity epidemic because changing habits is hard. Tobacco kills 7 million people each year. We all know about the opioid epidemic. Addictive substances aside, I know I should exercise every day. I don’t. I should bring my own bag to the grocery store, but I often forget and end up with a collection of those plastic bags. I know I should make a larger payment on my HELOC, but you better believe I bought those tickets to Honduras to scuba dive instead.

Hello humanity. Doing the healthy thing is hard. Your hope + my hope = plastic bags and smokes. Hope is not a strategy.

Practicing in Alignment with Your Values – Patient-Centered Care

You got into the rehab business to help people. You value contributing your precious time and skills to making peoples’ lives better. Your heart will give you the strength to face the sting of disengaged patients.

I know I’m getting touchy-feely here. But I believe in the rehab industry. I think it’s necessary for a sustainable and successful healthcare system. The best therapists combine a high level of expertise with a high level of patient engagement. Great therapists empower their patients to live healthier lives. Defining that healthier life is a collaboration between the therapist and the patient.

I encourage you to look at your self-discharge numbers and take that giant brain and giant heart of yours and start moving toward solutions. It is not a one-size-fits-all answer. You start with the messy, complicated process of connecting with a real human being and finding the answer together. Then you both commit to making it happen.

Patient-Centered Care starts with Patient Engagement