Enterprise Risk Management (ERM) Patient Safety/Clinical Care

Breaking Up is Hard to Do

Breaking up with difficult patients is a hot topic for health care providers. Having a properly structured termination process for the ambulatory/physician practice setting is essential in any Risk Management program to help manage difficult patients. Ending a physician/patient relationship is a last resort when all other efforts have failed.

When expectations are not met, patients can act out and become difficult, leading to a breakdown in communication, along with a breakdown of the physician/patient relationship. Patient terminations are failed communications and unmet expectations. Each side suffers. To obtain optimal resolution of care, it is essential to have a beneficial relationship between providers and patients. Not everyone feels comfortable with managing conflict. Providers and staff need to be made aware of your Risk Management resources, which can provide assistance with navigating through conflict and determining potential resolution options.

Careful considerations should be applied when contemplating a patient termination. Here are components to review when evaluating the strength and effectiveness of your termination process.

Common reasons for patient terminations

  • Non-compliance with treatment plan
  • Rude or abusive behavior
  • Not showing up for appointments
  • Drug-seeking behavior
  • Non-payment for services

Understanding the “why” behind the situation can give great insight on how to move forward with difficult patient situations. Equally important is determining whether or not the behavior warrants a complete discharge from an organization or if switching providers is a viable solution. Again, rely on your Risk Management resources for help.

Elements of a valid termination

  • Conversation happens between the provider and patient regarding the issue prior to any termination
  • Documentation of the conversation in the chart or medical record is essential
  • Giving at least two warnings and documenting in the patient’s chart prior to any termination (when possible)
  • Giving the patient a 30-day written notice after any verbal conversations have taken place, if the decision to terminate the relationship has been made. Any notice letter should be sent by regular and certified mail
  • Termination letters should come from the provider, when possible. The patient’s relationship is with the provider, so the provider will have to be involved in any conflict management
  • Termination of a patient in an acute phase of treatment must be delayed until the acute phase has passed
  • Decisions to terminate may not be based upon the patient’s race, color, religion, sex, sexual orientation, gender identity or expression, age disability, marital status, citizenship, genetic or disease information, or any other characteristic protected by law
  • Pregnant patient terminations can be attained during the first trimester. Thereafter, terminations should be carefully considered and evaluated to make sure the patient can obtain care and treatment with another established provider prior to delivery

What should go in a termination letter

  • Reason for termination; non-compliance; behavior issues, unable to meet expectations, etc.
  • Effective date of the termination; usually 30 days from the date of the letter
  • Explanation that the relationship is no longer beneficial to either side; that the patient would benefit from establishing care with another provider
  • Medication refills only provided up to the effective date of the termination
  • Medical Records should be offered the patient for the new provider by including an authorization form with the termination letter

Please keep in mind that terminations are different than banning a patient. These terms should not be used interchangeably. For a patient to be banned, there are higher organizational thresholds and criteria which must be met prior to a patient banning. Some of these include reckless behavior that jeopardizes the safety of staff, providers or other patients; threatening harm to staff, provider or patients; criminal activity; identity fraud; physical altercations with staff, providers or patients.

A well-established termination process in your Risk Management resources will help make breaking up with a patient a professional and less difficult situation.

Leigh Ann Yates, AIC, MBA, CPHRM, FASHRM, is the director of Insurance and Risk Management for the George Washington Medical Faculty Associates, Washington, DC.


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