New Pain Management Agreement from NORCAL Mutual
In response to a request from a consortium of community health centers in San Diego to help educate physicians on the legal aspects of controlled substances, NORCAL Mutual has developed a pain management agreement with which clinic physicians and other providers can improve patient understanding and use of pain medications.
Physician concerns about pain medications are well-established. Among the barriers to the successful management of pain, NORCAL Mutual’s continuing medical education (CME) course on pain management cites "fears of physician sanctioning by regulatory bodies for negligent prescribing (reinforced by medical malpractice lawsuits alleging excessive prescribing)."
In analyzing the overall problem of physician education, NORCAL Mutual identified a specific need for a better pain management agreement that spells out basic rules on how the patient will access and use the drugs.
Pain management agreements are excellent tools for helping to manage patient use of pain medications. "It is prudent for physicians to consider establishing [agreements] with the patient that include prescribing rules," NORCAL Mutual's CME course states, adding that an agreement "helps the physician and the patient define and agree on appropriate behavior for the patient; it hinders addicts from obtaining an unlimited supply of medication; and it helps staff members verify the legitimacy of refill requests."
However, such agreements are often hard for patients to understand, especially those with poor health literacy. Also, they are sometimes perceived as disrespectful and untrusting when they are introduced as a "contract" and complicated medical and legal terminology is used. Since the primary purpose of the agreement is to help manage a patient's use of pain medications, it is crucial to ensure the patient understands the agreement.
Robin Webster, a NORCAL Mutual Risk Management Supervisor, and Jim Schultz, MD, of Neighborhood Healthcare Center (one of NORCAL Mutual's insureds) made a presentation on pain management at the 2010 Annual Healthcare Symposium on January 29, 2010, in Huntington Beach, CA. The symposium was held by three separate clinic consortiums (San Diego Council of Community Clinics, Community Clinic Association of Los Angeles County and the Coalition of Orange County Clinics). Robin presented the new pain medication agreement and discussed the creation of the agreement.
To build a better agreement, NORCAL Mutual turned to Helen Osborne, author of Health Literacy from A to Z: Practical Ways to Communicate Your Health Message. An expert in health literacy, Osborne helped adapt an existing agreement to the needs of the consortium physicians. The goals of the agreement are to:
- Be clear to most patients, including those with poor
health literacy - Ensure that patients feel respected and able to trust
their doctors - Establish patient responsibilities without being judgmental
Once the agreement was drafted, a community health center in San Diego field-tested it to ensure that their patients understand the agreement. As Osborne told NORCAL Mutual, "Readers are the experts on whether a document is useful, understandable and relevant." Because patient populations vary among facilities, she encourages all facilities to field test the document with their own patients to ensure understanding, relevance and usefulness. When patients make suggestions for revisions, take their feedback seriously and use their suggestions to revise the document.
NORCAL Mutual intends its new agreement to serve as a template with which providers can customize an agreement that conforms to internal policies and procedures. To receive a copy of the agreement and learn more about how best to use it, contact the Risk Management Department at (800) 652-1051, ext. 2244.
Southwest Community Health Centers
Keeps Growing and Innovating
With seven sites, Southwest Community Health Centers (SCHC) is already a huge provider of healthcare services to uninsured and underinsured patients in Santa Rosa. The growth has been dramatic, from 20,000 patient visits in 2001 to over 100,000 last year. Despite the current economy, however, SCHC plans to keep on growing, both in terms of "bricks and mortar" and technologically.
This year SCHC, a federally qualified health center, will buy and remodel a 42,500-square-foot building to expand access to primary care and mental health services in Santa Rosa, a city of 161,000 people. The new site will also provide space to develop a county-wide hub for specialty services, accessible to all seven community clinics in Sonoma County (known collectively as the Redwood Community Health Coalition or RCHC).
As part of the information revolution in healthcare, SCHC is part of a collaboration through the RCHC that will link the electronic health record (EHR) system that it rolled out system-wide in 2009 to the other clinics in the coalition. Not content with that singular feat, the coalition will then link the EHR system to clinic networks in Yolo and Napa counties—the same system for everyone, achieving something still rare in healthcare, seamless information flow across a broad patient population.
At the head of SCHC's exploding growth is Naomi Fuchs, Chief Executive Officer. She took on the job in 2001, after serving several years on the board. Her background was in developing physician organizations in managed care.
"I majored in medical anthropology in school," Naomi says, referring to Wesleyan University in Middletown, CT. "It's about how culture interfaces with healing—and it serves me well in my current work."
That may be an understatement. SCHC's patient population is 74 percent Hispanic, and about 60 percent are best served in Spanish. Cultural competency is crucial to fulfilling the SCHC mission of providing comprehensive primary healthcare, prevention and health education to the uninsured and underinsured in Santa Rosa, regardless of the ability to pay.
Naomi says the impact of the new EHR system is already being felt. "It has brought tremendous benefits to patients, providers and staff," she says. "We know we are providing better care already." The comprehensive system includes clinical, scheduling and billing information.
Cultural acceptance by staff has been swift but training demands are ongoing and significant, particularly for medical residents. SCHC partners with the Santa Rosa Family Medicine Program to train 36 family practice physicians who each provide about 12 hours a week at the clinic. Thanks to the EHR system, they are learning not only how to be doctors but how to be 21st century providers.
Naomi is particularly excited about the quality improvement potential of a broad EHR system. "We will be able to do comparative outcomes studies across participating clinics on such vital issues as obesity, hypertension, asthma and diabetes," she says. "We will be able to identify and share best practices, and spot emerging healthcare trends."
How the Economy Is Affecting SCHC
"We're getting 200 calls a week from people who want to become new patients," Naomi says. "Our homeless facility has gotten much busier in the past year, but so have all the other sites."
Even SCHC programs at Roseland Elementary School have seen spikes in utilization, the result of upheavals in the overall healthcare system. Concerned about the ongoing erosion of support for both the pediatric and homeless clinics, SCHC formally acquired them in 2008 to make sure they survived.
With 230 employees and 25,000 patients, SCHC has come a long way from the little clinic that opened in the southwest corner of Santa Rosa in 1996.
"We're here to serve our community," Naomi says. "We want to deliver care that is not only good but is viewed as good by the patient, so they truly feel cared for."
Frequent Risk-Management Queries from CPG Members
NORCAL Mutual Risk Management Specialist Phyllis Drummond, RN, MSN, provides risk management guidance to community health centers insured by NORCAL Mutual. Based on her call log, the table below indicates the most frequent issues raised by clinics in the past several months.
Risk Issue
Clinic Concerns
Terminating the Physician-Patient Relationship
Questions about appropriateness and potential liability of terminating (discharging) patients from the practice who are:
- noncompliant with care/treatment recommendations;
- exhibiting acting out behaviors;
or - behaving violently toward or threatening clinic personnel
Medical Records: Access and Release of Records
Clinics want to know how to respond to requests from many entities—including personal injury attorneys, workers' comp carriers, health plans, social service agencies, and law enforcement—for access to patients' medical records. There are questions about what can be released, what must not be released, and whether patient authorization is required.
There are also questions about patient or family access to records. When is a durable power of attorney valid? Who can access the records? What, if anything, can the provider withhold from the record when the patient requests a copy? What are the regulations regarding access to a deceased patient's records?
Medical Records: Retention/Destruction
Calls about how long medical records must be retained. Also, how long records have to be maintained after they have been scanned into an electronic medical record system; and whether records can be destroyed after a period of time.
Medical Assistants—Scope of Services
Questions about what a medical assistant (MA) may or may not do. Physicians tend to want to expand the MA's scope of service, and supervisors or managers are concerned; they want to be sure such expansions are within the legal bounds of an MA's designation.
Electronic Health Records (EHR)
Many clinics that do not already have EHRs are working on implementation of EHRs or preparing to purchase and implement a system. They have many questions about scanning documents, how much of the record to scan into the electronic system, how long to hold charts after scanned (as above), security issues, and so on.
When one of these issues—or any risk-management issue—arises in your clinic, contact Phyllis at (800) 652-1051, ext. 2696, or pdrummond@norcalmutual.com. She is an experienced risk management specialist and is eager to assist you in any way she can.
Facelift for CPG Web Site
NORCAL Mutual has redesigned the Web site dedicated to community clinics in the Clinic Purchasing Group (CPG). Visit www.norcalmutual.com/cpg to discover the wealth of resources available, including how and when to report a claim and a brief, clear overview of the claims process.
A new feature of the site is an archive of the e-newsletters produced quarterly to keep you abreast of relevant news from NORCAL Mutual. You will also find all the forms and applications you need to keep your policy up to date, including forms for adding and deleting providers, and for reporting changes to the annual number of services, procedures and surgeries you provide.
Downloadable resources include our Five Steps to Respond to Adverse Events and the Litigation Handbook: A Guide for Risk Managers & Healthcare Providers.
The Web site provides a thorough introduction to CPG, including it's history and current board members. When you interact with administrators of non-CPG clinics who may be interested in the unique value it offers to community clinics, please direct them to the CPG Web site.
Account Support
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Policyholder Services Department
(877) 443-7232
www.norcalmutual.com