Discharge.....or maintenance??....

Image by Marco Kaufmann (via Unsplash)

Lets think about the patient that we saw earlier. Remember Lucy? She has right-sided LBP that we thought was secondary to some degenerative change in her right knee.

Consider the following scenario:

After two treatments her LBP has disappeared and she says ‘I’m fine now’.

I have frequently discharged patients at this point, thinking that they will be very pleased with me and will refer all their friends and family to me. Is this the appropriate thing to do?

To answer this, we have to refer back to our job description: ‘to get the whole body functioning as well as possible’ and decide whether we have done this.

Looking at our agreed functional goals will help us to answer this question:

1. to be able to squat without pain in the right knee

2. To increase the strength of the right quads on resisted testing

3. To increase balance when standing on the right leg

If our patient has achieved these goals, then great, it’s all happened more quickly than we expected. If not, then it makes sense to continue with our treatment plan (that has the appointments in the diary already)

Lets consider another scenario:

As our treatments progress, the patient appears to be making a functional improvement, but still has the right sided LBP, and her abdomen continues to be tender when we palpate it. We wonder whether the two issues are related. What will you do? Write your thoughts below:

Most practitioners would agree that the tenderness needs further investigation and would write an appropriate letter of referral to the patients GP…

End of treatment: 

OK, we get to the end of our treatment plan and have two choices:

1. Discharge the patient

2. Move them on to a programme of maintenance?

What would be most appropriate for our patient, and why?

Write your thoughts down in your notebook

Most practitioners answering this question feel that our patient would benefit from maintenance treatment, because she has an on-going knee issue. This is something that might benefit from some maintenance care....

Here is a little writing task for you:

Does everyone need maintenance treatment? Yes/No

List those patient groups who you think would benefit from maintenance care

Here are some of my thoughts about maintenance treatment:

Who needs it:

• Patients with degenerative changes in lower limb and spine

• Patients doing repetitive tasks that may cause mechanical overload (sports/work etc)

• Stressed people with muscle tension

• Patients who are lonely/unhappy and want contact

Who doesn’t need it:

• Patients who have nothing wrong with them. Discharge them at the end of their initial treatment programme!

• Patients who don’t want it. Discharge them too! They will be happy that you’ve helped them this far!

Pearl:

• Give patients a choice. At the end of their initial course of treatment (assuming their symptoms have largely resolved) give them a choice of either coming back if symptoms recur, or taking a preventative approach (assuming that you have good reasons for thinking that a preventative approach would help).

• It’s absolutely right to discharge patients if they feel well and there is nothing more that you can do for them functionally.

• If you clearly understand why they would benefit from your preventative treatment, you will easily be able to explain it to them.

How not to implement a maintenance plan (imho) aka ‘seeing how it goes’.

‘Lets see you once a month for two or three months and see how it goes, before we stretch it out a bit’…..

This was how I used to transition patients from their acute treatment plan into a maintenance plan. It kinda worked, some patients would stick around long-term, some would come in for a while, and some wouldn’t attend at all. You could argue that it was self-selecting, I suppose.

One of the problems with this approach is that it returns the motive for treatment back to PAIN. When the patients pain is gone, they will stop attending. Remember that we have decided that this is not what our job is. Our job is to keep the whole body functioning as well as possible. Just like a car mechanic. We should not wait for the oil light to come on before we check the oil level!

Furthermore, a common problem is that the patient and the practitioner will continue to focus treatment on the source of the symptoms (the sacro-iliac) rather than the cause of the mechanical trouble (the knee).

So how can we more appropriately implement a maintenance plan (assuming that we feel that it is appropriate)?

Write your thoughts down.........

Here is what I moved towards:

Implementing a maintenance plan at the end of a course of acute treatment

After many years of using an interim ‘lets see how it goes once a month for a few months’ policy, I changed things.

At the end of their course of treatment for the problem that they attended with, I would tell them what I thought their status was. Thinking about Lucy, our patient from earlier, I might say:

‘you have a mildly degenerative right knee’ or:

‘you have what looks like a severely degenerative right knee’

or similar, mildly quantifiable, opinion about what the issue is. This would have a bearing on how often I wanted to see Lucy over the next twelve months:

A patient with mild degenerative changes in the knee might perhaps benefit coming in once every couple of months. A patient with severe degenerative changes might benefit from a monthly visit, in my opinion (and I know that not everyone will agree with me).

I would then ask the patient how often they felt they should come in over the next twelve months. Very often their answer was a to come in more frequently than I would have predicted!

Mostly what I thought, and what the patient thought, were similar, so no problem.

I would then say to the patient that I like to do an annual review of my long-term maintenance patients, in order to have a re-assessment of their situation. A review appointment takes longer than a regular appointment, so we have to book all the appointments for the year in advance, with the last appointment being a review appointment. I told them that if we didn’t book a review appointment now, we would never get around to doing one.

Furthermore, I explained that they could move their appointments if they needed to, the appointments were not set in stone. Nor did we charge in advance, or even charge more for the longer appointment.

Remember the advantages to the patient of pre-booking their course of acute treatment? Pre-booking a maintenance plan is just the same!

What I like about creating a maintenance plan for the year is that:

• We have a plan
• I know what I’m going to do when I see the patient. The appointments are less likely to be like a learner golfer zig-zagging around the golf course, and more likely to be like a professional player hitting the ball in a straight line
• The patient knows why they are attending (if we remember to set some goals)!
• The patient can explain to their friends and family why they are coming to see us long-term, rather than come up with a rather woolly philosophical explanation
• It’s honest. Rather than sliding insidiously into long-term care, the plan is driven by goals and it has an end-point in twelve months time.
• Having a plan is way less stressful than not having a plan!Treating patients without having a plan is a bit like sailing a ship without a compass, and seeing where you end up!

Homework:

For your next ten patients, when they come to the end of their short-term treatment, either discharge them (if there is nothing more that you can do to help them) or tell them the specific reasons why you think that maintenance would be a good idea, and give them a choice to either:

• come back when they want to, or
• come in at intervals that you agree over the next year in order to achieve the goals that you agree and either
• depart, satisfied, or depart with a maintenance plan in the diary for the next twelve months, happy that you are helping them to achieve their functional goals.

Not sure? Just try it and see if it works!

(Remember to tell your reception team what you are doing now, in advance, so that they do not sabotage your new patient management strategy. There is nothing that staff like less than change, as you know......)