Medicine, Law, and Policy
Reducing Malpractice Risk for Physicians Providing Home Care
By Cinda Velasco, J.D.
Good communication, follow-up, and documentation reduce a physician’s risk of being sued for malpractice when providing or supervising home care.
The Minnesota Department of Health estimates that the number of people in Minnesota age 60 years and older will more than double between 2000 and 2030. If that prediction holds true, 26 percent of the state’s population will be older than 60 by 2030. With the aging of the population will come a greater need for health care services and a demand for more choices about where care is delivered. Those factors, along with the earlier discharge of patients from acute care facilities, better medical management of chronic conditions, and a desire for people to stay at home rather than live in institutional settings, are contributing to the increasing demand for home health care services.
According to the American Medical Association and the American Academy of Home Care Physicians, physicians are responsible for determining the necessity of home health care and supervising the delivery of that care. A number of considerations go into that including the level of assistance the patient requires, the patient’s insurance coverage and whether it will help pay for home health care, the availability of home health agencies where the patient lives, and how best to utilize the resources that are available. In order to decide whether home care is a realistic option, the physician also needs to consider the patient’s overall health including any physical or mobility limitations, the design of the home, and whether the patient is living alone or with someone else. For example, home care might be fine for an 80-year-old hip replacement patient who is otherwise healthy and living with a spouse or family member. On the other hand, it may not be the best option for a patient who is frail and lives alone.
If it’s determined that home care is necessary and feasible, the scope of the physician’s responsibility includes managing the patient’s medical problems; creating a treatment plan with short- and long-term goals; ensuring continuity of care as the patient transitions from the hospital to home; facilitating communication with the patient, his or her family, and other caregivers; making sure orders for care and documentation of care given are entered in the patient’s medical record; making house calls when appropriate; and making sure there is a physician on call 24 hours a day.1
Physicians who care for patients in their homes or who order home health care face many of the same malpractice risks as those who deliver care in hospitals and clinics. In most cases, at least one of the following is at the heart of a malpractice claim: malpractice itself, poor communication with patients, poor communication with other providers, lack of follow-up, failure to receive informed consent, and poor documentation. Although physicians cannot control all that goes on in the home environment, they can do certain things to reduce their exposure to risk. Good communication, follow-up, and documentation on their part can go a long way toward reducing their chances of being sued. This article will describe how improvement in these areas can help physicians minimize their malpractice exposure when treating home care patients.
Focus on Communication
Communication is the centerpiece of every physician-patient relationship, whether patients are in the hospital, at the clinic, or in their homes. Effective communication can improve patient satisfaction and compliance with treatment plans, thus reducing the likelihood of a malpractice claim.
♦ With Patients and Families
Maintaining good communication with patients can be challenging when they are receiving care at home. Instead of face-to-face contact with the patient, the physician must rely on reports from the home care provider about whether the patient is complying with the treatment plan. They also have to count on home health care providers or the patient’s family members to identify and immediately report potential problems in order to prevent them from becoming serious.
To determine what will work best for the patient, the physician needs to openly discuss the goals and limitations of home care with the patient and/or family members. Physicians need to involve them in treatment decisions and discuss with them who will provide hands-on care, whether the patient will be able to participate in his or her care, and what to do and who to call if problems arise. Discussing such issues can improve the chances of success and avoid unrealistic expectations on the part of the patient or family that can put a physician at risk.
♦ With Other Providers
According to the Joint Commission, communication breakdowns between health care providers are often at the root of patient injuries. Sometimes poor communication can lead to a malpractice claim. For example, in 2003, an Illinois physician and home health agency reached a $475,000 settlement with the estate of a deceased patient. The patient’s estate alleged that the patient suffered from nosebleeds, shortness of breath, and rashes and that the defendants failed to monitor and manage her Coumadin therapy. The family charged the home health care agency with failing to monitor the woman, document her condition, and relate her condition to the physician in a timely manner.2
Any time a patient is transferred from one provider to another or from one care setting to another, the chance of something going wrong increases. Case managers, discharge planners, and hospitalists are usually involved in planning for home care. Clinic-based physicians should request that the hospitalists caring for their patients inform them if those patients will receive home care and that the hospitalists provide them with copies of orders and care plans so they can follow their patients.
It’s important that physicians find out which home health agency is caring for their patient and establish a good relationship with the nurses and other caregivers who work there. One way for physicians to do that is by discussing with them who will have follow-up responsibility for patient test or lab results, who should answer questions the patient and family may have, and who will be responsible for after-hours call coverage should a question or problem arise.
Included in the National Patient Safety Goals for Home Health Care are steps to improve communication among caregivers. Some that can be used in a home health situation include:
- Reading back verbal orders. When a physician gives a verbal order to a home health care provider, having that provider read it back will give both parties a chance to confirm accuracy.
- Standardizing abbreviations and avoiding those on the Do Not Use list such as cc or µg.
- Using a standardized approach when handing off care for a patient to another provider that ensures all pertinent information is relayed and allows sufficient time for the new caregiver to ask
questions.3
Develop Follow-Up Systems
Proper follow-up is also important to preventing a lawsuit, especially when a physician is relying on a home health professional to deliver care in a patient’s home. In the case of the patient whose Coumadin level allegedly was not monitored, had the home health nurse reported the patient’s nosebleeds to the physician and made an appointment for the patient at the clinic the following day, the lawsuit might have been avoided.
To be effective, plans for follow-up need to be agreed on and in place before action is required. When working with patients who are receiving home health care, the primary care physician, as well as the home health agency staff and any specialists the patient is seeing, should receive in a timely manner:
- Test and lab results;
- Notification and review of critical test results;
- Notice of telephone calls from the patient, family, or caregiver; and
- Notification of missed or cancelled appointments.
Electronic medical records that are certified by the Certification Commission for Healthcare Information Technology can help with some of this, as they can track the status of orders and the results of tests and lab work and highlight critical values. However, physicians or their employers must decide to use this safety feature and not turn it off.
Document Work
The quality of medical record documentation is critical to preventing patient injuries and controlling malpractice losses, especially when working with home health care patients. Omissions or illegible or incomplete records can contribute to patient injuries and leave physicians open to lawsuits. Plaintiffs’ attorneys scrutinize records and quickly identify documentation issues when evaluating a possible malpractice claim. Problems with medical records make nearly 40 percent of malpractice cases difficult to defend.
Good documentation does not happen by accident. Time and effort are needed. Physicians managing home care patients must coordinate information from multiple providers into one complete record. In doing so, they should take care to include records of telephone calls; copies of orders, home health evaluations, and reports; an explanation of the rationale for continued home care; and all information that is pertinent to the ongoing care of the patient. Physicians should also note in their records the names of people and organizations involved in the patient’s care.
Other Considerations
Mistakes in prescribing, transcribing, dispensing, and administering medication are frequent, and can lead to costly lawsuits. When patients are at home, as opposed to in a hospital or nursing facility, they and their caregivers are responsible for making sure they receive the right dosage of a medication at the right time, thus increasing the chance for error. Therefore, it’s critical to give patients and their caregivers an accurate list of the patient’s current medications. Physicians need to provide them with information about medication indications, dosages, possible side effects, and schedules.
To reduce the chance of a bad outcome caused by medications:
- Reconcile prescriptions across the continuum of care, so providers, patients, and their families have an accurate list of current medications. Communicate any changes to the patient’s other providers.
- Identify medications with look-alike and sound-alike names. To reduce the risk of harm, avoid prescribing them, if possible. When you do have to prescribe these medications, include the dosage, directions, and indications.
- Make sure patients and their caregivers understand how and when to take medications.
Conclusion
Patient preference and the ability to provide care in the home that was once only available in a hospital or clinic have made home health care a fast-growing segment of the health care industry. Involving your patients, their families, and their home health care providers in decisions about their care and treatment improves the likelihood of good outcomes for the patient and reduces the chance of injury and medical malpractice. Although mistakes happen in medicine, communicating openly with patients, their families, and home health care providers; following up to make sure tests are administered and results are acted upon; and thoroughly documenting communications, orders for care, and results of tests are some of the best ways to reduce malpractice risk. MM
Cinda Velasco is an attorney with Midwest Medical Insurance Company in Minneapolis.
References
1. American Medical Association. Medical Management of the Home Care Patient provision for 24-hour on-call coverage by a physician. (Medical management of the Home Care Patient, third edition page 6, table 1). Available at: www.ama-assn.org. Accessed September 17, 2008.
2. Estate of Kari v. Elmhurst Memorial Home Health, et al. Case no. 03L676.
3. National Patient Safety Goals. Available at: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/09_ome_npsgs.htm. Accessed: September 17, 2008.