Troubleshooting A Direct Care Practice

No two direct care practices are created equal.  If you're debating how to begin your DPC, there are many blog posts that will discuss the basics of direct care, how to open a Direct Care Lite practice, and the nuts and bolts of startup costs.  (There are also some amazing and inspiring podcasts to help you start your practice).  If you have a game plan or are deep into your own practice (which might be months or even years in), this post is meant to help you identify the best ways to "troubleshoot" the issues you find you are having day-to-day.

Our DPC is a micropractice (think no staff) with an emphasis on simplicity and low overhead.  In our case, we find the simplest solution is most often the best solution.  Regardless of your point of view in politics, many of us can agree that the U.S. government approaches solutions to many problems, especially that of our healthcare system, by adding onto a broken system, rather than starting from scratch with a newer, simpler model.  So, when you find that your direct care practice is not working the way you had hoped, it may be time to consider a simpler solution.

I advocate the "step-back and analyze" point of view.  In other words, look ahead a few days, a few weeks on your work schedule and block out a few days entirely.  (If your practice is like mine, you can spend an hour or two a day on those days handling things that arise that are urgent for patients and using the rest of your time to analyze your practice).  When you are knee-deep in daily practice and seeing a full panel of patients, your efforts to make changes are unlikely to work because the urgent needs of the patients you are seeing will take over (as it should).  Hence, I strongly advocate taking time off from seeing patients and doing a full review of your practice.

If you know of an issue with your practice that you want to fix, start there.  If you just want to do an overview of your practice and shore up some improved procedures to save time and money then consider a more general review.  When you are focusing on a single issue here are some factors to consider:
- Why is this a problem? For me or patients? And therefore, is the issue time or money related or is it simply causing unnecessary frustration?
- Time related: how can this be done using less time?
- Cost related: how can this be done with less expense?
- Frustration related: why is this bothering me or my patients and is there another way to do it?

Here are a few case studies of these concepts.

CASE 1:
I have patients calling, texting and emailing me all day during the work day and I cannot see patients and respond to others at the same time.  I want to maintain no/low staff so how do I handle this?
When you step back and look at this issue, you want to decide what is YOUR preference.  Do you prefer patients text, email or call?  Do you prefer to handle issues (that are clinically safe to do so) remotely or do you prefer to have patients come in for a visit?  Many practices evolve to allow patients to contact you via all of these methods and each patient does not have a clear view of what the physician prefers.  Managing all avenues can be overwhelming.  So, this practice should pick their preference for weekdays and for after hours.  
- In my practice, patients can send an after hours email for things that can be handled during work days and I will manage those in between patients during my work hours.
- Patients can text me during regular works hours or email via the private patient portal.  I have scheduled a buffer of 15-30 minutes that I enter myself on my scheduler (which is part of my EMR) so that after and before patient visits I have time to handle visit-related tasks and/or respond to texts and emails.  
- If a patient sends a non-urgent text after hours, I send it to myself in email form and manage it during the week.  I also send a gentle reminder for repeat offenders that email over the weekend/overnight is ideal for non urgent issues so I don't lose the text by the next work day.
- When I determined these rules help me the most, I sent this to my patients in a brief email so that they could refer back to the best ways to reach me when they weren't sure!

CASE 2: 
I can't get through all this paperwork!
First of all, big step back - what paperwork?  At our practice we've really eliminated paper about 98% of the time.  I urge you to review what paperwork you use that is wasting your time - filling out forms, signing, scanning, shredding, filing, etc. 
Examples of switches to electronic options:
- Switch your sign up forms to an online format (most patients can sign a pdf on their phones so we email a link with forms to them from our website and they email back); there are tech-savy options like DocUSign, etc but because money is money, we go the free route!
- Change your medical records request to FAX only (eliminating the address has dropped the number of paper charts we get by about 90-95%). 
- Set up an electronic fax that integrates directly into your EMR so it's a one stop shop.  If you have to file away prior charts, sign and send a form and then save it in the EMR, or complete paperwork and keep it on file - an e-fax/EMR connection does it all without any printing/scanning/filing/envelopes/stamps/you get the point!
- Scanning and shredding are the single most time consuming things I did early in practice - switch to electronic but if you must have paper, get a high speed scanner that can run a lot of pages at once and invest in a shredding service.  We have one big bin outside the office and it gets replaced twice a year - that is the best $130 per year we spend in time-savings!
- Review your paper problems and decide where you can improve tech to save yourself time and money!

I'd love to help you brainstorm and troubleshoot so shoot me an email and I will write a blog about your problem or if it's more complex, talk to me about consulting directly to help you break your problem down and make your practice work.  Remember - if the practice is not sustainable for you, then it is not going to be around to help patients, hire staff, etc so if you suffer, everyone suffers.  It's not too late to make a working change!

More on the nuts and bolts of starting or improving your Direct Care practice...

---