Home Health & Hospice Week

Home care providers may find physician relationships getting frayed under burdensome regulatory requirements such as the face-to-face physician encounter rule. Try this communication approach to improve those critical affiliations.

For a home health nurse, getting a direct line to speak with a physician is a challenge. One way to help is to educate new nurses about this challenge and develop a strategy to address it before they start the work, says Boston-based nurse Debra Bertrand with Beth Israel Deaconess Medical Center.

Look at the big picture for establishing effective communication before you need to make that call, says Bertrand, who spent a number of years in the field as a home health clinician.

Consider the timing of your approach and the vehicle you use to communicate, Bertrand says. Check with the frontline manager of the physician's office. Ask what communication format the doctor prefers -- e-mail, a phone call during office hours, or a fax along with a "heads-up" call to staff? And what should you do if you have a timely issue?

The frontline manager can tell you when to call and how to get the doctor to call back. Using a cell phone and giving the doctor the option to call back can be a huge help.

Bottom line: Find out the doctor's preferences before you even enter into communication.

A Situation-Background-Assessment-Recommendation (SBAR) tool can be powerful in streamlining communication. This tool helps you to summarize the patient's situation, background, assessment, and recommendation so you have all the details at hand when you contact the physician. (See the sample SBAR worksheet from Quality Improvement Organization Quality Insights of Pennsylvania on p. 194.)

The stress of being on your own when assessing patients and determining when they need to see the physician can be a big burden, Bertrand says. And when you are under stress, consolidating and communicating your thoughts can be difficult. An SBAR work sheet gives you a format for creating a script before you call the physician.

Bonus: Having all of your points ready and practicing before you make the call can give you more confidence, Bertrand says.

Problem: Physicians can be busy and have similar stresses to ones nurses experience. They may have a tendency to view your call as an interruption, Bertrand says. Being able to communicate quickly and effectively shows the doctor that you value his time and can ease the stress all around.

The SBAR model forces you to think through the issue and to make specific recommendations, says Pat Jump with Rice Lake, Wis.-based Acorn's End Training & Consulting. "Sometimes clinicians are reluctant to make recommendations to the physician thinking this is akin to diagnosing." But most physicians appreciate it when the clinician makes a recommendation, because they recognize that the clinician often times knows the patient better than the physician does, she says.

Getting through the front-office "firewall" to speak directly to the physician can be difficult. Whether that firewall is manned by an RN or a patient technician, you need to be able to verbalize quickly what's going on with the patient or you may lose your opportunity, Bertrand says. You don't necessarily know who you're talking to at first, but try to make a connection with the person manning the firewall. Know their name and work to establish a relationship, Bertrand suggests.

Try this: If you are in the general area, drop in and say hello. Putting a face with your voice really helps, Bertrand says. You'll often find the "firewall" in the front of the office, and bringing her a cup of coffee and saying "Thanks for helping me out with Mrs. Jones" isn't bribery -- it's a show of mutual respect, she says.

Tip: Many clinicians report success with faxing their communication to doctors. That could be as easy as sending along your completed SBAR form. But you still need to establish a rapport with the folks in the physician office to make sure the fax gets to the doctor.

Note: The tool and a detailed 29-page packet on using the SBAR in home health from the Collaboration for Homecare Advances in Management and Practice (CHAMP) is at www.champprogram.org/static/Entire_SBAR_Package.pdf. The packet also contains an SBAR tool specific to patients with COPD.