Deal with with care: Minimizing threat with short-term and touring sufferers

By TDIC Risk Management employees

You have likely invested a lot of time and money in a marketing plan that will attract new patients to your practice, as well as the energy and resources to ensure those patients are retained. Building a thriving practice and expanding your patient base are even more rewarding when you have new patients referred to you by satisfied existing patients or other trusted healthcare providers and colleagues.

Some of these patients come with luggage – in the truest sense of the word! A variety of situations can result in patients who are away from home visiting a dentist while they are temporarily or temporarily near you. Some may have an established provider in their primary residential area, but are experiencing an unexpected dental emergency or trauma. Others may try to maintain an established treatment plan or receive preventive treatment while temporarily living off their regular dentist. These patients can include:

• Business travelers who are in your city on long business trips.
• Students at local colleges, universities or boarding schools.
• “Snowbirds” or others that live in an area seasonally then return to their permanent residence for the remainder of the year.

As an “emergency” general practitioner, you may have more difficult procedures to deal with, but you cannot guarantee continuity of care, follow-up treatment and maintenance after leaving your practice. An additional complication is that you have not yet had the opportunity to build a climate of trust with this short-term patient – an important step in the doctor-patient relationship that improves communication and improves outcomes.

So how can you look after temporary or traveling patients and at the same time protect your practice from increased risk factors? Dentists Insurance Company’s dedicated risk management analysts provide guidance on making complex decisions, and assist with patient selection and documentation.

A case study on the treatment of an out-of-town patient

A phone call to TDIC’s Risk management advisory line Involved was a retired patient who enjoyed spending the summers in the milder coastal climate of Northern California, but preferred to spend the winter months in Arizona. The patient did not disclose this information about her sun-hungry lifestyle to the dentist she visited in California. When she started having a toothache, the California dentist treated her and placed a temporary crown and advised the patient to return for permanent restoration in two weeks.

The patient did not return until months later; at this point the tissue around the tooth was inflamed and the tooth had developed easy mobility. At this second appointment, the dentist informed the patient of the cautious prognosis of the tooth. The patient chose to have the previously made crown put on, but the crown did not fit and had to be remade. When the patient heard the news that this would increase the treatment time, the patient stated that she would be leaving town soon. The attending dentist asked the laboratory to expedite the case so that the patient’s treatment could be completed before she left.

A few weeks after the permanent crown was shipped, the California dentist heard from the patient who now lived in Arizona. She reported that the tooth was broken at the gumline. Because the patient lived so far away and her return for follow-up was restricted, the dentist sought advice from the TDIC line of advice to manage the situation ethically and effectively.

The risk management analyst advised the dentist on the importance of patient and case selection, and on spending more time with patients on initial visits to understand their dental history and lifestyle. Realizing that the patient’s difficulty with continuity of care through their practice had been overlooked on previous visits, the dentist was willing to offer the patient a partial reimbursement to offset the cost of the treatment. The analyst reviewed the guidelines for offering a refund to the patient and reminded the dentist to encourage the patient to see a dentist in her current location as soon as possible. Such a reminder should be made in writing in order to create a basis for evidence.

The importance of patient selection

Also, when welcoming new patients, keep in mind that dentists are not required to admit all patients to their practice (subject to discrimination). The people you choose for your patient base should generally be people with whom you can build productive, healthy doctor-patient relationships. When patients come to you on demand and you are unable to get routine checkups or x-rays, you find it difficult to ensure continuity of care, proper diagnosis, treatment, and maintenance – all factors that increase risk.

With this in mind, you can sometimes weigh the benefits of temporary patient care against these known risks. Potential patients may require additional attention if they have been referred to you by current patients or trusted colleagues. Caring for these patients fosters a positive working relationship between you and the referring person, and ensures that you continue to receive referrals from them regularly – not all of which are temporary.

Online reputation management is another factor that should be considered when making a decision about admitting a temporary patient. If the patient approached your practice based on positive online reviews from vendors, it is more likely that they will provide their own review. Such reviewers are known to leave negative feedback based on their interaction with office staff when they first seek treatment.

Since your practice staff is the first point of contact for potential patients, they should be trained to provide thoughtful and empathetic service to anyone who requests an appointment.

As you decide to admit emergency or short-term patients on a case-by-case basis, make sure your practice staff understands the case review process and how to convey this process to those seeking emergency care. The ethical standard for emergency services for patients who are not patients is to “make reasonable provision for their emergency care” in accordance with ADA’s Ethics and Professional Code. To facilitate compliance with this standard, TDIC suggests maintaining a list of phone numbers of clinics and dental societies that can be made available to emergency patients who do not have an established dentist.

Considerate communication and documentation

Respectful communication and careful documentation at all service points protect the reputation of your practice and reduce risks. Questions about your admission forms are a good starting point for this documentation. Asking “What is the reason for your visit today?” and “When was your last visit to the dentist and what was the name of the dentist?” are suitable ways to identify short-term patients. If you decide to admit a short-term or travel patient, here are five additional critical communication and documentation points:

• Regardless of whether the patient has a regular dentist or not. If so, try to consult this provider directly. Request any recent notes or x-rays related to the current treatment.
• The patient’s detailed medical and dental history. This is especially important when you are unable to obtain records from another dentist on behalf of the patient. Document past medical and dental procedures, current diagnoses, and all medications.
• The patient’s lifestyle. For a complete picture of health, inquire about and document aspects of the patient’s lifestyle that may affect their care. This includes travel plans and any barriers to consistent access to medical care.
• Letter of acceptance. As with all patients, informed consent is a discussion, not just a form. Confirm their understanding and consent before offering treatment. Short-term patients should also be made aware of the risks involved in postponing follow-up care.
• The duration of treatment. When an out-of-town patient presents with a particularly complex case, it is best not to get involved beyond palliative care. Patients visiting or temporarily residing in your area may not be able to complete treatment under your care. Explain to the patient the importance of ongoing care and encourage them to make an appointment with their family dentist.

Treating snowbirds, college students, or patients who only present in an emergency can be challenging, especially if another general practitioner is your GP. As a “secondary” general dentist, you are exposed to a higher risk of liability than the dentist who performs routine dental care.

Again, the best defense is good communication between dentist and patient and between the two treating dentists. Proactively explain the importance of continuous medical care to the patient. And if the situation becomes too complex, ask the patient to choose their first dentist. If the patient is not ready, it is best to consider stopping treatment.

Trust your instincts and have the confidence to say no to times when you feel uncomfortable. When faced with difficult or uncertain patient care, consult with an experienced TDIC Risk Management analyst.

TDIC’s risk management advisory line is a benefit of CDA membership. arrange an appointment for consultation with an experienced risk management analyst or call 800.733.0633. Reprinted with permission from the California Dental Association, Copyright January 2022.