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23 Family-Oriented Primary Care in the Real World: Practical Considerations for Comprehensive Care
Translating a family-oriented approach from theory into daily clinical prac- tice presents a variety of broad pragmatic challenges. Such issues as, “How will I find the time? Who will pay for this approach? and How do I avoid getting caught in the middle?” need to be addressed. Questions about logis- tical details need to be answered (e.g., “How should I design my office brochure, the physical space, my records?”). In this chapter, we will provide very specific, family-oriented suggestions that take into account the reality of today’s healthcare environment. Some of these ideas work best when starting a new practice, whereas others can be incorporated into existing practices.
A Family-Oriented Image
First impressions are important. Family-oriented clinicians can begin by proclaiming their family orientation with the word family in the name of the practice or group (e.g., Family Medicine Group, Family Health Associates, Family Practice Center, or Family Health Clinic). A practice logo that represents the family is another way to communicate a family ori- entation. Promotional material about the practice should emphasize its family orientation and services for families of all types.
The staff of the practice can further support and encourage a family- oriented approach. For example, staff members can attempt to get to know family members of patients, even if they are not members of the practice.
When a patient calls, secretaries can communicate that family members are valued and included. Phone calls and visits by family members should be encouraged, and not viewed as intrusive. Family members in the waiting room can be invited into the examination room, if the patient so desires.
Enrollment of Patients and Families
A family orientation begins before the first visit (1). Whenever possible the entire family can be encouraged to register together with the same clini- cian at the orientation. Even when all members of the family do not have the same clinician, sufficient information about the entire family can be obtained at registration, or by mail, to construct a basic genogram. Self- administered genograms (2) and computerized genograms (3,4) can be completed at registration or before the first visit.
Family members can be encouraged to come in together for their first visit. For example, an older couple may make back-to-back appointments for complete physicals, or all the children in the family can be seen serially for well-child checks. This provides a time-efficient way to gather back- ground health information about the family and to construct a routine genogram. This type of first visit gives the strong impression that the clini- cian is family oriented and will appreciate the entire family’s participation in healthcare.
Despite a family invitation, the initial visit to the clinician often is by an individual patient. Even though not present, important information about other family members can be obtained by appropriate family-oriented questions (see chap. 4).“What kinds of illnesses run in your husband’s/wife’s side of the family? Is this his/her first marriage? What does he/she do for work?” It should not take long to obtaining an initial three-generation genogram. As such it provides an efficient representation of family, social, and genetic information. This initial “skeleton” template can be expanded at subsequent visits.
Physical Layout
Whenever possible, the physical layout of the medical office should be designed or adapted to accommodate families. Waiting rooms need to be large enough for several families and have reading material that is oriented to families. They should be accessible to the elderly and disabled and have separate play areas with toys for children. Pictures of families in the practice or babies delivered by the clinician can add a family touch to the waiting area or nurses’ station. Exam rooms should ideally be large enough to seat at least two family members comfortably (approx- imately 100 square feet), and should be equipped with a third chair.
Chairs can be readily moved from other exam rooms for additional family members. In addition, it is helpful to have at least one family conference or consultation room that can accommodate 8–10 people comfortably.
Range of Available Services
Whenever possible, a family-oriented medical practice should offer the services that a family most often needs. Pregnancy care, and the subsequent pediatric care, is an important part of family-oriented health care.
Pregnancy and childbirth (see Chap. 10) is a crucial stage in the develop- ment of the family during which a family orientation and continuity of care is important. Clinicians that practice family-oriented maternity care have a more balanced mix of ages of patients, with more children in their practices than family clinicians that do not (5). High malpractice premiums are unfor- tunately forcing many family clinicians to stop practicing obstetrics (6).
When a clinician does not do obstetrics, it is helpful to work closely with a family-oriented clinician that does provide maternity care to ensure as much continuity of care as possible. In some situations, a primary care cli- nician may participate in some of the prenatal care to maintain the conti- nuity, even though he or she will not do the delivery.
Family-oriented practices can either directly provide or ensure easy access to other health-related services (e.g., social work or nutrition coun- seling) using health professionals that also value the inclusion of families and significant others. For example, dietitians need to consider that fami- lies usually share the same diet (7), that dietary interventions must consider the entire family, and that counseling the family about diet is more efficient and effective than counseling one individual. Whenever possible, a family therapist is part of the healthcare team (8), with an office in the same prac- tice or building (see later for discussion of incorporating a family therapist into a medical practice and Chap. 25).
The family-oriented clinician needs to have a list of telephone and inter- net resources for services not provided in the practice. These resources com- monly include other family-oriented mental health professionals, alcohol and drug services (including detoxification, inpatient and outpatient treat- ment facilities, AA, Al-Anon meetings, Adult Children of Alcoholics groups), self-help and support groups for chronic illness, bereavement, divorce, and advocacy organizations. Many communities maintain directo- ries of these services.
A clinician can rent out space in the office, either when open or closed, to organizations that offer other related services to patients and families (e.g., Weight Watchers, Childhood Education Association, Alcoholics Anonymous, or other support groups). Patients and families may be more likely to attend a group that meets in their clinician’s office. Larger multi- clinician practices may want to organize their own family-oriented groups focused on such specific areas as dealing with normative family develop- ment (e.g., prenatal and parenting classes), nonnormative family crises (e.g., divorce and separation), behavior problems like smoking and overeating, or chronic illness or chronic pain.
Range of Available Services 401
Incorporating a Family Therapist into a Medical Practice
Collaboration and referrals to family-oriented mental health professionals will be discussed in detail in Chapter 25. The most successful referrals occur when the family therapist practices under the same roof as the clinician.
The clinician can personally introduce the patient or family to the therapist and, if necessary, can attend part or all of the first session. The therapist can easily meet with the clinician during a family conference or a regular office visit. Patients and families often prefer counseling sessions at the clinician’s office, rather than going to a therapist’s office or to a mental health center.
Communication between therapist and clinician is improved: Each learns more about the other’s work when they are practicing under the same roof.
There are several different models of collaborative family health care (8,9). In the most traditional model, the therapist has a private practice in the same building as the clinician. In a more collaborative model, the ther- apist may rent space within the clinicians office, but conduct a private prac- tice that is financially independent of the clinician’s practice. The therapist may do his or her own scheduling and billing, or he or she may contract with the clinician for secretarial and billing services. A therapist may be fully integrated into the medical practice as a partner or employee and treated as other healthcare clinicians in the practice. Services are billed by the practice, and the therapist is paid either on a straight salary or based upon a formula involving productivity or the overall profits of the practice.
One unique model of collaborative practice is when a family clinician and family therapist see patients together as a team. Dym and Berman (10,11) have described the theoretical and practical aspects of this innovative approach. Regardless of the model used, the different theoretical orienta- tion and style of practice between family-oriented medical practitioners and family therapists must be addressed directly (12).
When the therapist is seeing patients in a medical practice, a decision must be made whether the therapist’s notes are included in the medical chart or are kept in a separate mental health chart, or if copies of the mental health notes are put in the medical chart. Close communication is integral to comprehensive care. The therapist can see what medical visits and prob- lems have occurred since the last therapy session, and the clinician is kept up to date with the course of therapy. At the time of referral, the therapist should receive a referral note and should have access to the medical record containing the genogram and, if possible, the medical records of other family members. This method of communication encourages the integration of physical and mental health care. The clinician must be careful not to release the mental health notes to other clinicians or insurance companies, unless the patient specifically permits their release in addition to the medical records.
Record Keeping
Comprehensive family care includes family record keeping. In addition to the genogram, another tool in family-oriented care is the family chart or folder (13), in which the charts of all members of the family are filed together. Family is defined here for convenience as a group of persons sharing a common household. A relationship (not necessarily by blood or marriage) is implied (14). In addition to each family member’s chart, the family folder includes a separate family card that goes in the front of the chart to be easily identified and accessible for each visit. On one side, there is space for the genogram with a brief list of standard symbols and a section for family history. Family problems or family assessments can be written on the back.
The advantages of a family chart are many. Information about the family, especially the genogram, can be obtained from different family members and is available for each family member’s visit. Any family member can update the information at the time of visit. This important data does not need to be duplicated for each family member’s chart. Without a family chart, the clinician may not otherwise know that two patients with differ- ent last names are closely related. It is particularly valuable to have a genogram readily available in the family chart when caring for remarried or blended families where relationships may be quite complex.
Having all the family members’ charts in one family folder facilitates the detection of patterns of healthcare utilization, which may reflect family stress or dysfunction. Widmer (15) has shown that when one family member is depressed, other family members visit the doctor more frequently. These visits by different family members can be graphically illustrated by a family- care journal (16) in which dates and diagnoses (using a code such as ICD- 9) for all family members is recorded graphically. Huygens (17) kept very meticulous and elegant journals or charts of familial patterns of illness for more than three decades in his practice in the Netherlands. In their classic study of family stress and illness, Meyer and Haggerty (18) used similar charts to demonstrate that streptococcal pharyngitis is often preceded by stressful family events.
Knowing about another family member’s health problem at the time of a visit can be quite helpful. A family chart makes it easier to identify whether more than one family member has a cardiac risk factor (e.g., smoking or hypercholesterolemia). In such cases, an intervention aimed at the entire family may be more effective. Family charts also make family research easier to conduct. One can easily retrieve and compare informa- tion about the family. In time, however, family charts made of paper can become cumbersome because of their size. An electronic medical record solves this problem by providing instant access to all family members. In choosing an electronic medical record system, one should include consid- eration of how the system organizes family and household information. For Record Keeping 403
example, a family record number located in the individual record could link the clinician to family-related information.
A family member often requests information about another family member’s healthcare. For example, a mother at her yearly gynecological visit may inquire when her children should come in for their next visit or immunization. This information is readily available in the family chart. With family charts, however, the clinician must be particularly careful about con- fidentiality of information. The clinician should not provide information about an adult family member without that person’s consent: A patient should not have access to the entire family chart without permission of the other members of the family.
Confidentiality
Confidentiality is a concern that often arises in family-oriented medical care (see Fig. 23.1).
Chuck McNab, a 60-year-old African-American male, appeared for an appointment with Dr. D. He had been separated from his ailing wife, Martha, for more than 1 year. He was upset that his stepdaughter Cheryl had told him that his wife did not want him to visit her in the nursing home, and Cheryl would not tell him in which nursing home she was.
Dr. D. knew the answer to Chuck’s questions, but was reluctant to reveal this information to Chuck without his wife’s permission. He also feared that telling Chuck might put him in a coalition with Chuck against his stepdaughter and possibly Martha, yet he thought Chuck should know where his wife was, so he was uncertain what to do.
Cheryl Chuck Martha
Figure 23.1. Confidentiality in a blended family.
Confidentiality 405
In family-oriented primary care, it is important to determine the difference between a patient’s request for legitimate confidentiality and colluding with a patient or family member about a secret that may fuel individual and family dysfunction.
Confidentiality is an essential ethical standard in medical practice, but secrets are destructive to healthy family functioning (19). To deal with this dilemma, the clinician should never provide information about an adult patient to another family member except when the patient has given explicit permission [or is in immediate danger to him- or herself (i.e., suicide) or others (i.e., homicide)] (20). Even with permission, this process is best accomplished with all relevant parties present. When the clinician suspects a secret that may be damaging to family relationships (e.g., an affair, or a serious or terminal diagnosis), the clinician can use his or her influence to advise the patient or family to disclose any important infor- mation; however, the clinician should not be the party to actually reveal the confidential information. One should consider referral to a psychotherapist to manage any serious fallout if the information is likely to be provocative.
Dr. D. suggested to Chuck that he and his stepdaughter meet at the nursing home to discuss with Martha whether Chuck could visit his wife.
Chuck agreed to abide by whatever decision Martha made about his visiting. Dr. D. called the daughter, who reluctantly agreed to tell Chuck which nursing home her mother was in, and to attend a family conference, as long as Chuck promised to respect Martha’s wishes. Dr.
D. met with the three of them at the nursing home. Martha said that she did not want her husband visiting often or for long periods of time, but told Chuck that he could visit every 2 weeks as long as Cheryl was not visiting. Chuck agreed to come every other Sunday afternoon for one half-hour. After several months of this schedule, Martha invited him to visit every Sunday for up to 1 hour.
By maintaining simultaneous strong alliances with each family member, the family-oriented clinician can be the most helpful to the patient and the family. In this case, Dr. D. avoided getting drawn into taking sides in the family feud and helped the McNabb family successfully deal with some of their conflicts.
There are situations where it may be unethical not to encourage the family to be involved in the management of a health problem (21). In certain circumstances, failure to inform or involve the family can result in serious harm to the patient or family members. When a patient is suicidal, family members should be informed and involved in treatment planning to help protect the patient’s life, even if the patient does not want them told.
The sexual partners of patients with AIDS or other serious sexually trans- mitted diseases should be informed of the risk, even when the patient refuses. Most state laws now permit or even mandate such disclosure. It is more common that there may be situations where the clinician should
strongly urge the patient to involve or inform the family (e.g., when the diagnosis of a serious, fatal, or genetic disease is made, or when the patient decides to refuse treatment). In general, when the patient refuses or is reluc- tant to inform or involve the family in his or her healthcare, the clinician should inform the patient of the potential harm that may occur to the patient or the family if the family is not involved. The clinician must balance these risks with the patient’s reluctance to involve the family.
Working with Other Professionals
Anytime more than two parties are involved with an issue, triangulation is a possibility (see Chap. 3). There is virtually always more than just the primary care clinician involved in today’s healthcare, from physical thera- pists to case managers to any number of specialists. With each patient, the primary care clinician is at risk for triangulation in multiple ways, either with other members of the healthcare team or with the patient’s family.
Mrs. Smith, a 46-year-old Italian-American, presented several weeks ago to her primary care clinician, Dr. P., with a breast mass. Rapid work-up demonstrated carcinoma and Mrs. Smith met with Dr. S., the surgeon, and Dr. O., the oncologist. She and her husband were confused by what they perceived as conflicting messages from the two specialists. Dr. S.
highlighted all the risks associated with surgery, including infection, bleeding, and death, and painted a rather pessimistic picture of her future. On the other hand, Dr. O. seemed to think that because of her age, general good health, and lack of co-morbidities, Mrs. Smith’s prognosis was relatively good, and that if she needed chemotherapy, she would do well. Dr. P. reviewed the letters from the specialists, and concluded that there was agreement between the two, but guessed they had presented their views very differently, leading to the confusion. Dr.
P. met with the Smiths and worked to elucidate the specialists’ frames of reference so that their comments could be understood in the context of their respective professional disciplines—as a general rule, surgeons tend to emphasize risks, whereas oncologists tend to emphasize hope.
In the end, this corroborated the Smiths’ “gut feeling” and they were reassured that everyone agreed about the treatment and prognosis.
Key strategies to avoid triangulation are communicating clearly and avoiding taking sides, while maintaining patient advocacy. Encouraging direct communication between conflicting parties helps the clinician stay out of the middle. The primary care clinician may be tempted to overfunc- tion for the patient and speak for them to specialists or other profession- als in a well-intentioned effort to care for the patient; however, this robs the patients of their autonomy, fosters dependence, and often leads to impaired or inaccurate information exchange. The clinician can be helpful by offering to be present during a potentially difficult interchange.
Ms. Fernandez, a 28-year old Puerto Rican single mom, brought in her son, Jose, because of the school’s concern that he had ADHD. Ms.
Fernandez did not believe that he had ADHD and thought the school just wanted “to medicate everybody.” Two of his teachers had done evaluations, but Jose had not yet met with the school psychologist. Dr.
S. described the typical course of events in an ADHD evaluation (e.g., teacher input, testing done by the school psychologist classroom observation, etc.) and encouraged Ms. Fernandez to proceed because
“some helpful information might be derived from the evaluation.” Dr.
S. offered her assistance in whatever way possible “to best serve Jose’s interests,” including being available either by phone or in person for school conferences.
Dr. S. avoided triangulation by providing education and facilitating direct interaction between Ms. Fernandez and the school.
Maintaining a position of patient advocacy and working to promote the patient’s health is not equivalent to disregarding information from sources other than the patient.When there is conflict, the clinician may need to com- municate directly with the other parties before making any judgment: There are always to sides to a conflict.
Mrs. Yarowsky contacted the family doctor on call. Dr. C. learned from Mrs. Yarowsky that she had recently had surgery done by her OB-Gyn (in a different office) for endometriosis, and had been given little pain medication postoperatively. Mrs. Yarowky lamented that her OB-Gyn doctor was callous and cold-hearted, and she desperately needed more pain medication. Dr. C. contacted the OB-Gyn, who reported that the patient had a history of prescription narcotics abuse, and had been given more than adequate supplies of pain medication. Following this second phone call, Dr. C. offered his sympathy to Mrs. Yarowsky, confronted her about the actual quantities of pain medication that had been prescribed, refused to call in a prescription for more pain medicine, and suggested that a visit to the office might be helpful in order to sort out issues around chronic pain and whether a referral to a pain treatment center was indicated. Dr. C. encouraged Mrs. Yarowsky to contact her OB-Gyn.
Conflicting interests between the individual patient and other family members presents another opportunity for triangulation. The clinician is often asked by the family or by other caregivers to decide what should be done in a situation where there is disagreement. In these circumstances, the clinician should avoid being drawn into the role of decision maker, unless the decision is clearly a medical one. The clinician should instead bring all relevant parties together and facilitate a process in which the group can discuss the problem (22). The best solution occurs when all parties can agree to support the outcome. If not, the patient retains the right to make his or her own decision, but does so fully informed as to what others are willing Working with Other Professionals 407
to do (23–25) (see Chap. 3 for more details on avoiding triangulation when there are conflicting interests).
Home Visits
Home visits or house calls augment family-oriented medical practice. They offer an opportunity to see the patient and family in their own natural setting and can provide valuable information about how the patient is func- tioning and how the family is adapting to the health problem. Siwek (26) has argued that house calls may be the best form of intervention during a family crisis. Home visits are particularly important for the frail elderly where a visit to the clinician’s office during the winter may actually be dan- gerous. For homebound elderly, it can be helpful to arrange to meet other family members or the public health nurse at the home to get their assess- ments of how the patient is doing.
Home visits at the 2-week well-child visit can dramatically facilitate com- prehensive family-oriented care. This can be a difficult time for the family to get to the office, and a home visit avoids exposing the newborn to infec- tious illnesses in the waiting room. A home visit is also the best way to assess how the family is adapting to the new baby (see Chaps. 10 and 11), how the feeding is going, and what kind of help and support the mother is receiv- ing. Finally, making home visits is a very quick way to become known in a community. Word spreads through the neighborhood that the doctor is making a home visit, and one commonly has neighbors come by to meet this unusual doctor. For multiproblem or chaotic families, making a home visit sometimes may be the only way to assemble the entire family for a meeting. Such a home visit also may provide insights into the problems that the family is facing. Home visits are typically scheduled at the end of a session, and there are specific billing codes for these occasions.
Billing and Finances
A common concern about a family-oriented approach to medical care is that it takes too much time to implement and is not financially feasible.
Involving the family in medical care takes some additional time up front, which pays itself back in the long run with reduced visits. Inviting the father to prenatal and well-child visits should not take additional time; having both parents present when discussing problems is usually the most efficient way to proceed. Involving the spouse of a patient with a chronic illness in his or her care similarly does not take additional time and can facilitate care and prevent later time-consuming phone calls.
Family conferences do take additional time, and that time should be billed at the same rate as other visits. Clinicians should not undervalue the
worth of these family conferences or counseling by undercharging for them.
The billing procedure needs to be flexible enough to take account of the family’s income and insurance. In some cases the patient may be billed for an extended visit or consultation, or, if appropriate, for a counseling session.
In other situations, different family members can be billed for portions of the session. Whatever method is used, it should be acceptable to the insur- ance company, and discussed and negotiated in advance with the family, so that the method of billing and payment is clear to everyone involved.
Termination of the Clinician–Patient Relationship
Despite everyone’s best efforts, the relationship between clinician and patient occasionally does not work out. The clinician must make every effort to address the problems and to seek creative solutions. Even so,
“irreconcilable differences” may exist. It is generally the patient who initi- ates a change and seeks out another clinician to provide care. When the patient initiates the termination, it is crucial to find out why. The change is often discovered when a written request for transfer of medical records arrives from another office. No clinician enjoys making contact with patients that reject or “fire” them, but calling the patient to obtain feedback can be enlightening to the clinician and therapeutic for the patient. It may also reduce the likelihood of a lawsuit. If the request for medical records comes from a law firm, contact should not be made with the patient. The rationale for the phone call should be honest and straightforward.
Dr. T.: Hello, Mrs. Jones, this is Dr. T. I want to let you know that I re- ceived a request for transferring your medical records to Dr. A. We are in the process of doing that right now. In our practice, it is cus- tomary for us to call and find out if there were problems with how your healthcare was delivered so that we can try to do better with other patients.
People are usually quite pleased that the clinician took the time to call.
Even though they may be hesitant in the beginning, they are eventually relieved and relish an opportunity to discuss the situation.
With some patients, clinicians may want to be cautious about allowing them to return to the practice, particularly if they left to doctor-shop or because the clinician set limits, perhaps on prescribing narcotics. Patients who leave the practice because they moved out of the area or because their insurance changed should, of course, be welcomed back if either of these situations change. All of these issues underscore the profound responsibil- ities of the clinician (and patient, and family) to attend to the relationship issues that promote health partnerships.
On the rare occasion when a clinician initiates the termination, it is the clinician’s responsibility to outline the impasse. The patient rarely denies Termination of the Clinician-Patient Relationship 409
the problem once it is pointed out and the termination is usually mutually agreed upon. It is customary for the clinician to provide emergency care for 30 days after formal receipt of a termination letter; otherwise, the termina- tion is considered abandonment of a patient. It is important to avoid blaming the patient, and instead to ascribe the need for termination in terms of lack of fit between patient and clinician. Care must be taken to insure that the patient has other available resources for obtaining healthcare (i.e., a clinician-initiated termination may not be possible in some remote areas.) Even though it is rare for a clinician to discharge a patient from his or her practice, it is a possibility that when recognized may help both parties attend to improving the relationship. Instead of feeling trapped and forced to care for all patients, the clinician may feel freer to talk explicitly with patients about the strengths and problems in their professional relationship. A patient who realizes that he or she may be discharged from the practice may work harder to maintain responsible and mature relationships with his or her healthcare providers.
Conclusion
In the end, the practice of family-oriented primary care is time-efficient, cost-effective, and, perhaps most importantly, care-effective. At first glance, it may seem like gathering a genogram, for example, takes “extra” time, but this is time well spent. It is often time that must be spent in order to make a proper diagnosis and arrange appropriate treatment. This chapter has described some methods and strategies for streamlining these pro- cesses. Arranging an office system that facilitates the practice of family- oriented primary care minimizes the up-front time while maximizing patient care. Finally, a family-oriented approach allows us to know our patients as people. With today’s focus on speed and the bottom line, there is no substitute for the satisfaction derived from this human connection.
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Protocol: How to Set Up a Family-Oriented Practice Use a Family-Oriented Image
• The practice name should contain the word family.
• Staff should support and encourage a family-oriented approach.
Provide a Range of Available Services
• The practice should offer pregnancy and pediatric services when possible.
• Social work and nutritional services should be offered.
• A family therapist should be part of the practice or available for close collaboration.
• A comprehensive list of other family-oriented resources in the commu- nity should be available to the clinician, patients, and families.
Enroll Patients with Their Families
• The entire family should be enrolled together with an initial joint visit whenever possible.
• A genogram should be obtained on all families at the time of their first visit.
Use a Family-Oriented Medical Record
• The charts of all members of the household ideally should be filed together or electronically linked.
• There should be easy access to family information.
Plan the Physical Layout to Support a Family Orientation
• The waiting room should be able to accommodate families with all age members, including small children and disabled elderly.
• Examination rooms should be large enough to accommodate families.
Implement Flexible Scheduling
• Patient scheduling should be flexible enough to meet the needs of the families and allow longer appointments for family counseling.
Use Home Visits
• Home visits should be a regular part of the practice.
• When possible; homebound elderly, terminally ill, and postpartum pa- tients should be seen in the home.
Bill for Family-Oriented Services
• Family conferences and counseling should be billed appropriately.
• The waiting room should be able to accommodate families with all age members, including small children and disabled elderly.
Protocol: How to Set Up a Family-Oriented Practice 413
