Outcome-Management Questionnaires
Many outcome-management tools are available to assist you in setting goals for care. Two common examples are the Revised Oswestry Questionnaire and Neck Pain Disability Questionnaire. Both questionnaires provide a tool to objectively measure your patients' perception of pain and disability. The structure of each questionnaire consists of 10 categories of questions. The Revised Oswestry Questionnaire includes: pain intensity, personal care, lifting, walking, sitting, standing, sleeping, social life, traveling and change in pain. The Neck Pain Disability Questionnaire includes: pain intensity, personal care, lifting, reading, headaches, concentration, work, driving, sleeping and recreation.
Each category has six ranked questions with statements scored from zero to five. The total possible score is 50 points. The final score is then expressed as a percentage out of 100 and reflects the patient's perceived disability. In addition to the Revised Oswestry and Neck Pain Disability questionnaires, there are virtually dozens of others that are appropriate for other areas of the body and conditions.
You must be systematic in the way you administer the questionnaires to your patients. Outcome-management questionnaires should be completed by every patient upon beginning care, at each re-examination, whenever a third party requests a report of a patient's progress and upon completion of care. When you assemble a new-patient chart, include the appropriate outcome-management questionnaire(s). It is helpful to differentiate the forms by printing them on differently colored paper. Not only is this procedure helpful for doctors evaluating a patient's chart during an office visit, but it also helps support staff remember when to have the patient fill out subsequent questionnaires to document their progress during care. When a patient must complete a follow-up questionnaire, clip the form on the front of their chart to indicate priority.
Before implementing outcomes questionnaires in your practice, it is important to obtain permission from the copyright holder of each form. There are several resources that enable chiropractors to purchase copyright permission for the most commonly used questionnaires. Both the Foundation for Chiropractic Education and Research and the American Chiropractic Association sell a reasonably priced CD that includes electronic versions of the most popular questionnaires along with copyright permission. There are many benefits to using the electronic versions of the questionnaires.
Once a patient fills out a printed questionnaire, they can submit it to your support staff, who can type the responses into the software program. The program scores the responses and creates an organized report that can be reviewed by the doctor and distributed to any concerned parties. Savvy providers use this detailed report as ammunition to help document the medical necessity of their care.
Establishing Goals for Care
Outcome-management tools are functionally based and help to establish a patient's ability to perform ADLs. They also enable you to effectively set goals for care. Functional goals can be set for all questionnaire categories in which the patient reports a disability. Those categories scored the highest would be the highest-priority goals. The goal would be to move up the list of descriptors in the direction of lessening severity of disability. An example of an excellent functional goal for a patient who reported being unable to sit without pain for more than 30 minutes would be to increase tolerance for sitting without pain to more than one hour within the next two weeks. Use the phrases "increased tolerance to (name the function)" or "resume normal (name the function)" when converting questionnaire descriptors to functional goals. Always conclude your goals with the date by which you expect the goal to be accomplished.
With increasing frequency, practitioners are receiving requests for information by third-party payers who want to know the desired outcome for a patient, as well as the goals for care. You can use outcomes questionnaires to measure progress and to set short-term goals for your patients by comparing their current level of disability with their responses given during the initial assessment. A long-term goal could be the complete restoration of the patient's ability to perform the ADL in question (compared to a healthy, active individual in the same age bracket).
Criteria for Discharge
You can also utilize outcomes questionnaires as a component in determining when a patient has reached maximum improvement and is ready to be discharged from therapeutic care. In addition to accomplishing the goals set utilizing the appropriate questionnaires, I recommend four additional criteria for discharge. A return to normal function, or a plateau in improvement, in these criteria may be used to indicate that a patient has reached maximum benefit from care.
- Range of motion: A goniometer or inclinometer provides an accurate tool to assess this function.
- Muscle testing: Assess muscle strength, endurance and flexor-extensor ratios utilizing manual or computerized testing devices.
- Postural analysis: Assess anterior translation of the head, spinal curves and other postural landmarks with computerized devices, digital photos or plumb-line analysis.
- Special functional goals for care: Evaluate other ADLs, essential functions and critical demands of employment necessary for the patient to return to pre-injury status.
OIG Compliance
One of the elements of the compliance program as set forth by the Office of the Inspector General (OIG) is that you must perform patient-satisfaction surveys. This enables the OIG to literally grade your practice on how good a job you're doing in terms of not only patient care, but also your patients' overall experience in your office. As a way for your patients to grade you quantitatively, I recommend "The Chiropractic Satisfaction Questionnaire," available free of charge from the RAND Corporation (www.rand.org/pubs/reprints/RP374) Patients should fill out a patient-satisfaction survey when they transition from therapeutic to wellness care. In addition, any time a patient discontinues care prematurely, reach out to them by way of mail to request their feedback. Along with the survey, include a stamped, self-addressed envelope and allow the patient to complete and return the survey anonymously. This will ensure that you receive the most honest and useful responses.
These outcome-management tools can be made part of the office procedure without placing a large amount of stress on the doctor, staff or patients. When applied in the manner and at the intervals described above, they can dramatically improve your documentation without causing your patients to focus on their pain or symptoms. You will improve your ability to communicate the great work that you do and the extraordinary results you achieve, increasing the efficiency and profitability of your practice, which will allow you more free time to spend doing the things you enjoy most.
Dr. Jeffrey Lewin graduated from New York Chiropractic College and maintained a successful multidisciplinary practice in Coral Springs, Fla., for 11 years He is the director of coaching services for Breakthrough Coaching (www.mybreakthrough.com).