The relationship between an NP and a patient is an important one, as it is built on mutual trust and respect and serves as the foundation for optimal patient outcomes. Once a provider-patient relationship is established, patient care is expected to continue until such time as care is terminated by either the patient or the NP. When this relationship becomes compromised, terminating the care of a patient may be necessary. However, terminating a patient from your care, or from the practice, should never be an easy decision or taken lightly.
Reasons for terminating care
There are numerous reasons an NP may decide to terminate a patient's care, such as inappropriate or disruptive behavior from the patient (for example, physically or verbally assaulting a provider or staff member).1 A practice may also terminate care when the patient's provider leaves the practice and the current provider panels are at capacity and unable to accommodate the patient.2 Providers who disenroll with an insurance company may be forced to terminate the care of patients who remain members of that plan.1
Repeated failures to show up for scheduled appointments or pay their medical bills are also common reasons for care termination, although some states prohibit the termination of care for lack of payment.2 A breach in a patient-provider agreement surrounding controlled substances or failure to follow recommended treatment plans may be additional reasons. While there are many reasons to terminate a patient's care, there are also unacceptable reasons for care termination. Care should never be terminated based on race, age, gender, religious beliefs, or sexual orientation.2,3
Steps to terminating care
It is important to follow a series of steps when terminating the care of a patient to avoid litigation or claims to the Board of Nursing for patient abandonment.2 These steps are the same for all NPs regardless of employment site or setting. First and foremost, the practice or facility should have clearly written policies that focus on the termination of care procedure.4,5 These will serve as a reference for management and for legal documentation if it is needed. Consultation with legal counsel in developing these policies is important and should be strongly considered, as the criteria for care termination vary by state.
Patients must also be given sufficient or reasonable notice that care will be terminated.2 Generally, 30 days is considered an acceptable notification in most states.5 Notification of care termination is generally done through a certified letter, which is signed by the provider and mailed by the practice manager, with a return receipt requested.1 The same letter should also be sent via regular mail. Termination of care may also occur during a face-to-face conversation, if the decision to terminate care occurred prior to the patient's office visit. Should this face-to-face termination occur, the provider should discuss the topic directly with the patient. Another staff member should also be present during this conversation.
The provider and staff member may wish to alert security prior to the visit if there is a concern that the patient may become aggressive. Each situation and the safety of the staff should be assessed on a case-by-case basis. Upon completion of the face-to-face conversation, both the provider and the staff member should immediately document the conversation in the medical record. This direct face-to-face notification does not eliminate the necessity for sending both a certified and traditionally mailed letter to confirm termination of care. The letter should include the date in which care will be terminated, the reason care is being terminated, an offer to provide care for the next 30 days, and an offer to help find a new provider.3
During the 30 days, the NP must act reasonably and continue to provide emergency care for the patient, including appropriate diagnostic testing and prescription refills if needed.3 Just as the practice of medicine requires the exercise of good judgment, so does the assessment of action to be taken during, even after the 30-day termination of care period. The results of diagnostic tests must be shared with the patient or a new provider, particularly if any of the results are abnormal.
Therefore, regardless of the termination letter, until communication of results with the patient or new provider can be made, continued communication with the patient may be necessary depending upon the circumstances. In the termination letter, it is customary to offer staff assistance to ease the task of finding another healthcare provider.5 Many providers will assist the patient by including a list of local providers accepting new patients.
The phone number of the patient's insurance company may also be included to make it easier for the patient to notify the insurance company of a new primary care provider or seek assistance in locating providers within the plan. If possible, NPs working in a specialty should provide a list of comparable specialists in the area who are accepting new patients.
Although the certified letter is sent and multiple attempts are made by the postmaster to deliver the letter and obtain a signature, it is possible that the patient will refuse to sign the document or fail to pick up the letter.3 Should this occur, the 30-day termination is still in effect. Copies of the certified letter, patient signature, and return receipt (signed or unsigned) should be placed in the patient chart for documentation.3 Regular mail that is not returned by the post office is presumed to have been received.
If a practice generally communicates with a patient via secure e-mail or a patient portal, the notification letter may also be sent by that means; however, e-mail is not a substitution for notification by regular or certified mail. Getting the notification of care termination into the hands of the patient and having documentation that this was accomplished is of the utmost importance.
It is also imperative that all staff be notified that the care of this patient has been terminated.4,5 The staff should be reminded that appointments need to be offered to the patient, if requested, until the care termination date.3 Many insurance or managed care organizations also have specific language pertaining to terminating the care of a patient. If the NP is not familiar with the policies of the insurance company, the policies and procedures should be reviewed.5 Some insurers require notification of care termination of their insureds.5
NPs should avoid the termination of care if the patient is in the middle of a critical illness or an important healthcare workup.5 As an NP, it is important to avoid interfering with or delaying the workup or treatment of a critical health issue.2 Ideally, the patient should be stable and not in need of a significant amount of acute or chronic care when termination occurs. Termination of care must in no way result in direct harm to the patient.
Do not take this decision lightly
Care of a patient should never be terminated without the practice or clinic owner's consent. The NP or staff member who requests that the care of a patient be terminated is responsible for presenting the case as well as the reason for this request to the management team, including the practice owner. It is only after this presentation, a careful review of the situation, and consensus from the management team that termination of care occurs.
Termination of patient care in the author's clinics has been conducted for failure to pay medical bills after a payment plan has been agreed upon, abusive language to the staff or NPs, and inappropriate sexual advances to a member of the healthcare team. In the past 10 years of clinic ownership, the care of approximately five patients has been terminated. It has never been nor will it ever be a decision made hastily and without regard for the implications of such a decision.
What to do after care is terminated
Upon care termination, the patient may request a transfer of his or her medical records. In all cases, the original records or a clear copy of the records must be retained. Many states prohibit the withholding of medical records or refusal to transfer medical records for unpaid balances.2 Although practices frequently charge for the transfer of medical records, failure to pay for these records, in many states, cannot be a reason to refuse record transfer.2 NPs should consult state law or statutes regarding this specific issue.
While it is permissible to charge a reasonable and customary fee for the duplication of medical records, charging for records may further frustrate a patient already angry about care termination and should be considered prior to requiring payment. The cost of the record duplication may not be worth escalating an already difficult situation.
Once a patient has been terminated from the practice (the 30 days has elapsed), the patient should be "inactivated" in the medical record to ensure that all staff are aware of the patient's status and do not prescribe medications or book appointments without realizing that the patient's care has been terminated.3 This may happen frequently in larger systems or in smaller systems without electronic health records. Clear documentation of care termination should be present.
Should the patient be booked for an appointment or if a medication is refilled, some states recognize this as a reestablishment of care, regardless of the reason for the occurrence.2 Should this occur, the termination process must begin anew. Additionally, once a patient's records have been transferred from a facility, no prescriptions or care should be rendered even if within the 30-day notification period. For instance, if the patient finds a new provider in 10 days, requests records, and the release of records is completed on day 14 of the termination notice, the patient is considered terminated from the practice.
Be cautious and collaborate
If questions arise regarding care termination, the requirements for documentation, or the management team has concerns, an attorney should be consulted. For the author's clinics, a corporate attorney is always on retainer should any questions or concerns arise. It is better to handle a situation correctly the first time. Failure to consult with an attorney in a questionable situation can result in a lot of time, aggravation, and monetary expenditures-all of which may have been preventable.
In today's healthcare environment, NPs will likely be confronted with the need to terminate the care of a patient. The decision should never be made hastily and without a full review of the implications. A series of steps must be followed to reduce the risk of liability or a report of abandonment by the patient to the Board of Nursing. While there are instances where termination of care is unavoidable and essential, NPs should seriously consider this decision and then act according to the recommendations as previously outlined.
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