Family oriented primary care second edition

1. Family-Oriented
Primary Care in the
Real World :
Practical
Considerations for
Comprehensive Care
NUNANONG RODCHEUY
5/7/2016

3. Introduction
– Translating a family-oriented approach from theory into
daily clinical practice presents a variety of broad
pragmatic challenges
– In this chapter, we will provide very specific, family-
oriented suggestions that take into account the reality of
today’s healthcare environment

4. A Family-Oriented Image
– First impressions are important
– The practice name should contain the word family
– A practice logo that represents the family

5. A Family-Oriented Image
– Promotional material about the practice should
emphasize its family orientation and services for families
of all types
– Staff should support and encourage a family-oriented
approach

6. Enrollment of Patients and
Families
– A genogram should be obtained on all families at the
time of their first visit
– Even when all members of the family do not have the
same clinician, sufficient information about the entire
family can be obtained at registration to construct a basic
genogram

7. Enrollment of Patients and
Families
– The entire family should be enrolled together with an
initial joint visit whenever possible
– This provides a time-efficient way to gather background
health information about the family and to construct a
routine genogram

8. Enrollment of Patients and
Families
– This type of first visit gives the strong impression that will
appreciate the entire family’s participation in healthcare
– The initial visit to the clinician often is by an individual
patient
– Important information about other family members can
be obtained by appropriate family-oriented questions

9. Physical Layout
– The physical layout of the medical office should be
designed or adapted to accommodate families
– 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

10. Physical Layout

11. Range of Available Services
– A family-oriented medical practice should offer the
services that a family most often needs
– The practice should offer pregnancy and pediatric
services when possible
– Social work and nutritional services should be offered

12. Range of Available Services
– The family-oriented clinician needs to have a list of
telephone and internet resources for services not
provided in the practice

13. Range of Available 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
– Larger multi-clinician practices may want to organize
their own family-oriented groups focused on such
specific areas

14. Incorporating a Family Therapist
into a Medical Practice
– The most successful referrals occur when the family
therapist practices under the same roof as the clinician
– 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

16. Incorporating a Family Therapist
into a Medical Practice
– Models of collaborative family health care
– The therapist has a private practice in the same
building as the clinician
– The therapist may rent space within the clinicians
office, but conduct a private practice that is financially
independent
– A family clinician and family therapist see patients
together as a team

17. Incorporating a Family Therapist
into a Medical Practice
– Close communication is integral to comprehensive care
– The therapist should receive a referral note and should
have access to the medical record containing the
genogram
– 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

18. Record Keeping
– The charts of all members of the household ideally
should be filed together or electronically linked
– There should be easy access to family information
– Front : A separate family card
– Back : Family problems or family assessments

20. Record Keeping
– Advantages
– No need to be duplicated genogram for each family member’s chart
– Any family member can update the information at the time of visit
– Relationships
– Detection of patterns of healthcare utilization, which may reflect
family stress or dysfunction
– Identify member’s health problem and risk factor
– Easier to conduct family research

21. Confidentiality
– A family member often requests information about
another family member’s health care
– The clinician must be particularly careful about
confidentiality of information
– The clinician should not provide information about an
adult family member without that person’s consent

24. Confidentiality
– 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
– The clinician should never provide information about an
adult patient to another family member except when the
patient has given explicit permission

25. Confidentiality
– The clinician can use his or her influence to advise the
patient or family to disclose any important information
– Consider referral to a psychotherapist to manage any
serious fallout if the information is likely to be
provocative

27. Confidentiality
– There are situations where it may be unethical not to
encourage the family to be involved in the management
of a health problem
– There may be situations where the clinician should
strongly urge the patient to involve or inform the family

28. Working with Other
Professionals
– Anytime more than two parties are involved with an
issue, triangulation is a possibility
– 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

30. Working with Other
Professionals
– Key strategies to avoid triangulation are communicating
clearly and avoiding taking sides, while maintaining
patient advocacy
– The primary care clinician may be tempted to
overfunction for the patient and speak for them
– The clinician can be helpful by offering to be present
during a potentially difficult interchange

32. Working with Other
Professionals
– Dr. S. avoided triangulation by providing education and
facilitating direct interaction between Ms. Fernandez and
the school
– When there is conflict, the clinician may need to
communicate directly with the other parties before
making any judgment: There are always to sides to a
conflict

34. Working with Other
Professionals
– 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
– The best solution occurs when all parties can agree to
support the outcome

35. Home Visits
– Home visits or house calls
– Home visits should be a regular part of the 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 functioning and
how the family is adapting to the health problem

36. Home Visits
– House calls may be the best form of intervention during
a family crisis
– Home visits are particularly important for
– Frail elderly
– Homebound elderly
– Postpartum patient

37. Home Visits
– A very quick way to become known in a community
– For multiproblem or chaotic families, making a home
visit sometimes may be the only way to assemble the
entire family for a meeting
– A home visit also may provide insights into the problems
that the family is facing

38. 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
– Which pays itself back in the long run with reduced visits
– Family conferences do take additional time, and that
time should be billed at the same rate as other visits
– The billing procedure needs to be flexible enough to take
account of the family’s income and insurance

39. Termination of the Clinician–
Patient Relationship
– 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 initiates a change and
seeks out another clinician to provide care
– It is crucial to find out why

41. Termination of the Clinician–
Patient Relationship
– People are usually quite pleased that the clinician took
the time to call
– 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

42. Termination of the Clinician–
Patient Relationship
– 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
– 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

43. Conclusion
– The practice of family-oriented primary care is time-
efficient, cost-effective, and, perhaps most importantly,
care-effective
– 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