Treatment Planning: Good Clinical and Public Health Practice
By Kristen Porter, MS, MAc, LAc and Beth Sommers, PhD, MPH, LAc
Working with new and returning patients not only provides us with the opportunity to use training and diagnostic expertise, but also offers "teachable moments," during which we can be involved with health and wellness promotion and education.
Treatment planning encompasses the spectrum of discussion that we initiate with patients that provides them a framework of what might be expected from treatment, as well as an estimate of the length of time required to gain clinical benefits. It is a mutual agreement between patient and provider that can set the tone for a positive and enriching healing experience.
The treatment planning process is an opportunity to build rapport, foster trust and develop the patient relationship. It can serve to inform the patient on the steps of care and the process by which Asian medicine works. If done correctly, it will provide your patients time to have their questions addressed in order for them to become fully engaged in their own treatment.
Treatment planning is valuable from two perspectives: it is a way to boost patient education, as well as to implement aspects of quality assurance and improvement in your practice. By periodically reviewing patients' progress, we can gain a different type of impression or overview. The treatment plan offers an explicit set of guidelines that can be examined, evaluated and modified over time. This type of process can be particularly relevant when dealing with chronic issues that may not be able to be cured. Successful management of long-term illness will critically depend on patient-provider interaction that includes both clinical intervention and adjusting lifestyle factors.
Understanding your patient's desired treatment outcomes is crucial in developing the frequency and length of the treatment plan. The importance of a dialogue about the prognosis is essential so that the patient has realistic expectations. A written treatment plan outlining your recommendations gives the patient a visible reminder to take home with them. The intake appointment can be overwhelming because of its all-consuming nature, including baseline information about health and medical history; the reason the patient is seeking acupuncture or herbal medicine; and their concerns about treatment. Having a tangible written agreement, albeit one that can change over time, can offer patients some clarity and focus as they begin their treatment process.
Our colleagues in other areas of health care have also adapted the treatment planning process so that it is relevant for their patients. Mental health providers routinely integrate treatment planning into the therapeutic process.1 These plans offer road maps for determining how patients have responded to treatment. Routine assessment of clinical and behavioral changes also creates the space for dialogue and frank discussion of progress. Dentistry is another example of an area of health care that provides ongoing guidelines to patients about what to expect, how to minimize risk, and how to maximize the possibility of favorable outcomes.2
Introducing treatment planning
We recommend that all new patients receive a written plan specifying the number of treatments and number of weeks before reevaluation. The goal-setting process is helpful if the patient's main complaint changes or when a returning patient has not received care for six months or more. The actual form that is used can be purchased or self-designed. We recommend that it include treatment goals and frequency, and length of treatment. Printing the form in duplicate allow you to retain a copy and the patient to take one home.
Building rapport means engaging in meaningful dialogue, but these conversations can sometimes be challenging. Either we may not know how to approach the subject of the treatment plan, or we may not feel confident in our prognosis. Provide both a general, long-term overview, as well as factors specific to the patient. Explain that prognosis is based upon many factors such as how long the issue has been present, the patient's overall health/strength, and how deep the problem is in the body. Problems that are deeper and of longer duration will require more time and pose more challenges. This will be especially true for patients who have been weakened by long-term illness or age. Conversely, for conditions that are more recent or superficial, the response time is more likely to be quicker, especially if the patient is relatively more healthy or younger. Most courses of treatment gradually progress to where a patient no longer needs acupuncture at all, but establishing a maintenance schedule after major symptoms are controlled may be desirable. Therefore, an initial concentrated series of treatments is recommended that will depend on the patient's response. Gradually lengthening the time between treatments can occur over time as the patient responds to treatment.
Discussions with patients
We find that using analogies are very helpful.
Acupuncture, similar to physical therapy in that it often requires several treatments. Treatment benefit accrues and grows over time.
Health is like a hike: you walk into the woods or up the hill a certain distance then you have to return that same distance to get back to where you started. The encouragement comes with knowing that the return trip can be a little faster and has some guidance.
Your treatment plan is like a prescription for penicillin. Although you may feel better before all the medicine has been taken, you must complete the full course of medicine or your symptoms will come back. With acupuncture, your symptoms may resolve early but in order to address the root cause and help sustain long-term results, you must complete all the recommended treatments.
The role of acupuncture is to help create windows of time of varying lengths - possibly quite short initially, but expanding in duration over time - in which you feel better and more like yourself.
Treatment planning can be an integral component of planning for success. In addition to resolving or controlling the conditions that brought patients to the acupuncturist, it can be part of a comprehensive approach to education and treatment that results in deep and lasting effects.
Thanks to Mary Kinneavy and Jeff Miller, acupuncturists at Pathways to Wellness, for their contributions.