#PTonICE Daily Show – Wednesday, September 6th, 2023 – Setting expectations: the HH patient-client relationship

In today’s episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses setting expectations with patients as a home health provider, learning when to “fire” patients in order to “hire” patients who are better able to utilize your time & services.

Take a listen to learn how to better serve this population of patients & athletes.

If you’re looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don’t forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.


00:00 INTRO

What’s up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today’s episode, let’s chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they’ve made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can’t miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you’re make sure to use the code ICEPT1MO when you sign up as that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today’s show.


Hello, everyone. Welcome to the Geri on ICE segment of the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Julie Brauer. I am super excited to be talking to you all this morning all about setting expectations with your patients and I’m going to focus this on the home health setting in particular. Okay, setting expectations with your patients. I think we can all agree that really successful relationships are built upon effective communication of setting expectations. Think of arguments you’ve had with friends or your partner, relationships you’ve been in. I know I’ve been here where when you come out on the other side, you think, man, if I just would have communicated what I wanted or if I just would have set that expectation, maybe things could have been different or you say, man, like if I knew that that’s what you wanted, if I knew that that’s what you expected of me, maybe things could have been a little bit different. Like I definitely can reflect on a lot of relationships I’ve had or arguments I’ve been in and that would have saved a lot of heartache if those expectations were laid out in front, if they were communicated up front. And what I think we should be doing when we are starting a plan of care with our patients is to remember that we are entering a relationship with our patients and ideally they are going to have expectations of us and we are going to have expectations of them. We should level set those expectations and we then can hold each other accountable. When we are introducing a plan of care to quote Jeff Moore from his process lecture, you are coming to a mutually agreed upon plan where you pitch optimal and then you agree on acceptable, right? Like these are ways in which that relationship can really thrive. Unfortunately, and I’ve been here, we get really burnt out from being in long term shitty relationships with patients. Long term shitty relationships. I know you guys have been there, right? I mean, think about it, especially in a home health situation, you get that patient on your caseload and right away you know, you’re like, this patient is going to be an absolute pain. You’re already thinking like, oh my God, I have to deal with this patient for eight weeks. You dread seeing them. They dread seeing you. They’re not motivated. They don’t follow your HEP. They don’t want to be there. You don’t want to be there. You kind of sandbag your treatments because this person is just sucking all of the life and joy out of you. They don’t answer when you try and schedule. They cancel on you all the time. You have been so frustrated for weeks on end, but you didn’t say anything to begin with. You know this relationship is going nowhere, right? You are dreading running that outcome measure at the end of your plan of care because you know that it definitely hasn’t improved at all. You feel this frustration. However, we have as clinicians, we have this feeling that we don’t want to upset our patients. We really prioritize just keeping the peace. We don’t want our patients to fire us. We want our patients to like us so much. We want to be liked. I think a lot of times we have the pressure from our companies to show progress and we’re just afraid to have those hard conversations.


We’re afraid to just tell our patient that this relationship isn’t working. And I want you all to reflect about, you know, how much heartache and time and effort could have been saved if we level set expectations and had those hard conversations right out of the gate? How much time could have been saved if we really discovered if this person was appropriate for therapy services to begin with in the very beginning? If we discovered if we were actually a good match for our patient and our patient was a good match for us? Instead of thinking that having those hard conversations and maybe discharging that patient early as a failure, like think about the opportunity that you can create when you discharge a patient. You end that relationship instead of dragging out a plan of care for eight weeks that is going to go nowhere. I think we have to remember that like ending a relationship with the patient, discharging them, whether it’s because they’re not appropriate for therapy services, they’re not meeting the expectation, they’re not being compliant, or maybe they’re just not a good match for us in particular, right? They could be a good match for a colleague, but maybe for us in particular, it just doesn’t work. We have to reflect it and realize that that’s okay. That doesn’t mean we don’t bring value as clinicians. That just means that this relationship in particular was not a good match. And that’s a good thing that you can find that out early.


So instead of thinking about discharging a patient early, ending that relationship as a failure, I want you to think about it as an opportunity because there are so many patients out there who need our services, who want our fitness forward services. We want to find those people and we are not going to be able to find those people if we are staying in bad relationships with other patients where this is just not a good match. We need to remember that we have a choice, right? We have a choice to have hard conversations, to level set expectations, and we have a choice to end that relationship. Every single patient now that I approach with my home health patients, I think, is this someone that I want to enter a relationship with? Is this person a good match for therapy services? Is this a good match between just my personality and their personality, right? I know, like, hey, if this person isn’t willing to put in the work, I can go be like LeBron James and take my talents elsewhere to someone else who is rearing to put in the work and get on board with therapy. So that is the first thing that I want you all to be thinking of as you walk into your patients going forward today and the rest of the week. So I am going to give you a couple ideas of expectations and how to make sure that you are getting the right person to go with your patient. I am going to give you a couple ideas of expectations that I have set with my patients and things that I have said that have been really helpful in starting that relationship out on a good foot and knowing pretty clearly right away how this plan of care is going to go, if this is going to be someone I keep on my mind, I am going to give you a couple ideas of expectations that I have set for you. So first of all, I want you to know that you don’t get into this situation where your week is in and it is not going anywhere and you are frustrated and you are getting burnt out, right? And the patient, too, on their part, they are getting frustrated. This isn’t even anything that they wanted to begin with, right? These are some ways that I have kind of nipped that in the bud with my home health clients. Many times home health patients have no idea what home health is. So the very first thing, the very first conversation I am having with them in level setting in terms of expectations, what the heck is home health? What does it look like? What can they expect, right? So I am talking about things like frequency of visits in a week. I am talking about things like duration of a visit and intensity of a visit that there is one person coming in their door, not multiple. These are things that patients who are in acute care should already know. And for any of you acute care therapists who are out here listening, I mentioned this before in a previous podcast, for the love of God, please level out these expectations first and foremost so that when that home health, when that clinician, home health clinician goes to see the patient, they already know what to expect. But like I said, many times patients who are, patients in home health have no freaking clue what they are in for. Many times they are coming from, for example, acute care where they are used to two people coming in, maybe a clinician and a tech and they bring in the ultra move or they bring in big pieces of equipment. And we know in home health that is not realistic. So setting expectations like that, there is one clinician going to be coming in to see you. I don’t have fancy equipment and I don’t have the extra sets of hands. Setting the expectation that I’m at most going to be seeing you two times a week. However, you are going to be having other clinicians, most likely nursing, OT, maybe speech, who are coming into your home throughout the entire week. Right. We know that a home health client could have, my God, five visits in one week. That can be incredibly overwhelming for a patient. That’s something that we want to tell them about right out the gate. So just setting those initial expectations of what they can expect from home health services in general can go a long way. Many times that first week patients are so overwhelmed because they didn’t know that people were going to be calling them constantly. Multiple clinicians were going to be coming in the door. They’re thinking that they’re going to have, you know, extra sets of hands to stand them up if they’re like a max assist. We need to level set that immediately. Okay. So you get like the bare minimums out of the way. What is home health? What is it going to look like?


Next, I am telling them what they can expect from me. And the very first thing I start with is that I tell them I am going to be here on time. Punctuality is incredibly important. If you talk to a lot of patients who are in home health, that is, and they’ve had other home health services before, that is one thing that bothers them a lot. Clinicians don’t show up. Clinicians show up late. They want to know that they can rely on me from a punctuality standpoint. They want to know that I’m going to show up. So I put that out there right away. I am going to be here on time. You can count on me for that. If I am going to be late, I am going to call you as soon as possible. I appreciate your flexibility, but I know that you are able to cancel our session without penalty if your schedule cannot accommodate it. So right away, I am holding myself accountable. I am wanting them to feel like they can rely on me. Then I want them to feel that I am here for them. I am going to do everything in my power to show up for them in terms of helping them get to where they want to go. I want them to feel like, whew, this person gives me hope. So I am going to say something to them like, I will do everything in my power, in my capacity to advocate for you. I’m going to meet you where you’re at, and we are going to work as a team to move towards a healthier, stronger, more purposeful life. Okay? I am going to tell them, I am going to hear your concerns. I am going to actively listen. If I cannot help, if I cannot solve your problem, I will do everything in my capacity to find someone who can. I right away want them to realize that I am trying to be that resource dealer. If I cannot solve the problem, I will find someone who can. And then lastly, I am holding myself accountable again. Hey, if I am not meeting these expectations I just laid out, please bring it to my attention right away. Right out the gate, right? I am setting expectations of things that they can expect from me and I am giving them the power to hold me accountable. That is so incredibly powerful when it comes to building a strong relationship with your patient. Okay, so next, I used to really lay in about what I expect from the patient in terms of bringing this fitness forward approach. They’re going to have to work really hard. They’re going to be sweating, da da da da da da. And I realized that that was way too much. That was coming on too hard and heavy. I saved that conversation about really expecting them to work hard and you’re going to sweat and you may be sore. I saved it. Saved it for the next visit with them. When we’re really getting into loading them up and putting them through an EMOM or an AMRAP or something like that. So I wouldn’t, please learn from my mistake and don’t throw that out at them right away. It’s too much too early. What I do lay the expectation of is my visit time and scheduling compliance. And I’m very strict about this because too many clinicians in home health get the run around. They are exhausted because their patients are late or they’re late. They’re with patients for too much time. They’re asking to be seen at crazy times. That burns clinicians out all the time. You have to set barriers and you should be doing that day one. So what has been successful for me is that I am telling my patients that they will have a 30 minute visit time. I know that’s very unorthodox for acute, I’m sorry for home health because usually you’re seeing patients for various times. However, I approach it as if it’s outpatient. You get 30 minutes, not any more, not any less. They expect that. And how I have made that 30 minute visit work is that I am laying the expectation that I will be following up with you on with a phone call on my drive to your home. We are going to talk about what’s happened this week. We’re going to get a plan in place. I have a whole podcast that I talked specifically about that that I’ll put in the comments here, but I’m giving them 30 minutes so they know when I walk in that door, we got to get to work because I’m only going to be there for a 30 minute time period. The next expectation I lay is that if there are more if there are three non medical cancels, we’re done. I’m discharging them. If there are three non medical cancels, right, we got to give a lot of grace to these patients. They’re freaking sick. Many times they go back to the hospital. They got a lot going on, but we have to hold them accountable as well. When our patient cancels, it screws up our day. We don’t get paid for that patient, right? It affects all of our other patients and our scheduling. We have to hold them accountable. So I give them three strikes and then they’re out and I’m discharging them. So those are the main expectations that I am saying to them they can expect from me and the things that I am saying. This is what I expect from you. Next, when we get further into conversations about goal setting, right, I am digging into their meaningful goal. If you listen to the MMOA crew, you know that we talk about make it meaningful, load it, dose it. I want to visualize exactly what they want out of this relationship. What are they trying to reach? What is that goal? What does it look like? I want to visualize it. When we are getting into that goal setting, I am asking them a very important question that helps dictate our plan of care and gives me a lot of info. I am asking them, how long do you think it will take to reach that goal? And what do you think it’s going to take to get there? That is going to tell me a whole lot of information. Is this someone who is like come to me three times a week? I will do anything. I will do all my homework. I am. I am just willing to put in as much effort as I possibly can. Or is this someone who’s going to be like, you are not coming into my house more than once a week. No way. And there is no way that I’m going to do any sort of therapy after that. Right? You have to approach those two people very, very differently. It’s going to dictate your plan of care. What is the frequency that you start out with? What type of HEP do you start out with? Is this somebody that you have to give one very, very simple exercise to? Or can you give them a very simple exercise? You are going to get an idea of how compliant this individual is going to be right off the bat. So you’re already thinking this may not be an eight week plan of care. This person is nowhere near ready to put in the work. So I’ll do my due diligence and maybe see them for the first two weeks. And then we can reevaluate the plan to see if they’re going to be able to do that. So I’ll do my due diligence and maybe see them for the first two weeks. And then we can reevaluate the plan to see if we’re going to continue. Incredibly important question to answer that it really helps dictate your plan of care. Okay, that’s it. That’s all I’ve got for you guys to recap. Really realize that you are entering a relationship with your patient. And just like any other relationship, you get to break up with them if you want. Right? If you’re able to fire you, you’re able to fire your patient as well. It’s a relationship that you can have control over. Next, a couple things to start level setting those expectations. First off, what exactly is home health services going to be like? Next, lay the expectation of what the patient can expect from you. You will be there on time. You are going to advocate for them. If you have not solved the problem, you are going to find someone who can. Then you are going to lay the expectation of scheduling. I will be there for 30 minutes. You can expect that I will be there on time. You are going to give them three chances of three non-medical cancels before you discharge them. Then you talk about your goal setting. You get an idea of where they are at. What are they to put in the work? That’s really going to help you develop that plan of care and know what this relationship is going to look like. All right, y’all. I hope that was helpful. Go ahead. I would love to hear you all, what you think about this. Try some of these expectation level setting when you go into your patients today and for the rest of the week. I’d love to hear comments, questions, and thoughts that you have. I will leave you with courses that are coming up in the MMOA division. We are all over the globe. Not the globe. We are all over the US. In September and the fall, we are super, super busy. In September, we are on the road. We have a course here in Charlotte and Colorado this weekend. These are open courses. We have more, but some of them are private. Then we are also in Oklahoma for September and October. Our eight-week online Essential Foundations and Advanced Concepts is starting up. Then we are also in Virginia, California, and New Jersey in October. Plenty of chances to catch us on the road or hit up one of our online classes. All right, guys. Have a wonderful rest of your Wednesday.

23:47 OUTRO

Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up. Thanks for watching.