How to Keep Your Prosthetics Patients for Life

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By Miki Fairley

"Their passion shows in their commitment to me as a human being. I really feel that they are on my side." —Jeffrey J. Cain, MD, family physician, bilateral transtibial amputee, Amputee Coalition of America (ACA) board member

Jeffrey Cain's glowing praise of his prosthetist and prosthetics facility would be music to any practitioner's ears. But what does it take for prosthetists to reach this level of patient satisfaction? Although it may not be possible to achieve a 100-percent satisfaction rate, many practitioners would agree that it's important to strive for this ideal—and this article explores some key ways to increase patient satisfaction and retain your prosthetics patients for life. We'll look at how some prosthetists and facilities have achieved high levels of patient satisfaction and established long-term relationships with their patients, along with what some recent patient surveys have revealed.

Cain identifies some of these keys from an amputee's viewpoint. He has been with his current prosthetist, Christopher Hoyt, CP, of Bio Design Inc., Denver, Colorado, for about 10 years. His current prosthesis, which he has had for about two and one half years, includes an elevated suction system designed by Stan Patterson, CP, Prosthetic & Orthotic Associates Inc., Orlando, Florida, along with carbon fiber sockets and Freedom Innovations feet. "I realize that this is a business, but I really feel that they look for what will work best for me—what will give me the best function." Hoyt has been willing to "go the extra mile" to get it right for Cain. "I have very long residual limbs, I'm a bilateral, and I'm very active—it's a tough situation. Sometimes Chris has to tweak and tweak and tweak to get it the way I want."

Cain owns four planes, loves flying, and enjoys water and snow skiing, and surfing. "Some of these have required Chris to have a better understanding of these specific activities, since they all involve different needs," he says. "For example, if you're water skiing, you want a rigid foot and ankle, but if you're out walking your dog, that wouldn't work well—so Chris became a problem-solver."

At one point, Cain had issues with skin breakdown and pain. Hoyt tried different liners and then went to the elevated vacuum system. "It's essential to have a prosthetist who is willing to work through these issues," Cain says.

Cain thus identifies three important qualities a prosthetist needs in order to retain patients: (1) willingness to listen; (2) willingness to work through challenges to achieve desired function; and (3) a caring, positive attitude.

A challenge confronting prosthetists is walking the fine line of helping amputees set realistic expectations without unduly limiting or discouraging them. "Amputees have limits just as able-bodied people have limits," Cain says. "I believe prosthetists should not tell amputees what their limits are but should work with them to discover their limits. For instance, I don't ski as well as I used to, but I still enjoy every single second on that hill. There are certain planes I can't fly because I can't safely work the controls with a prosthesis, but there are others that I can. Part of the journey of being an amputee is rediscovering what you can do and what you can't do and what your skills are."

However, what if the patient's expectations and goals are clearly unreachable, due to comorbidities or other factors, and she does not want to accept that? "Then the prosthetist needs to stand by his professional experience and training and realize that unrealistic expectations just do not fit into what he can do. It's hard to lose a patient, but if you have done your best and have achieved a comfortable fit and function, you have done all you could," Cain says.

Here's another scenario: a patient presents with a complicated condition such as a hip disarticulation or transpelvectomy that might be better managed by someone with more experience in that area. "Prosthetists are professionals, just as I as a physician am a professional," Cain says. "There's no sin in saying that a particular case should best be seen by a specialist, just as a family physician may refer a patient to a specialist. One of the most important skills is knowing your own skill sets."

Clinically, a comfortable socket fit is essential to patient satisfaction and retention. Says Cain, "If your leg hurts you, if you can't be active, you can't live your life, you can't be comfortable in your prosthesis, you're definitely not going to be happy."

Surveys Reveal Patient Dissatisfaction

Should prosthetists be concerned about how well they are meeting patient expectations and building long-term relationships with these patients? Some recent surveys reveal some disturbing statistics.

Seaman

John Peter Seaman, RTP, conducted a survey in 2009 to fulfill his residency requirement. Those surveyed revealed that they had changed prosthetists on average almost three times (2.71), with 62 percent changing because of dissatisfaction with either the fit and/or function of the prosthesis (44 percent) or service/treatment by the prosthetist (18 percent). A limitation to the survey is that the great majority—44—of the participants were patients at one facility, Fourroux Prosthetics, Huntsville, Alabama. The other six were patient models from Seaman's prosthetics classes at Century College, White Bear Lake, Minnesota.

In his study, Seaman urges additional similar surveys of lower-limb amputees in other geographic regions to either contest or validate his survey results. He also advises prosthetics facilities to consider surveying their own current and past patients to determine their satisfaction in clinical and customer service areas.

When asked if possibly his residency site had more than the average number of complex cases who had not been able to achieve desired outcomes with previous prosthetists, he responds, "The practice I am working for in Newark, Delaware [Independence Prosthetics-Orthotics Inc., owner John Horne, CPO], has its share of new amputees, but it also sees a lot of amputees who have been to other companies and have not been satisfied." He adds, "My sense is that amputees are pretty willing to give a prosthetist a chance, but if they are not satisfied with the service or clinical results after a period of time, they will seek out other options. And if they live in a highly populated area, they will have more options to explore."

In the survey, Seaman notes similarities between his results and the landmark study almost 20 years earlier by Caroline Nielsen, PhD, titled "A Survey of Amputees: Functional Level and Life Satisfaction, Information Needs, and the Prosthetist's Role" (JPO, Vol. 3, No. 3, 1991). In the 1991 survey, 58 percent indicated they had changed prosthetists due to "dissatisfaction with professional skills and/or the way they were treated by the prosthetist [compared with Seaman's results of 62 percent]."

Another challenge is providing adequate information for prosthetics patients. "In 1991, 53 percent of the amputees surveyed indicated that 'little or no prosthetics information was available either prior to or immediately after their amputation,'" compared with Seaman's findings of 59 percent.

Carroll

Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics for Hanger Prosthetics & Orthotics, Bethesda, Maryland, disagrees with Seaman's assessment that, in terms of patient satisfaction, today's prosthetics picture is remarkably similar to that of 1991. "There's more communication, and the quality of prosthetic components and technology is much improved," Carroll says. "Socket comfort is off the charts today compared to 10 or 15 years ago, with gel liners and other advances." Specialized practices, with strong experience in such areas as myoelectric upper-limb prosthetics, transpelvectomy, and hip-disarticulation amputations, offer solutions for more complex or difficult cases, he adds. Carroll praises the readiness to share information among colleagues via such avenues as the OANDP-L listserv.

He points out that patients come in prepared with Internet research and that consumers "are better educated than ever before," a conclusion backed up by other prosthetists' comments.

A 2005 survey by Limb Loss Research and Statistics Program (LLR&SP), a collaboration between the Amputee Coalition of America (ACA) and Johns Hopkins Bloomberg School of Public Health, titled "People with Amputation Speak Out," revealed, among other findings, that the majority were satisfied with their device. However, one-third reported being dissatisfied with the comfort of the prosthesis.

"Interpersonal manner" received the lowest score on the survey, including "does not discuss issues," "does not explain issues," and "in a hurry," although, again, the majority of respondents report being satisfied.

Whatever the actual picture may be, the surveys offer some good "take-aways" to help prosthetists improve patient satisfaction and retention.

Prosthetists Share Insights

What has worked for some prosthetists and facilities with strong patient satisfaction and retention rates?

One of the most important pieces of advice can be summed up as follows: Listen to them!

Buffat

"We really listen to our patients," says Drew Buffat, CP, director of prosthetics at De La Torre Orthotics and Prosthetics, Pittsburgh, Pennsylvania. "The biggest complaint we get from patients who come to us from other facilities is that the prosthetist didn't listen to them but was just following his own agenda."

Says Cain from the amputee's perspective: "An amputee comes in with certain expectations. You need to help them articulate these with focus questions: 'What do you want? What are your goals?' Help them see how the prosthesis you are creating will help them achieve those goals. Have that conversation, set those expectations at the beginning. If it will take six weeks to fabricate and fit the prosthesis, they're not disappointed if this doesn't happen in two weeks."

Hall

After assessing a patient's lifestyle, job needs, and recreation, Mike Hall, CPO, owner of Rehabilitation Technologies of Syracuse Inc., a family-owned firm in Syracuse, New York, discusses componentry options and may make a recommendation. "But he's involved in that decision. We don't simply say, 'this is what you need' and leave it at that. We try to educate the patient on the advantages and disadvantages of the various options and then discuss what fits in with his particular needs." If a change later is warranted, Hall suggests it, and he keeps patients abreast of new technology developments.

Creating a Caring Environment

Tied closely to good listening and communication skills is creating an environment that says, "We care."

Supan

"The time commitment we can make to the patient has diminished," says Terry Supan, CPO, FAAOP, FISPO, Supan Prosthetic Orthotic Consultations, Rochester, Illinois. "We need to make the patient feel we care about him—we don't want him to feel that all we care about is getting the insurance payment, the co-pay, and then on to the next patient. We need to really listen to them, and sometimes we need to take some extra time with them."

Supan points out that the front-office staff also needs to be perceived as caring. "If they aren't, it can destroy the prosthetist-patient relationship." One simple way to create a respectful, caring environment is keeping the person in the waiting room informed if there's an unexpected delay and apologizing for it.

Sometimes the device is simply too complicated to understand and use easily and requires too much maintenance for a particular patient, Supan notes. Again, listening to the patient and possibly making a change can keep that patient happy.

"Keeping in touch with patients helps keep that relationship alive," says Joyce Perrone, practice administrator for De La Torre and partner in PROMISE Consulting Inc. "Sometimes patients get caught up in their daily lives, and you don't hear from them again unless there is a problem. Just checking in with them every so often with a letter or phone call helps, and you can let them know about new products that might interest them."

"We want to create a friendly, open atmosphere and good customer service," Buffat says. "We try to see patients within 15 minutes of their scheduled appointment and make sure our office staff is friendly and returns calls and schedules appointments promptly."

Perrone

An open, friendly, and cooperative atmosphere among clinicians benefits patients as well, Perrone adds. For instance, during Monday morning staff meetings, the clinicians can discuss whatever problems they are having and others can offer possible solutions.

Prosthetic companies may need to fight for patients when insurance companies deny payment for covered items and services. Perrone points out that De La Torre's billing department is knowledgeable and experienced in dealing with insurance issues. This is vital because, as Perrone says, "They make us jump through all these hoops and keep changing the rules as we get them."

She continues, "The team approach works best financially as well as clinically. As part of that team, the patient may need to get involved. He can call the insurance company and say if payment is not made, he will notify the insurance commissioner. That gets their attention! We can't do that, but we are happy to give the patient that name and phone number."

Adds Buffat, "If the physician recommends, for instance, a particular knee, then that takes it out of our hands. [The physician] is the one who makes the diagnosis and does most of the legwork as far as paperwork and documentation, although we provide the insurance company with as much information as we can."

"Patients have been through a traumatic experience and are usually paying other medical bills as well," Perrone says. "We want to get them up and running again literally as well as figuratively. We try to balance the caring, compassionate part of prosthetics with a healthy bottom line."

Another reason that patients may leave is due to loss or changes in insurance coverage. As well as benefiting amputees, the ACA's prosthetic parity legislative initiatives, passed in 18 states as of this writing, help prosthetists keep those patients, Cain points out.

Today's prosthetists face multiple challenges: keeping abreast of technological and knowledge-base advances, meeting patients' high expectations, plus dealing with insurance and regulatory issues and a tough business climate. In light of all of these challenges, Carroll says he believes the state of O&P patient care is excellent. "I think clinicians—whether they work for Hanger or whether they are independent clinicians across the country—are doing a phenomenal job."

Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted via e-mail at