Addressing Parent Accountability With Pediatric Patients

Managing nonadherent and difficult patients is not uncommon in various types of healthcare settings. In practices that treat pediatric patients, healthcare providers may encounter issues with parents (or guardians) rather than with the patients themselves. Many pediatric providers can give examples of parents who (a) won’t authorize testing or treatment for their children, (b) fail to follow through with agreed- upon treatment plans, or (c) simply “fade away” before treatment can be initiated or completed. 

Other difficult situations include parents who expect special treatment — accommodations for uncooperative children, preferential appointment scheduling, and extended payment schedules are a few examples. In their desire to appease these parents, healthcare providers may inadvertently inconvenience their staff members as well as their other patients. 

The ability to differentiate between providing good customer service and conducting good business practice is vital in the healthcare setting. Ideally, both should reflect the needs of all patients, staff accountabilities, and the standard of care. If not, accommodations that aren’t compatible with the practice’s mission and policies may result in unintended negative results for providers, staff, and patients. 

Healthcare providers and staff members can implement various strategies to create more positive outcomes when dealing with nonadherent or difficult behavior from parents. 

1. Schedule extra time during new patient appointments to learn about parents’ expectations and treatment goals and to discuss the importance of mutual trust, respect, and shared accountability in the provider—patient/parent relationship.
   
2. Consider potential red flags for nonadherence or difficult behavior when determining whether to accept a pediatric patient into the practice. Red flags might include parents who have unrealistic expectations or demands, a history of “doctor shopping,” and complaints about previous providers. 
   
3. When electing to not accept a new patient, do not charge the family for the initial consultation. Refer the family to their health insurance carrier or to the local medical society for the names of other healthcare providers. It’s not advisable to directly refer this type of patient/family to another provider. 
   
4. When accepting a pediatric patient into the practice, clarify boundaries, limitations, and expectations with the patient’s parents. Provide parents with written information (e.g., a welcome brochure) that explains the practice’s policies and emphasizes the roles and responsibilities of each member of the care team in shared decision-making and treatment goals. 
   
5. Provide parents with written information that explain practice policies related to tests, screenings, consultations, etc. Explain why these procedures are useful and how they help the healthcare provider diagnose, treat, and/or monitor a pediatric patient’s health. 
   
6. Reinforce treatment planning discussions with parents by using plain-language educational materials and requesting verbal commitments. These interactions should be documented in each patient’s health record.
   
7. Using a technique such as teach-back to ensure that parents fully understand recommended treatment plans, benefits and risks, and alternative options. 
   
8. Address nonadherence when it first occurs. Follow up promptly with parents about missed appointments, deviation from home care instructions, failure to respond to recalls, and nonadherence with referrals. Document those follow-up actions. Reinforce the importance of teamwork to deliver high-quality care and optimal outcomes for the patient.
   
9. Engage hesitant, noncommittal, or nonadherent parents in discussions to further identify obstacles and barriers, assess concerns, and work collaboratively to devise plans that best address the needs of all parties. If a family has financial, physical, or emotional limitations that lead to nonadherence, determine whether any community services are available to assist the family.
   
10. Document all instances of nonadherence and any education provided to the family regarding the consequences of not following the care plan. When documenting, use subjective statements from the parents and objective information obtained through patient encounters. 
    
11. Consider using patient agreements that detail both provider and parent/family responsibilities relative to treatment planning and ongoing care. Both parties should sign the agreement, and it should be filed in the patient’s health record.
    
12. As a final step, consider discharging patients from the practice when nonadherence or difficult behavior is not resolved. Note, however, that discharging a patient requires careful planning and consideration of the circumstances.

A Note About Child Abuse/Neglect 

Parental nonadherence to pediatric patients’ healthcare also might raise questions about suspected child abuse or neglect. Healthcare providers who treat pediatric patients play a vital role in identifying and reporting suspected abuse and neglect and preventing tragedies. 

Healthcare practices should develop an abuse/neglect policy and educate providers and staff members about their reporting obligations under federal and state laws. The practice should consider posting this policy or including it in the welcome brochure so that parents are aware of these regulations. In some instances, providers might need to work with members of other healthcare professions to determine whether a child’s condition warrants a report of suspected abuse or neglect. 

Resources

• American Academy of Pediatrics: Family Engagement Quality Improvement Project 
• American Medical Association: How Physicians Should Approach Hard Calls Involving Child Patients 
• Medicine: Communication Skills in Pediatrics — the Relationship Between Pediatrician and Child 
• MedPro Group: Addressing Potential Maltreatment in Pediatric Patients 
• Wolters Kluwer: Dealing With Difficult Parents of Patients