Beyond Dispensing, Part 1
By Dr. Martin DziakFeatures Clinical Patient Care
Orthotics are medical devices that correct improper foot mechanics.
Orthotics are medical devices that correct improper foot mechanics. Many of us dispense custom orthotics as a part of our clinical practice and understand the positive impact that properly fitted orthotics can have on helping our patients with foot, knee, hip and low back pain.
Common clinical practice involves the dispensing of orthotics with instructions as to how the orthotic should be gradually broken in. However, how many of us have a follow-up program following dispensation?
The importance of a follow-up program, which significantly helps with quality of care and patient satisfaction, cannot be understated.
Follow-up calls should be made:
- two weeks post-dispensation
- at recurring yearly intervals
- to schedule re-exams
TWO WEEKS POST-DISPENSATION
Follow up calls should be made: two weeks post-dispensation; at recurring yearly intervals; and to schedule re-exams. Two weeks gives patients enough time to determine if the orthotics are helping them in the way they were designed. In my practice, about 90 per cent of two-week follow-up calls are positive and patients report significant pain relief. However, in about 10 per cent of my first follow-up calls, the patient feels no change or may even feel worse. These patients are then scheduled for a follow-up appointment to determine if it is a problem with incorrectly breaking in their orthotics, an error of improper fit into their shoes or a problem with the orthotics themselves.
The most common complaint that I receive in the two-week follow-up call is that new pain is now present that was not there pre-orthotics. First, I check to make sure that the orthotic is sitting in their shoe properly and second, I ask if they have followed the proper break-in instructions to get their feet used to their new orthotics. I sometimes find that they have moved their orthotics into a new pair of shoes and they are not sitting in this new shoe correctly. Alternately, I may find that they have worn the orthotics for too long, or have gone for a long run or intense workout prematurely, which has caused the discomfort they are experiencing. In this situation, I ask them to stop wearing the orthotics for a week or so and then start all over again with the correct instructions. I then make another follow-up call two weeks later, to see if they are feeling better. If their new pain has returned, the problem is most likely with the orthotic itself: most commonly the arch of the orthotic is too high or the apex of the arch of the orthotic is slightly forward or backward from where it should be (this could be due to a casting error or a lab error). The patient will complain of a hotspot of high pressure in that area of their arch. The orthotic will require a slight adjustment and then be redispensed followed by another two-week follow-up call.
Occasionally, the arch of the orthotic is not high enough. This is most commonly found in patients who have previously had a pair of rigid and high-arched orthotics from another provider, to which the patient had become accustomed. Patients that come in for an orthotic casting appointment should bring their most commonly worn pairs of shoes as well as their old orthotics with them to their appointment. If they like the orthotics that have been previously dispensed to them, the orthotics I make will be as similar as possible to the pair that they have and like. I am often surprised by patients’ previous orthotics – they tend to be overly rigid or have overly high arches – and not something I would have made for them. However, at this point they are used to that style, and like it, so I duplicate what they have.
AT YEARLY INTERVALS
The second follow-up call should be made at one year post-dispensation and calls should be made once a year after that. Follow-up calls every year post-dispensation serve as a friendly way to maintain contact with the patient as well as to acquire statistical information about the orthotics. During the follow-up call, patients are asked the percentage of the time they are wearing the orthotics and their per cent reduction in pain.
As a result of the diligence practised at the two-week post dispensation follow-up calls, it’s rare to get a patient complaint in the yearly follow-up call. However, this serves as a reminder to the patient that they should be wearing their orthotics, and that they have not been into the clinic for a treatment in a long time. Often they end up scheduling an appointment, which is a nice bonus for both of you.
If there is a complaint at a yearly follow-up call, it is usually due to compliance issues, meaning that the percentage of the time that the patient is wearing their orthotic is low. Many people start off with one pair of orthotics and do not switch them from shoe to shoe, though instructed to do so. During the call they are asked to rate the reduction of their original pain in percentage terms as well as what percentage of the time they are wearing their orthotic. Once they understand that the problem is not with their orthotic but rather a compliance issue, they understand that they need to switch their orthotics from shoe to shoe to increase compliance and get better results. At the end of their call they are told that they will be called in another year and, if eligible, they will be scheduled for a re-exam and dispensed another pair of orthotics that will increase their compliance by reducing the amount of shoe-to-shoe shifting that they have to do.
TO SCHEDULE RE-EXAMINATIONS
In my practice, I schedule re-exams upon insurance eligibility for insured patients, and at three-year intervals for uninsured patients. The re-exam assesses the physical condition of the orthotic and the patient’s feet and gait. In my experience, the vast majority of my patients are happy with their orthotics; however, I often find that they are breaking down and need to be replaced, or compliance is an issue. This gives me an opportunity to explain to them the benefits of having another pair, perhaps designed for a different pair of shoes. Multiple pairs of orthotics result in increased compliance, thereby resulting in happier patients.
I always ask my patients to bring their shoes to their dispensing appointment so that I can fit the orthotics right into their shoe and make sure they sit into their shoes correctly. At this time, the patient is given the correct break-in instructions and I explain my follow-up program. Patients are told that they will be called in two weeks and then at yearly intervals and that a re-exam will be scheduled upon insurance eligibility.
All of my patients are happy to hear that there will be follow-ups and it gives them peace of mind to know that they will be called to make sure that the device is working correctly. It’s common to find that the follow-up calls slightly increase the number of adjustments made to patients’ orthotics, but this is due to the fact that many of these patients may have thrown their orthotics into their closet, thinking they were no good, and would likely not have returned to your clinic, had you not followed up. In other words, if you hadn’t called, you wouldn’t have found yourself adjusting the patient’s orthotics, because the patient never would have told you there was a problem with them in the first place. But when you follow up, the patient is more likely to bring the orthotics in for an adjustment and to be satisfied with your service the final product.
Since implementing a follow-up program, I feel more confident about the quality of care I am providing and the quality of orthotics that I am dispensing. My patients are more satisfied and, as a consequence, my returning patient numbers and new referrals have increased.
In Part 2 of this series, Dr. Dziak will discuss The Importance of Proper Record Keeping when dispensing custom orthotics – it will appear in the May issue of Canadian Chiropractor.
Dr. Martin Dziak is a chiropractor and certified pedorthist. He is the creator of ORTHOTRACK.ca, a customizable orthotic practice management software. For questions and information, visit ORTHOTRACK.ca , e-mail firstname.lastname@example.org, or call 519-954-6100 or 1-888-337-7362.
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