Published by the American Animal Hospital Association with a generous educational grant from
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LifelongCare . . . Tools Techniques Conversations
Health Risk Assessments
Taking preventive care to the next level
Published by the American Animal Hospital Association with a generous educational grant from
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LifelongCare . . . Tools Techniques Conversations
Lifelong Care from Zoetis™ is an initiative providing veterinarians with educational tools and resources to help transform veterinary care to a healthier proactive model. For more information, go to zoetis.com/lifelongcare.
Health Risk Assessments
Taking preventive care to the next level
Published by the American Animal Hospital Association with a generous educational grant from
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LifelongCare . . . Tools Techniques Conversations
Pet Wellness Report How to implement lifelong care.
Published by the American Animal Hospital Association with a generous educational grant from
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LifelongCare . . . Tools Techniques Conversations
Communicating with Clients Build strong and lasting relationships
Published by the American Animal Hospital Association with a generous educational grant from
Pet Owners Want More From Us
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Quiz: How Committed Are You?
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Health Risk Assessments
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Preventive Care Is Lifelong Care
11
Prevent
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Detect
14
Treat
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Guidelines Used in Lifelong Care
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References
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3-Month Practice Team Action Plan
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LifelongCare . . . Tools Techniques Conversations
Sustaining Success
Your next step in lifelong care.
Don’t miss Dr. Lowell Ackerman’s Introduction to Lifelong Care web conference, airing March 3–16, 2014. His presentation can be viewed at aahanet.org/webconf. ©2014 American Animal Hospital Association (aahanet.org). All rights reserved.
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2 Lifelong Care
Our shared goal: Preventive care for every pet, at every life stage. A client has just entered your practice with a pet—infant, adult, or senior. What is your goal? It should be to establish a lifelong relationship with that pet and a lifelong partnership with the client. Research conducted for AAHA’s 2013 State of the Industry report shows that veterinary practices focused on nurturing long-term client relationships that lead to consistent, lifelong preventive care are thriving. This is good news, as many veterinarians are facing pressures with declining client visits, drops in pharmacy revenue, increasing competition, and low-to-middling compliance figures that stubbornly refuse to budge. AAHA is committed to ensuring that pets receive the health care needed to keep them healthy and happy for life and that practices have access to the tools needed to help them succeed. Both commitments require skills in medicine as well as good client communication and relationships. The Partners for Healthy Pets preventive care initiatives, the 2011 AAHA/AVMA Preventive Care Guidelines, and the spread of prepaid preventive health care plans all support these commitments. We’re pleased to introduce two relatively new concepts in veterinary care: health risk assessments and lifelong continuum of care. Although they’ve been used in human medicine for many years, it hasn’t been until recently that health risk assessments have come into use in the veterinary industry. Although these assessments could (and should) be of great value, most fail to meet all of the criteria that make assessments most useful. Lifelong care is a platform, conceived by Zoetis, that builds on preventive care, expanding it from addressing common health risks to a detailed approach to prevention, early detection, and treatment tailored to each pet. The health risk assessment is a tool to help clients accept their pet’s health care needs, as well as your recommendations. It helps to get things started, but we must work to establish ourselves as the client’s trusted advisor, to make clear recommendations, and to follow through with them consistently. Looking to the future, practices are asking what else they can do to improve pets’ health, engage clients, and secure the future of their practices. The answer is simple: Prevent. Detect. Treat. It’s the concept of lifelong care. AAHA, with a generous educational grant from Zoetis to promote the concepts of lifelong care and the use of effective health risk assessments, is providing the tools you’ll need to take your practice to the next level. In each quarterly issue of Lifelong Care and its accompanying Web conference, you’ll get insights, data, advice, and real-life stories to optimize the lifetime value and health of the clients and patients you serve.
Michael T. Cavanaugh, DVM, DABVP AAHA Chief Executive Officer
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Enhancing Preventive Care 3
Pet owners want more from us‌
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4 Lifelong Care
and we can deliver!
A health risk assessment like the Pet Wellness Report can redefine the value of routine exams and bridge the recommendation gap.
1. Bayer HealthCare LLC, Animal Health Division, Bayer Veterinary Care Usage Study, 2011, bit.ly/187JdfT. 2. Veterinary Pet Insurance, “Veterinary Wellness Visits Keep Pet Costs Down,” March 5, 2013, press. petinsurance.com/pressroom/378.aspx, accessed Nov. 6, 2013. 3. AAHA. State of the Industry 2013, bit.ly/1h0FQgZ. 4. Laboratory screening revealed 31% of dogs had profiles consistent with a range of medical conditions, including renal disease, hepatic disease and diabetes. Zoetis, Pet Wellness Report, 2013, data on file. 5. Banfield Pet Hospital, State of Pet Health, 2012, bit.ly/XDYwbW.
Tools to support lifelong care: • • • •
Pet Wellness Report (petwellnessreport.com) Veterinary Management Report (bit.ly/1fhB9hI) Maintenance scheduler/tracker (in development) frank: Communication Series: Workshops on Communication Skills for Exceptional Customer Service (bit.ly/1cCybXK)
See future issues of Lifelong Care for these tools (and more)!
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Enhancing Preventive Care 5
Quiz How committed are you?
1
How much time do you schedule for an annual or wellness visit?
2
How often do you audit your medical records for compliance?
3
What percentage of your clients are current with senior screenings?
4
Do you require the following diagnostic screening for animals younger than 7 years? A. Fecal exams and heartworm antigens
Take the quiz to find out!
5
Does your team use written protocols or algorithms for preventive care visits for infant, adult, and senior pets?
6
When you see a new pet in your practice for the first time, which statement(s) below represent(s) your goals? A. Gather necessary information, perform exam, make recommendations, and follow up with test results and reminders. B. Chat. Smile. Listen. C. Make two new friends: the pet and client. D. All of the above.
B. Parasites (including heartworm), basic laboratory panel (some hematology and selected clinical chemical analytes) C. Parasites (including heartworm), comprehensive laboratory panel (CBC/ clinical chemistry, urinalysis, T4)
Scoring: 1. Score 0 points for 15 minutes, 1 point for 20 minutes, 5 points for 30 minutes.
2. Score 0 points for irregularly/never, 1 point for yearly,
They’re the picture of health…
2 points for quarterly or more often.
3.
Score 0 points for below 59% (the average), 2 points for above 59%.
4. Score 0 points for (a), 1 point for (b), 3 points for (c). 5. Score 0 points for No, 1 point for Yes. 6. Score 3 points if you answered (d).
but there’s a piece missing.
Key:
14–16: Congratulations, you are a preventive care practice!
12–13: You are committed to preventive care and are making progress.
8–12: Your practice does not fully reflect your commitment to preventive care.
7 or less: You are committed to providing sporadic, transactional care.
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6 Lifelong Care
Health Risk Assessments: A powerful new tool to boost the value of preventive care visits Health risk assessment? What is that? A health risk assessment (HRA) is a process that veterinary teams use to expand preventive health care and kick-start client thinking about their pet’s health care as an ongoing, lifelong affair. The HRA process begins and ends with a conversation, guided by the results of an online questionnaire and diagnostic tests. Asking clients to complete a health risk questionnaire encourages them to think about the big picture of their pet’s health and gets them involved in ongoing care. For clients, the combination of questionnaire, tests, written HRA report, and personal conversation adds tremendous value to the wellness exam. They feel listened to, like they’re a key player on their pet’s health care team. For staff, the written report offers many opportunities to engage clients as responsible partners in maintaining their pets’ lifelong health. Perhaps most importantly, the report acts as a “gap finder,” identifying areas of need that may be overlooked or unmentioned in the wellness exam. According to AAHA’s most recent compliance research, a key driver of success is closing the recommendation gap—that is, having veterinarians make all of the appropriate recommendations for a pet’s preventive health care. The HRA is a tool to help you do that. Ultimately, the HRA process helps uncover risk and disease that are not readily apparent, so it’s easy to make recommendations and easy for clients to accept them.
How does an HRA augment the medical history? An HRA provides pet owners with educational information about modifiable health risks for their pets and gives the veterinary team more complete information about possible health risks. It also creates an opportunity for the veterinarian and pet owner to develop a plan to work together to address those risks. While a medical history helps a doctor diagnose and treat a patient, the HRA process helps everyone involved in the pet’s care consider how lifelong care—ongoing prevention, detection, and treatment—can improve the pet’s quality of life.
But I don’t want to talk to my clients! Your clients don’t want you to talk; they want you to listen.
Electronic data management & analysis
PWR implements several aspects of the HRA framework developed for human patients 1
Shared process Identifies modifiable pet health risks Encourages dialogue Monitor progress & compliance Basis for a health care plan
1. U.S. Centers for Disease Control, A Framework for Patient-Centered Health Risk Assessments, 2011, http://www.cdc.gov/policy/opth/hra/.
Exams are rarely conducted in silence. Why not let the client do the talking? Use the HRA report to guide ongoing conversations with clients. Ask a relevant question, then slow down and be quiet. You’ll learn more about the pet— and your clients will go away feeling close and bonded to you.
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Enhancing Preventive Care 7
My practice is all about preventive care. What can an HRA do for us? First, congratulations on avoiding the trap of veterinary practice as “problem solver”! The veterinary profession is moving away from sporadic, acute care toward a culture of prevention; as a result, practices and pets are thriving.
An HRA supports your current preventive care protocols and opens the door to expanding them.
When you’re ready to take your practice to the next level—to expand your vision from year-round preventive care to a lifelong continuum of care—the HRA is the tool to help you do it. Lifelong care extends preventive care to take into account things that can’t be prevented but can be detected, monitored, and treated. Pain is one good example: There’s no magic pill to prevent it, but there are lots of ways to treat it. Lifelong care is the next
logical step for veterinary professionals and pet owners committed to improving their pets’ long-term quality of life and strengthening the human–animal bond.
How do HRAs build client engagement? By leading clients to think broadly about their pets’ health, the HRA gives them a new way to think about veterinary care. The veterinary team becomes the client’s partner and trusted advisor in the pet’s lifelong care. Pet owners may become more engaged in the care of their pet and more open to veterinary recommendations for care. Instead of feeling they must search the Internet for information about their pet’s health, they get it first-hand from a trusted source: you.
My practice is ready to take the next step. How do we get started? Throughout 2014, AAHA will publish Lifelong Care four times: once every 3 months. Each issue of Lifelong Care includes tips, insights, and advice—plus a 3-month action plan for the whole practice team. By the end of 2014, you’ll have completed all the steps you need to put lifelong care and HRAs to work in your practice.
Are they at risk? True or False.
(Answers on page 9)
With questions about a pet’s behavior and habits, the HRA reveals risks not indicated in the medical history, so you can teach clients to identify and avoid them.
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8 Lifelong Care
1
2
3
5
6
Health risk assessments online HRAs have really taken off in the past 3 years. The best are comprehensive and process-oriented. They gather all the information you need and present the results in a way that makes it easy for you and the client to act as partners focused on the pet’s health. The result? Productive conversations and more information to use in identifying risks and disease. It’s easy to make recommendations and easy for clients to accept them. AAHA’s Pet Lifestyle Assessment Forms • Pet Lifestyle Assessment Form—aahanet.org/ protected/Pet_lifestyle_Assessment_Form.pdf • Canine Lifestyle Assessment Form—aahanet.org/ protected/Canine_lifestyle_Assessment_Form.pdf • Feline Lifestyle Assessment Form—aahanet.org/ protected/Feline_lifestyle_Assessment_Form.pdf AAHA assessments are paper-based questionnaires that cover home care, travel, outdoor environment, home environment, and unusual behavior. They give veterinary teams lots of productive conversation-starters.
Pet Lifestyle Assessment For Office Use Only:
Review by Technician
Review by Veterinarian
Pet Owner Name: Pet’s Name:
My pet is a:
Other pets in the household include:
Dog(s)
Cat(s)
Dog
Cat
Other:
My pet’s products, medications or supplements include: Flea and Tick Control Products:
Heartworm Preventive:
Pain Medications:
Other:
Dental Products:
1
2
3
Do you observe wild animals or other wildlife in your neighborhood? Feral Cats
Raccoons
Wild Canines (Coyotes, Foxes)
Squirrels, Chipmunks, Skunks or Small Rodents
Deer
Other
Wild Turkeys
Which of these places does your pet go? Indoors Only
Dog Parks
Obedience/Training Classes
The Backyard
Travel with Family
Pet Stores
Kennel/Day Care
Around the Neighborhood
Communal Areas for Pets (Apartment/Condo)
Which of the following is true? Other pets come into our home
My pet visits homes with other pets
Other pets come into our yard
We feed our pets outside We feed wild animals/feral cats
For Office Use Only: Describe agreement on pet’s preventive health care: Did the pet owner take action based on your agreement:
Yes
No
When complete, place in Client folder.
WebMD Pet Health Evaluator pets.webmd.com/pet-health-evaluator/default.htm— This site offers generic information based on an animal’s age, breed, sex, etc. Pet Wellness Report® from Zoetis PetWellnessReport.com—To support lifelong care, veterinarians offer this comprehensive service to clients. The online questionnaire covers cancer, heart disease, dental health, nutrition, and safety. This health assessment is coupled with comprehensive laboratory screening provided by ANTECH Diagnostics® to offer a more complete view of the pet’s health. Together, clients and veterinary teams respond to risks with preventive care and treatment. Also included is a management dashboard you can use to identify risks common to pets in your practice and how well you are working with clients to respond to them. With a focus on filling the recommendation gap and boosting compliance, this tool will support your practice’s current wellness protocols.
Answer Key: Are they at risk? 1. True 2. False 3. True 4. False 5. True 6. True
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Enhancing Preventive Care 9
I’ve got it covered. Really?
20
Duration of routine veterinary exam 1
36%
minutes Number of seconds before a doctor assumes a diagnosis and interrupts patient 2
Reduction in errors using checklists 3
100% Practices that overestimate their success with compliance 4
1/3
Difference between average practices’ estimated and actual rates of compliance 4
Working fast, details get missed. HRAs, like checklists, help cover all your bases—without taking up valuable exam room time.
Really.
1. Veterinary Fee Reference, 8th edition (AAHA, 2013). 2. How Doctors Think, by Jerome Groopman, MD (Houghton-Mifflin, 2007). 3. The Checklist Manifesto: How to Get Things Right, by Atul Gawande, (Macmillan/Metropolitan Books, 2009). 4. The Path to High-Quality Care (AAHA, 2003).
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10 Lifelong Care
Lifelong Care encompasses comprehensive, ongoing veterinary care throughout a pet’s life including preventive care visits, diagnostics, nutrition, vaccination, and lifelong management of chronic disease… The approach goes beyond emergency and “routine” veterinary care to enhance the human-animal bond, resulting not only in healthier pets but also healthy families, practices, and communities. * * The Zoetis Lifelong Care Initiative: Putting the Promise into PracticeTM, Zoetis, 2013.
Preventive Care Is Lifelong Care Preventive care focuses on the first line of defense. It steps in before a disease or other health issue takes shape. Perfect examples of this are vaccinations, parasite preventatives, proper nutrition, and reproductive counseling. Sadly, many diseases and health issues simply can’t be prevented, including genetic predispositions, accidents and injuries, allergies, cancer, hip dysplasia, osteoarthritis, heart disease, dementia, and even periodontal disease. The best we can do is delay or manage them. Often, this takes the form of thoughtful, long-term management of chronic conditions. For the sake of simplicity, we may refer to efforts to delay or manage health conditions as “preventive care.” But that is misleading and may raise false hope in clients. When a disease progresses despite our “preventive care,” clients may feel disillusioned and betrayed. That’s one good reason why more and more veterinary professionals are taking care to be clear about the difference between prevention and ongoing care. We call ongoing care “the lifelong continuum of care.”
Prevent. Detect. Treat. It’s what we do, over and over, throughout a pet’s life. Sometimes the steps progress in tidy order: prevention, then detection, then treatment. Other times prevention never enters into it: You detect and treat a condition that can’t be prevented. Moreover, detecting one condition leads you to detect the primary or secondary diseases. And treating one health issue may lead you naturally—or unexpectedly—to prevent another. Even though we talk about the principles in a certain order, they really are “all over the place all the time.” Rather than a juggler catching and tossing balls in order, imagine a basketball game where everyone has a ball.
Many diseases and health issues simply can’t be prevented. That’s why more and more veterinarians are explaining to clients that preventive care is lifelong care.
3 Yays for Lifelong Care!
Healthy pets: Painful, debilitating, or fatal diseases can be prevented or mitigated. Every pet deserves longevity and quality of life.
Happy families: Clients want the comfort of knowing they are doing whatever they can to spare pets the trauma of an erupting crises. And they appreciate that early detection and treatment costs less than deferred health care.
Healthy practices: When we partner with clients, we see pets more often—so we can prevent, diagnose, and treat all the conditions and illnesses that compromise a pet’s quality of life. Isn’t that why we’re here?
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Enhancing Preventive Care 11
Prevent Here’s a boring story: My dog Dudley was healthy.
He had one major illness on the way to old age, and he did get on the wrong end of an angry bee once. But mostly he cruised through life into dementia. When his time came, he went quietly in the backyard with the help of Dr. Sarah, whom he had known and loved all his life. Never had rabies, parvo, bortadella, heartworm, fleas, ticks, or any preventable disease. Was never overweight, no kidney failure, or cardiac disease. He had good teeth, sweet breath, and healthy gums. Never minded when anyone, even kids, rubbed him all over or peered into his ears. He was used to that. At our very first visit, Dr. Sarah showed me how to look in his ears, examine his teeth, and feel for lumps and bumps. Over the years, Dr. Sarah changed Dudley’s diet, added glucosamine and pain medication for his hips and suffered with him (and me) through a brutal week of spinal meningitis before he pulled out of it. After that, we called him Miracle Boy. Dudley and I saw Dr. Sarah at least twice a year for 13 years “whether he needed it or not.” I thought he was healthy by nature; now I know those regular visits kept him that way. Our visits were more like conversations than consultations, and I always came away having learned something new. It ’s been more than 10 years, but whenever I hear that someone has a new pet or is looking for a new doctor, I still send them to Dr. Sarah. —Constance Hardesty, Editor in Chief, AAHA
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12 Lifelong Care
Our profession has come a long way, rebalancing the traditional role of problem solver with new emphasis on our role as the client’s partner in lifelong health care. Successful veterinary practices are emphasizing long-term client relationships and prevention of disease or health conditions. It’s safe to say that no one needs to be convinced that preventive care is a good thing—good for practices, clients, and, most of all, pets. So, what are we talking about when we’re talking about prevention? In some settings, prevention is a catchall, meaning “everything but acute care.” That broadbrush definition was useful at first, when the profession was rethinking its role as problem solver. Now, as we shift to a culture of problem prevention, it’s a good time to look more closely at what it means to be fully engaged in pets’ health care over the course of their lifetime. In the lifelong continuum of care, preventive care starts with at least one preventive health care visit per year—or more often, if a pet’s condition warrants it. Through the health risk assessment, physical exam, and diagnostic testing, prevention encompasses: • Vaccinations • Parasite control • Optimum nutrition • Exercise • Oral care • Behavioral issues • Spay/neuter and breeding recommendations • Care of lifestyle-specific diseases, injuries, or conditions And that’s just for the patient. Preventive health care exams benefit clients, too, helping them become more bonded to their clinician and more committed to their pet’s care. That’s because preventive care visits do more to build veterinary–client relations than acute-care visits do.
In a series of videotaped sessions involving both “problem” and “prevention” visits, investigators compared the tone of the visits as well as how veterinarians and clients related to one another. In preventive care visits, veterinary professionals and clients discussed a broad range of topics, with emphasis on client education around the pet’s lifestyle and relationship with the owner. The sessions were relaxed, with small talk and laughter, and the veterinary team offered reassurance and compliments to the client and pet alike. Compare that to problem-solving appointments, where interaction focused almost exclusively on the problem. The atmosphere was sometimes tense, dominated by a sense of urgency and anxiety. The preventive health care exam helps clients see the big picture of what constitutes good pet health care. Likewise, the relaxed atmosphere, laughter, compliments, and reassurance go a long way to building a trusting, loyal relationship. Reporting on this investigation in 2012, AAHA observed, “It is the dialogue that occurs in preventive health care exam settings that is most critical to building the veterinary–client–patient relationship that motivates the pet owners to obtain regular veterinary care.” Partners for Healthy Pets (partnersforhealthypets.org) has developed a Resources Toolbox to help practices move more fully into preventive care. The key tool is The Opportunity Survey—an online survey given to a practice’s staff and its clients to reveal possible gaps between how the two groups understand and perceive the value of preventive care. Other tools include videos on client communication and staff training materials for implementing the 2011 AAHA/AVMA Preventive Healthcare Guidelines for Dogs and Cats.
3 Yays for Prevention! Prevent needless suffering. Prevent loyal clients from straying. Prevent the inevitable decline of acute-care practices. Preventive care: Good for your practice and better for pets!
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Enhancing Preventive Care 13
Detect
Frankie was 8 years old. He had been drinking more water than usual and had had a few accidents in the house, but was generally his perky, mischievous self. I knew that dogs could get diabetes, and I even knew that excess water drinking was one of the signs of the disease. Frankie was never fat; ergo, I thought he couldn’t possibly be diabetic. We lived in the desert—maybe the dry heat was getting to him, I rationalized. I might have remained in a state of denial for a long time. Luckily, one of the things books and friends alike emphasized was the importance of regular veterinary visits. I already had one scheduled when the water guzzling began. Blood and urine tests soon confirmed my worst fears. I realize I was lucky to have found out sooner rather than later, before a manageable condition turned into an expensive medical emergency. Who knows what would have happened if we had not caught this early, all because I believed in regular checkups with my veterinarian? —Edie Jarolim, author of Am I Boring My Dog? And 99 Other
Things Every Dog Wishes You Knew (Alpha/Penguin 2009).
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14 Lifelong Care
Go anywhere pet owners congregate, and you’ll hear stories about how early detection saved their pet’s life or mitigated the effects of a chronic condition or kept a manageable condition from spiraling out of control. Early detection means finding evidence of a disease or disorder while the condition is still subclinical and the pet appears to be healthy and well. Because 6–12 months lapse between veterinarian visits, early detection can also mean diagnosing a disease or health issue in an early, though not subclinical, stage. Frequent preventive health care visits, with a comprehensive history, health risk assessment, physical exam, and appropriate periodic screenings, make early detection possible. Guidelines from AAHA and other organizations offer recommendations for diagnostic screening that vary by age, lifestyle, and other pet-specific characteristics. See page 18 for a list of guidelines. Besides teary-eyed anecdotal evidence, statistical evidence supports the value of early detection. In one study, a prospective health screen revealed at least one previously unrecognized problem in 80% of senior dogs examined. What makes that even more surprising is the fact that, in addition to a medical history and physical exam, only one diagnostic test was used: urinalysis. In another study of apparently healthy cats aged 6 years and older, more than 200 abnormalities were found, ranging from proteinuria to heart murmur to gingivitis. It’s no surprise that clients with apparently healthy pets are oblivious to hidden dangers. But some clients remain oblivious, even when the problem is obvious. How else to explain the fact that, in a recent survey, just 18% of pet owners said their pet was overweight—when evidence from medical records indicates that about half of all pets are overweight or obese. Asking clients to complete an HRA does two things: It allows you to detect whether a pet is at risk for a certain condition and whether the client recognizes the risk that
Two abstracts recently published at the American College of Veterinary Internal Medicine (ACVIM)* showcase the benefits of robust laboratory screening, and this data was also supported in findings when possible risk was examined in more than 7,827 dogs in a Pet Wellness Report data analysis. The analysis found that 31% of apparently healthy pets had laboratory findings indicative of an underlying medical condition. More studies need to be conducted, but it wouldn’t be surprising to find that a good look inside is just what the doctor ordered. *K.J. Prosser et al., An Assessment of Routine Wellness Blood Testing in Companion Dogs (Lakewood, Colo.: American College of Veterinary Internal Medicine, 2013), bit.ly/1iN8DEN. K.J. Prosser et al., An Assessment of Routine Wellness Blood Testing in Companion Cats (Lakewood, Colo.: American College of Veterinary Internal Medicine, 2013) bit.ly/1iN8DEN.
is staring them in the face. Sometimes “early detection” may have more to do with opening the client’s eyes than finding a previously undiscovered disorder. If early detection is largely a search for abnormalities, then it must include diagnostic tests for setting baseline values and long-term monitoring to establish trends that can indicate subclinical disease. Entered into the medical record and considered along with the HRA, this data lets you see invisible threats as they develop—and discuss them with clients so they are prepared to comply with your recommendations if or when disease requires treatment. Of everything a veterinary professional can do to win a client’s lifelong loyalty, nothing is more meaningful than sparing their beloved friend pain and suffering. Indeed, detection is essential not only to the lifelong continuum of care for pets, but to the lifelong relationship you’ll have with clients.
3 Yays for Detection! Detect diseases early, when they are still relatively inexpensive to treat. Detect opportunities to partner with clients over time to safeguard their pets. Detect gaps and inconsistencies in protocols, recommendations, and compliance. Detection: Good for your practice and better for pets!
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Enhancing Preventive Care 15
Treat
My cat, Lena, is 13 years old. She’s a long-haired tuxedo cat, the queen of our household. Her subjects are two 3-year-old cattle dogs and, of course, my husband and me. She has been with us through three dogs and a guinea pig. She watched over them as they aged and grieved with us when we lost them. Now her time is coming. I’m very glad she has had regular checkups. For the last 3 years, she’s had annual blood tests as part of her physical, because as pets age it is increasingly important to uncover problems as early as possible. Last fall, her blood tests showed low potassium levels. Not a big problem. With medication, that count was normal a month later. However, she then tested as hyperthyroid, and she was losing weight fast. Since she’s a fluff ball, it took a while to really notice how light she had gotten. We added thyroid medication. After another month, she went downhill again with nausea and more weight loss. The vet did an ultrasound, which uncovered the real problem. She found an enlarged lymph node, extracted some cells and gave us a heartbreaking diagnosis of small cell lymphoma. If I hadn’t taken her in for her yearly exam and blood test, I know without a doubt that I would have lost her at least 6 months ago. As it is, she is still here and has a good quality of life. She sees the vet regularly and receives treatments that will keep her feeling good awhile longer. Our family knows what is coming, and we are blessed to have the opportunity and privilege to watch over her and love her until the end. —Ann Lucero, Thornton, CO
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16 Lifelong Care
In the context of lifelong care, treatment most often involves the thoughtful, long-term management of chronic conditions, like pain, atopic dermatitis, recurring otitis externa, diabetes, kidney disease, or osteoarthritis. That’s not to say a pet will never fall ill or become injured, but, for the most part, lifelong care is about everyday needs, not exceptional ones. For many conditions, early therapeutic intervention offers the best chance of a successful outcome or, when that is not possible, greater comfort and longevity. This has been shown time and again for conditions ranging from cancer to kidney disease. That said, success needs to be clearly explained early on. Subject to wishful thinking or simply uninformed, clients may not differentiate between curing and managing a medical condition. Setting realistic expectations will help build clients’ trust and support for your recommendations. Discussing possible issues early, before they require action, helps prepare clients to understand and accept your treatment recommendations if or when they become necessary. Conversing with clients about their pet’s health risks builds the long-term relationships that are essential to lifelong care. Obesity: When the HRA indicates a pet is overweight and the client is blissfully unaware, it will be your intervention that may save the pet from diabetes, osteoarthritis, cardiac disease, and the host of other problems related to obesity. Periodontal disease: Periodontal disease is rampant, but you’d never guess it from talking to pet owners. Clients and, too often, veterinary professionals don’t show this potential killer enough respect. Pet owners may be unaware that bad breath can mean dental disease. While it progresses visibly in the mouth, it can also work elsewhere
in the body. Cardiac and kidney diseases have been linked to periodontal disease in dogs. Here’s the good news: When the periodontal disease was treated, the risk of life-threatening kidney failure dropped dramatically. Kidney disease: In a survey of cat owners, more than half did not know that cats could have subclinical kidney disease. Yet there is evidence that cats diagnosed and treated early in the disease’s progression can live for 2–3 years, while those diagnosed in later stages survived less than 6 months. Regularly scheduled preventive care visits, with their relaxed atmosphere and conversational tone, allow you to bring up the benefits of early intervention when the client is receptive and most likely to hear you. Pain: This is another area where the profession has made huge gains in the past decade. There is no good reason for a pet to “suffer in silence” any more. Whether pain is due to an injury or chronic condition, early intervention not only improves the pet’s quality of life but can also prevent cascading effects or secondary problems—for example, injury caused by lameness. Many pet owners don’t recognize the signs of pain in their pets and may attribute the signs to aging. Despite the profession’s focus on pain management, many veterinarians believe that osteoarthritis is under-diagnosed and under-treated. A simple HRA question and follow-up conversation can help more pets get the pain relief they need. Beyond strict medical management, treatment can also mean managing a pet’s quality of life through lifestyle recommendations. This is especially relevant when behavior issues are damaging the bond between pet and owner. Again, an HRA can allow early intervention by revealing areas of difficulty before they become crises.
3 Yays for Treatment! Treat conditions early to get better outcomes. Treat clients to many more years with a happy, healthy pet. Treat pets, clients, and staff with the professional respect they deserve. Treatment : Good for your practice and better for pets!
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Enhancing Preventive Care 17
References
AAHA, Compliance: Taking Quality Care to the Next Level (Lakewood, Colo.: AAHA Press, 2009), bit.ly/1bbK0NR. AAHA, Six Steps to Higher-Quality Patient Care (Lakewood, Colo.: AAHA Press, 2009), bit.ly/19DCPkv. Knesl, Oliver, et al., Technical Bulletin: Pet Wellness Report, Canine Health Risk Assessment, A review of 7,827 Cases (Florham Park, NJ: Zoetis, 2013).
Guidelines related to preventive care AAFP-AAHA Feline Life Stage Guidelines
aahanet.org/resources/ FelineLifeStageGuidelines.aspx
AAFP Feline Vaccines
catvets.com/guidelines/practice-guidelines/ feline-vaccination-guidelines
AAFP 2008 Senior Care Guidelines
catvets.com/guidelines/practice-guidelines/ senior-care-guidelines
AAFP Feline Retrovirus Management Key Points
catvets.com/guidelines/practice-guidelines/ retrovirus-management-guidelines
AAFP Feline Behavior—2004
catvets.com/guidelines/practice-guidelines/ behavior-guidelines
AAFP Zoonoses Guidelines—2003
catvets.com/guidelines/practice-guidelines/ zoonoses-guidelines
AAHA Canine Vaccine Guidelines, Revised
aahanet.org/Library/CanineVaccine.aspx
AAHA Dental Care Guidelines for Dogs and Cats
aahanet.org/Library/DentalCare.aspx
AAHA Senior Care Guidelines for Dogs and Cats
aahanet.org/Library/SeniorCare.aspx
AAHA Nutritional Assessment Guidelines for Dogs and Cats
aahanet.org/Library/NutritionalAsmt.aspx
AAHA/AAFP Pain Management Guidelines for Dogs and Cats
aahanet.org/Library/PainMgmt.aspx
2011 AAHA/AVMA Preventive Healthcare Guidelines for Dogs and Cats
aahanet.org/Library/PreventiveHealthcare.aspx
AHS Current Canine Guidelines
heartwormsociety.org/veterinary-resources/ canine-guidelines.html
AHS Current Feline Guidelines
heartwormsociety.org/veterinary-resources/ feline-guidelines.html
ACVIM Small Animal Consensus Statement on Lyme Disease in Dogs
onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.2006. tb02880.x/pdf
ACVIM Guidelines for the Identification, Evaluation, and Management of Systemic Hypertension in Dogs and Cats
onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.2007. tb03005.x/pdf
2010 ACVIM Small Animal Consensus Statement on Leptospirosis
onlinelibrary.wiley.com/doi/10.1111/j.19391676.2010.0654.x/full
CAPC Current Advice on Parasite Control
capcvet.org/recommendations/guidelines.html
CAPC Recommendations for the Diagnosis, Treatment, Prevention and Control of Parasitic Infections in U.S. Dogs and Cats
capcvet.org/recommendations/index.html
AAFP, American Association of Feline Practitioners; AAHA, American Animal Hospital Association; ACVIM, American College of Veterinary Internal Medicine; AHS, American Heartworm Society; CAPC, Companion Animal Parasite Council
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18 Lifelong Care
Lifelong Care/HRA Action Plan Start now
For the next 3 months, devote one staff meeting per month to investigating how embracing lifelong care using an HRA can help your patients and practice thrive.
February
March
April
As a team, revisit your practice’s mission, vision, and values. • To what extent are you a preventive care practice? • How could you use an HRA to expand what you’re currently doing to provide better care for the life of pets and lifelong relationships with clients? • Brainstorm some of the ways an HRA builds value in the annual exam and engages pet owners in their pet’s care. • Use the Partnership for Healthy Pets Opportunity survey (part of the Practice Resources Toolbox) (bit.ly/1hnuKnk) to explore gaps between staff and client perceptions about preventive care.
Explore existing HRAs to see what works. • Compare the HRAs mentioned in this booklet, noting how they are alike and how they are different. • Which HRAs have all the features the Centers for Disease Control recommends? • On average, how long are your wellness visits? How often do emergencies or double-bookings impinge on the time available? Would it be helpful to have a way outside the exam room to gather information about a pet’s health and modifiable risks and to communicate with clients? • Health starts on the inside. How can an HRA help you persuade clients to accept your recommendations for diagnostic tests? • Given all those considerations, which HRA is best for your practice? • Reviewing the HRA you chose, what services or products would you recommend in response to various health risks? • Start thinking about how lifelong care using an HRA can work effectively in your practice. The next issue of Lifelong Care (delivered with the May issue of Trends magazine) will cover the nuts and bolts of implementation.
The continuum of care— prevent, detect, treat—is a lifelong commitment, centered on the veterinary team–client–patient partnership. Compare your time with clients to the client experiences described on pages 12, 14, and 16. Then use this conversation starter: • Ask staff to write on a slip of paper one word that describes preventive care or wellness visits. • Collect these into one pile. • On another slip of paper, ask staff to write one word that describes the ideal preventive care visit. • Compare the words in the two piles. How can the practice move from current reality to the ideal? • In March, you identified an HRA that would work best for your practice. How can that HRA help move you from reality to ideal? Be specific! Lifelong care based on an HRA is all about improving pets’ longevity and quality of life. But it’s good business, too. • Go to aahanet.org/library/ lifelongcare and answer 10 key questions to help ensure that your practice delivers on the promise Healthy Pets, Happy Families, and Healthy Practices!
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Enhancing Preventive Care 19
Next issue: Implement the Pet Wellness Report to engage clients in their pet’s lifelong health. Look for it with your May issue of Trends magazine!
The American Animal Hospital Association is an international organization of nearly 6,000 veterinary care teams comprising more than 48,000 veterinary professionals committed to excellence in companion animal care. Established in 1933, AAHA is recognized for its leadership in the profession, its high standards for pet health care, and, most important, its accreditation of companion animal practices. For more information about AAHA, visit aahanet.org.
Zoetis (zĹ?-EH-tis) is the leading animal health company, dedicated to supporting its customers and their businesses. Building on a 60-year history as the animal health business of Pfizer, Zoetis discovers, develops, manufactures, and markets veterinary vaccines and medicines, with a focus on both farm and companion animals. The company generated annual revenues of $4.3 billion in 2012. It has more than 9,300 employees worldwide and a local presence in approximately 70 countries, including 29 manufacturing facilities in 11 countries. Its products serve veterinarians, livestock producers, and people who raise and care for farm and companion animals in 120 countries.