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Session 1: Medical Records and Scheduling

Before you can see any clients, you need to have a medical charting system in place. Paper charting is always an option but having an electronic record is more efficient and easily accessible from multiple computers, a tablet or even your phone. 

 
 

Electronic medical record

Having an electronic medical record (EMR) or electronic health record (EHR) system is essential to running an efficient practice. It will allow you to keep all of your charting, client information and scheduling in one place. It will also help you track your client’s progress over time and will improve the overall quality of care. 

As previously mentioned in Module 3, some EMRs/EHRs have the capability of creating insurance claims as well. Kalix has special features, such as automatically sending email or text reminders, storing referring physician information, and is designed especially for dietitians.

For example, Kalix has specific terminology and areas designed for writing PES statements, with an online portal where you can access your EMR from any computer. This will come in handy if you are traveling, have multiple dietitians at your practice, or work between your home and main office.

Another platform that many dietitians use is Healthie, which is a HIPAA-compliant EHR and telehealth platform with features specific for dietitians to run a private practice.  In addition to charting, scheduling, and billing, they also have a patient features for easier communication, messaging, picture-based food journaling, and telehealth.

Here are the links to EMR platforms for you to check out and consider:

*Affiliate link

Scheduling

When scheduling a new client, ask what day of the week and time would work best for their schedule, so they will feel that you are putting their needs first. However, when you are setting your schedule in general, do always provide the clients with the general time range in which you accept appointments. Here are some additional tips on creating the schedule that is right for you:

  • Set boundaries for the earliest and latest appointment you want to take. 
  • It is helpful to group the appointments together in the morning and then again the afternoon, so you can give yourself lunch break.
  • I typically do not see clients first thing in the morning, and wait until 9:30 or 10 am so I have the morning to answer emails, send faxes, and work on projects.
  • Saturday mornings is a popular time for working professionals.  I will typically offer appointments until 12pm so I can still have most of my weekend to myself.


Session 2: Forms For New Clients, HIPAA, Credit Card Authorization, and Policies

Having the right forms to collect information about your new patient will keep you organized and legally protect your business. It is usually easy to find example templates of these forms by downloading them from other RD's websites and modifying them to fit your business needs.

 
 

Here are a few essential forms that will help you keep your appointments uniform, and will benefit both you and the client. It is helpful to have these blank forms uploaded on to your website so your clients have access them and print them at any time.  Let's get started:

1. Provide a questionnaire prior to your initial session.

Your questionnaire should have them identify problem areas and what they hope to achieve from working with you. Start with the basics on their current health, and include any additional questions that you would want to know about their habits or interests.  The more you know and are prepared about your client beforehand, the more engaging your session will be. 


Activity

STEP 1: Make a list of all the questions that would be beneficial to know ahead of time about your client.

STEP 2: Browse through other private practice RDs’ questionnaires on their websites and write down the questions you like off of their questionnaire.

STEP 3: Combine the two lists and edit anything unnecessary to make your custom questionnaire.


2. Client Policy Agreement

To help both you and your clients to be successful and form a respectable business relationship, have clients sign a form listing your business policies. You want to be treated with respect and compassion just as you will be for your client, so having them sign your policies from the beginning forms a solid foundation for your professional relationship. Your policies should discuss or include:

  • Insurance billing and payments - Include a sentence stating that they will be responsible for any claims unpaid by insurance. Also list your all forms of accepted payment methods, such as cash and credit card.
  • No show and cancellation fees - This is also where you will indicate the required notice for canceling an appointment. 
  • Secure sources for communication - Make sure they understand that information they send to you via email will not be secure unless it is encrypted, and that a phone call is always the best way to ensure security. If they submit information in a non-secure way as you have described in this section, indicate that they have waived their right to hold you liable for any sensitive information they may have submitted. This topic will be discussed again below in the HIPAA section.

Activity

Download and review these example client forms from INSPIRD Nutrition. Simply replace with your business name and full name.

Please keep in mind that these are examples of client forms. It is highly recommended that you review and modify these forms with legal help to ensure your private practice is adequately protected based on your needs.


 

3. HIPAA

Health Insurance Portability and Accountability Act (HIPAA) is a federally-mandated regulation designed to protect personal patient information stored in medical records. There are no hard and fast rules of HIPAA-compliance. It's about maintaining patient privacy and taking reasonable measures to protect it.

First, you must have your clients sign the following two forms:

  • Acknowledgement confirming receipt of privacy notice 
  • Release of information form to coordinate with your patient's other health care providers

These forms can also be sections included in your consent and general privacy policy forms (see #2 above).

Second, you need to ensure that your office setup is reasonably private such that others cannot hear your conversation during sessions.

And lastly, you have to ensure that any information and documents transferred to you (either in-person, email, or fax) has a process set up such that it is out of view from others who have not signed a Confidentiality Agreement with you. Again, never allow patient information to be sent via email, unless it is encrypted.  

  • Virtru is an email plugin that encrypts your emails

  • If you use G-Suite, you can take measures to set up HIPAA compliant email.

 

4. Confirmation emails

While this isn't necessarily a signed form, sending a confirmation email with the following information to your patients will:

  1. Ensure your patients have been sufficiently informed about your policies.
  2. Provide proof that you sent all of the appropriate information to your patient.

Your confirmation email can be saved as a template on your computer for you to reuse and should include a summary of the following: 

  1. A summarized cancellation policy
  2. Your contact information to reschedule
  3. Date, time and location of the appointment 

You can also attach the initial questionnaire and other necessary forms to this email if they have not already completed them. Consider having handouts ready to help them get started before your appointment, such as:

  • Meal plans
  • Snack lists
  • Proper portion sizes
  • Recipes
  • Grocery lists
  • Goal sheets and other educational material.

Consider other confirmation communication such as text messages or even phone calls for clients who do not check their computer or cell phone often. Do keep in mind that text messages are not considered HIPAA-compliant, so be mindful if you are texting any sensitive patient information.



Session 3: The Consultation Session

We have discussed so many important things about getting your business started, but that is only half of what will make your practice successful. One of my favorite pieces of advice I have received is that 75% of successful counseling is making people feel like they are cared for. You have years of education and experience, but none of that will matter if you can’t reach your clients.

 
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Building rapport

The most important concept to remember is that you are meeting your client where they are already at on their journey. Some tips to keep in mind are the following:

  • Use the client’s first name when speaking to them. Not only does this feel personable to them, but the more you say someone’s name, the easier it is to remember.
  • Always introduce yourself at the first session. Provide a small background about yourself so the client learns a little about you.
  • Use small talk after introductions to help the client feel more comfortable. Some of my go-to’s are the traffic or the weather.
  • Ask them to tell you a little bit about their self and what brings them to your office.
  • If it is a follow-up visit, start by asking how they have been doing since the last time you met.

Diving into the session

Motivational interviewing - When working with patients, I have found that motivational interviewing techniques work best. This is a goal-oriented, client-centered counseling style for eliciting behavior change by helping clients explore and resolve their doubts and struggles. Using open ended questions is the key, and the client should be doing most of the talking. 

Example: “What do you normally have for breakfast?” instead of “Do you normally eat breakfast?”

Reflective listening - This is a great communication strategy that helps you understand a speaker's idea, then offering the idea back to the speaker to confirm the idea has been understood correctly. It allows you to express understanding and empathy to your client, so they may be more receptive to the advice you have to offer

Example: “I completely understand that you have no energy by the time you get home from work which makes prepping dinner seem daunting. What are some things you think could help make dinner preparation a little less time consuming?”

Assess their behavior - Another important aspect is to monitor the client’s readiness to change, so you have a better understanding of where they are currently at.

Example: The client is struggling to meet their goals, maybe they are really still in the contemplation stage of change and you should dive deeper into the deeper issue.

By helping the client identify their motivators and keeping these present in your sessions, the client will begin to explore their own options instead of just listening to you explain it to them. They will want more than just the facts: clients need compassion, connection and care. Communication is key. If you are interested, Molly Kellogg is a great resource to learn more about motivational interviewing.

Remember, the key points to address during your consultation are to:

  • Take time to listen to your client. Do not give too much information away the first session. 
  • Emphasize the importance of follow-up appointments every 1-2 weeks in the beginning. 
  • Follow up with your clients, and let them know they can email you with questions. Don't forget to send your charting notes to their physician if necessary.


Session 4: How To Find Ideal Clients With Discovery Sessions

Discovery Sessions serve a very important purpose as both a marketing tool and as a way to get to know a potential client. They are meant to 'discover' if you and your potential client are a good fit for each other. This is very important to establish because not every single client is the right fit for you, and vice versa. You don't want to waste your time, or the potential client's time. If it's not the right fit, one bad client experience may end up impacting future word-of-mouth referrals, so making sure you manage the situation from the start is critical.

 
 

What is the mindset going in?

Before we begin, let’s review what Discovery Sessions are NOT about: they are NOT to sell yourself or for you to provide free consultations.

The point is to ask insightful questions so that both you and the potential client can discern whether or not you want to work together. It’s actually a very strategic conversation comparable to a mini-interview! If it is the right fit, the goal is to make them see that what they want most in the world can be achieved by working with you as their guide.

The mindset that you need to have for this Discovery Session is to look at it as though you’re presenting an opportunity that they can say yes or no to.

Remember, they have health concerns they need help with, and it’s that simple. You have valuable information you’ve had years of education on, and this is simply your opportunity to share it and change their life. It’s truly up to you!

You get to decide what works for them based on the services you offer. You can decipher how long you want them based on your experience, price point, and time you have available.

Industry average for Discovery Sessions are usually around 15-30 minutes.

 

How to put together a discovery session offering

1. CREATE

Create a Free Discovery Session Page on your website that speaks directly to your prospective client clearly stating the value of the free session, and ask them very specific questions about their lifestyle and goals via an online form.

The meaning of value isn’t to say: “Here’s a FREE session, a $50 value!” It’s to inform the client of how you want to dive in a bit deeper so they’ll learn if you are the best one to help them.

This can done through a simple contact form or one of the many existing integrated scheduling systems out there. Examples include Acuity SchedulingCalendly, and Setmore.

If you are taking private pay, any of these options are fine. However, keep in mind that if you are insurance provider, you must follow HIPAA rules and will need to make sure any contact information you receive complies.

 

2. SET EXPECTATIONS

Once you schedule the session, set clear expectations of what you’ll leave them with through a quick follow-up email or message. For instance, that could be clear and specific goals, a mini action plan, increased awareness, more motivation. Whatever is true for you, state that.

 

3. REVIEW

Review their thoughtful answers before the session so you can really think through how you can best serve this potential client so you can relay that information during the session. Perhaps outline a loose action plan before the session.

 

4. LEAD THE CONVERSATION

Get to know the client, determine their readiness, ask questions that help you decide if they are really ready for change. Use a pre-prepared list of suggested topics/questions. Some examples include:

  • Ask them what’s going on with the issues listed in their answers in their pre-session form, or what are they looking to change?

  • Ask them what their life would look like if they had what they were looking for.

  • Explore what challenges or roadblocks they’ve experienced in the past. Get an understanding of what’s stood in their way.

  • Determine how not reaching their goals in the past has impacted their life.

  • What would be the best part about achieving their goals?

 

5. SHARE YOUR SERVICES

Once you understand what they’re looking for and that you have the solution to their problems, now is the time to tell them about your services. Always relate it back to their goals. After clearly stating what your available packages are that will meet their needs, ask them what option feels like the right fit for them. Empower them to decide.

 

6. BOOK THE FIRST SESSION

Collect all of their payment or insurance information necessary for you to enter them into your system as a client. Then pick a date and time that work best for the initial consultation.

 

Here are some additional tips to keep in mind during the Discovery Session:

  • Establish an initial connection (2-3 minutes) by finding something you can relate with them on.

  • Take notes during sessions.

  • Listen more than you talk.

  • Use their words back to them.

  • Suggest simple, initial action plan based on what’s not working for them.

  • Guide them to understand that they see that the results they’re going to get from working with you that can change their life.

  • Be clear and concise when you state your prices stating them as a fact.

 

What do you do if they are not ready to sign up?

If they are not ready to work with you and you truly feel that it’s the right fit, you can ask:

  • Ask them directly what their objections are and help them overcome it.

  • What do you need from me to know if this is right for you?

  • If my services were free, would you be willing to set up your first session with me now?

 

What do you do if it's not the right fit?

As an entrepreneur running your own practice, you want clients who are truly the right fit for you, so if a Discovery Session doesn’t lead to a client, don’t be disappointed! You know what you do best and who you best serve as you’ve defined through your speciality.

When it’s not the right fit, refer out to a fellow colleague who can best meet the needs of that client. It will still give that person a great impression of you because you’re trying to help them out. That might even come back to you in the future in the form of a referral if they have someone in mind who they think would be a great fit as your client.



Session 5: Virtual Counseling and Telehealth

Through technology, dietitians are no longer limited by location and have the ability to access prospective clients from near and far. Virtual counseling is allowing you to branch out from the traditional office or in-person setting through a variety of different platforms, ranging from a simple phone call to HIPAA-compliant video conferencing. So what does this all mean for you and your client?

 
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Convenience is a plus.

Virtual counseling is mutually beneficial because of the convenience factor for both you and the client, especially since counseling services primarily require spoken communication. This allows you to work from any location, and clients have the option of calling in from the comforts of their own home or at the workplace during a lunch break. It is especially helpful when all you need is a quick follow-up session: your clients will be more likely to oblige in continuing under your care when it can be done at their convenience.

 

But…let’s not put the cart before the horse!

One common misconception is that if you offer virtual sessions, the increased accessibility to your services will directly translate into more clients.  However, that is often not the case because you still need to focus first on finding a way to reach the right audience and market that will consider working with you, whether in-person OR virtually. Having a virtual option is definitely a value-add in working with you, but it will not likely be the determining factor of whether a client WILL work with you. The same determining factors will definitely still apply, such as whether you take insurance, or if you’re a health professional that they connect with and want to work with.

This is something to consider before dropping a hefty monthly subscription on investing in a telehealth platform, especially if you haven’t figured out a predictable client flow yet.  Clients will not magically appear because you have a virtual platform to connect with you, so it's important to ask yourself: do you have a means of obtaining a steady client flow to make it reasonable for you to invest in a platform?

The other question you need to ask yourself is: will your client will require a telehealth platform, especially one that has additional bells and whistles that your clients may not even use? For example, if you work with a senior clients who are older and are not tech-savvy, going the route of a platform where they need to access through a smart phone that integrates different apps and devices may be too confusing for them.  It’s possible all they want is a simple phone call! 

So this all goes back to knowing who your clients are and their needs before you decide to invest in a specialized virtual platform for your practice.

 

What about patient privacy?

Patient privacy and handling sensitive information is always something that needs to be top of mind when you are considering a virtual platform. Consumer-based video conferencing platforms, such as Skype or FaceTime, are not HIPAA-compliant, so be aware of what your notice of privacy practices state in how you’re protecting your patient’s information. If it’s in the contract, you are legally bound!

Phone is also considered HIPAA-compliant as long as you are holding the call with those privacy safeguards in mind.  In other words, having an open conversation in a coffee shop with a client is NOT private! 

Staying HIPAA-compliant in your communication does give both you and your client piece of mind, but if you decide to not follow exact HIPAA-compliant guidelines, your notice of privacy forms should appropriately reflect that to your clients.

It is absolutely required to be HIPAA-compliant if you are a covered entity (i.e. as an in-network insurance provider). When you are dealing with HIPAA-compliant virtual counseling, that is when the term ‘telehealth’ applies because it is a HIPAA-compliant health care service you are providing.

Here are a few HIPAA-compliant telehealth platform options that you can look into if you are considering moving forward in this area.

 

Do all states and insurance companies cover telehealth?

Unfortunately, telehealth coverage really is dependent on both your state as well as the different levels of health plans offered by the insurance company. Sometimes, the requirement may be that the initial visit must be in-person, while the follow-ups can be done virtually.

If you take insurance as an in-network provider, you will have to call the insurance company to verify whether virtual sessions will be covered.  If you are not contracted with insurance and want to provide a superbill to your patient for their out-of-pocket reimbursement, coverage again will vary. Here are some additional tips to consider if you are trying to determine eligibility for telehealth for a client.

The main takeaway: there is no general rule of thumb on telehealth insurance coverage, you will need to call the insurance companies because each patient’s insurance plan coverage will vary!

However, remember that telehealth is still changing as health care is catching up to technology. For some additional reading on telehealth in different states courtesy of Healthy Bytes:

 

How does virtual counseling or telehealth work across state borders?

In general, private pay client can request to work with you through virtual counseling across state lines, although there are some considerations to keep in mind. For those considering virtual counseling in private pay in other states, the broader rule is that you must be licensed in the state you are working in (if your state has licensure) specifically when providing medical nutrition therapy (MNT). However, health coaching and general education can be practiced by you (and anyone else) across state lines, so you may still be able to work with patients across state lines who are not requesting MNT. 

As you're well aware, dietitians have the option of becoming licensed in any/all states that have licensure IF your home state has licensure. So if you are getting many inquiries from patients of a neighboring state, getting licensed in that state would be a great option to work with more patients. This applies regardless if the patient pays out of pocket or uses insurance.

Also be aware that even if you accept insurance in a specific state, that may not mean you’re covered for a client in another state with the same insurance company.   In other words, even if you are part of insurance company X in State 1, you’re not necessarily considered "in-network" with the same insurance company X in State 2. Therefore, you still have to look into getting credentialed and contracted with insurance company X in both State 1 and State 2, if a state happens to have great telehealth coverage and there are clients who can potentially work with you.

Note: For Medicare patients, Medicare Part B will only cover telehealth under the following condition: “If patients are receiving counseling online, CMS requires that the "originating site be located in either a nonmetropolitan statistical area county or rural health professional shortage area, and can only include a physician's or practitioner's office, hospital, critical access hospital, rural health clinic, or Federally Qualified Health Center".

The virtual consulting world has been the source of some confusion right now because laws haven't caught up with technology yet. To be safe, dietitians should following the above mentioned protocol regarding licensure when counseling clients online.