Spectrum of care: The business case for improving access to veterinary medicine

Practicing spectrum of care medicine is one component of improving access to veterinary care for pets and their families. Spectrum of care is “a continuum of acceptable care that considers available evidence-based medicine while remaining responsive to client expectations and financial limitations.”¹ When this approach is taken, veterinarians offer a range of diagnostic and treatment options that vary in their expense, invasiveness, and intensity. Clients are encouraged to play an active role in determining which of the options presented fits the needs and limitations of their individual circumstances in partnership with the veterinary team.

Ultimately, this style of practice offers a way to serve more patients and clients by offering some level of care instead of an all-or-nothing approach. Improving patient care in this way has far-reaching benefits for veterinary practices, including improving relationships with clients as well as team satisfaction, utilization, and retention.

Improving client satisfaction

Pets are considered family members by the majority of pet owners.² When a pet owner is unable to provide veterinary care for their family member, it creates mental and emotional distress.² Veterinary teams practicing a spectrum of care can reduce this stress by being open about their ability to partner with clients. They form a care team that includes the client and work together to determine the best plan for a pet within the family’s individual circumstances.

By far, the most common client limitation is financial.² However, there are many other factors that must be considered when discussing a diagnostic and treatment plan with a client, including:

• Patient stress levels with obtaining diagnostic samples. Both the true stress experienced by patients as well as the client’s perceived level of patient stress and discomfort should be considered.
• Patient compliance with the treatment plan, including willingness to accept oral medication, tolerance of topical medications or injections, and cooperation with lifestyle changes such as dietary changes or exercise restriction.
• Owner ability to return for rechecks or travel to specialty referral, which can be affected by schedule constraints and available transportation.
• Owner ability to comply with the treatment plan, including appropriately administering prescribed medications, comfort with administering treatments, particularly injections, and understanding the importance of lifestyle changes.

Veterinary teams must ask questions to identify perceived and actual barriers to care to successfully practice a spectrum of care. This style of communication, known as relationship-based communication, along with shared decision-making—where clients and veterinary team members work together to select the best plan—improve client satisfaction with veterinary visits.^3,4 Further, strong communication skills strengthen the bond between a veterinarian and client.⁵

Once individual factors are identified, veterinarians and team members should educate clients on the variety of options available, including prognosis, possible outcome, and associated costs. Options should be presented to clients in a nonjudgmental, empathetic way. Clients are most satisfied when the option presented first is the one believed by the veterinarian to be the best fit, as opposed to presenting options from most advanced to least advanced.⁶

Working with clients by offering a spectrum of care not only improves patient outcomes and client satisfaction. Clients who are satisfied with their experience at a veterinary clinic, especially in the face of an illness, injury, or emergency, are more likely to bond to their veterinarian and remain with the practice over time.⁵ This increases revenue for the practice in the long term through repeat visits and can help grow the client base through word-of-mouth recommendations.

Reducing economic euthanasia

One of the goals of providing a spectrum of care is to reduce—and ideally eliminate—euthanasia for economic reasons. If an all-or-nothing approach to medicine is used, patients that could be successfully treated by a middle-ground option might be euthanized. Euthanasia for economic reasons has multiple consequences on the humans involved in the case. For clients, electing to euthanize in any situation can be a devastating decision, but when the decision is made for financial reasons, an additional level of distress and guilt is added.

For instance, a gold standard approach to a blocked cat includes diagnostics, placement of an indwelling urinary catheter, and hospitalization–often for multiple days. If a client cannot afford hospitalization, euthanasia may be recommended. However, a stable blocked cat could be treated as an outpatient using a spectrum of care approach.

Veterinary professionals should work with clients to avoid euthanasia for purely financial reasons. However, it is important to remember even though we work to reduce economic euthanasia, there are cases where euthanasia remains a valid treatment option.

Consider a dog presenting with a septic abdomen. While this pet might do well with emergency surgery and intensive hospitalization, the prognosis is guarded. Humane euthanasia is a reasonable decision for a pet family to make, regardless of their financial circumstances. In such cases, even if finances play a role in the family’s decision, it is especially important to speak with empathy and remind clients that the decision is a loving, albeit difficult, one.

Benefits for the veterinary team

Financial limitations are often considered one of the largest ethical challenges faced by veterinary professionals.^7,8 Client finances affect the care provided to patients on a daily basis for nearly 60 percent of veterinarians and contribute to professional burnout for veterinarians and team members.⁷ In particular, higher frequencies of economic euthanasia have been linked to increased levels of professional burnout.⁹ Spectrum of care medicine is an essential tool that can be used to navigate these ethical challenges, improve mental health, and reduce burnout for all team members.

Many veterinarians are already engaging in this style of medicine, even if they don’t use the term “spectrum of care.” In the 2018 Access to Veterinary Care Coalition report, nearly 85 percent of veterinarians agreed they were comfortable offering alternatives to the traditional standard of care when clients were unable to afford the recommended treatment.² However, fully embracing the spectrum of care requires veterinary teams to consider all the potential limitations a client’s circumstances might provide, not just the economic ones.

Having conversations that build relationships and identify barriers to care for individual pet families takes time. Unfortunately, this is one resource that is often limited in clinical practice, even if the clinic is fully staffed. The solution to this is to leverage credentialed veterinary technicians (CrVTs) to participate in client communication and education. Having a CrVT involved in communication and the clinical decision-making process improves efficiency during appointments and has also been shown to improve client satisfaction and clinical outcomes.¹⁰

As CrVTs maximize their involvement in client education and communication, they can build relationships with clients and positively impact the lives of patients and pet families. These activities are considered key intrinsic rewards that improve job satisfaction for CrVTs.¹¹ Building these relationships also helps to make work more meaningful.

Clinics encouraging their veterinarians and team members to embrace a spectrum of care approach see improved mental health and well-being, better utilization of CrVTs, and higher levels of job satisfaction and meaningful work. Each of these factors positively impact staff retention.¹²

In a profession where 30 percent of team members and 34 percent of veterinarians are considering leaving their current practice,¹² prioritizing retention is crucial—for the health of the individuals, the team, and the practice.

The bottom line

There is no question patients, clients, and veterinary professionals benefit from a spectrum of care approach, but some may wonder if consistently offering a range of options could lead to reduced production for individual veterinarians and overall reduced profit for veterinary clinics. This is an area sparse in data, but anecdotal evidence and personal experience suggest spectrum of care medicine is more likely to positively impact production and profitability over time.⁶

Let’s look again at the example of the stable blocked cat. There are four possible outcomes in a case where a client is unable to afford the recommended diagnostics and treatment plan.

In an all-or-nothing approach, the client will either elect euthanasia (outcome 1) or leave against medical advice to hopefully seek treatment elsewhere (outcome 2). In each of these outcomes, the clinic receives little to no revenue for the current visit and is less likely for the client to return with other pets in the future.

Alternatively, in a spectrum of care approach, the client will first be offered a leaner treatment plan that reduces the number of diagnostics and the length of hospitalization (outcome 3). If this is still not feasible, a stable patient can be offered an outpatient treatment plan (outcome 4). In both outcomes, although the initial client transaction is lower, the clinic has likely gained a repeat customer, who will seek care through follow-up appointments, dietary purchases, and ongoing care for other conditions—and perhaps even other pets. Over time, this creates a larger revenue stream than what would have been seen in an all-or-nothing approach to treatment.

Spectrum of care does ultimately benefit the veterinary clinic in many ways. Increased client satisfaction and bonding improves client retention and recruitment of new clients. Reducing economic euthanasia increases the number of active patients, contributes to the positive client perception of the clinic, and improves team well-being. Engaging team members to their full extent and creating opportunities for meaningful work improves team member retention. Over time, each of these factors will positively impact the clinic while maximizing outcomes for pets and their families.

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Kate Boatright, VMD, is a small animal general practice and emergency veterinarian, speaker, and author in Western Pennsylvania. Dr. Boatright enjoys discussing mentorship, the spectrum of care, well-being, communication, and professional collaboration. In March 2023, Boatright published the Veterinary Mentorship Manual, a resource for practices to help guide them in developing solid mentorship programs to support new graduates. In her remaining time, she stays busy running, reading, and watching movies with her husband, son, and cats.

References

1. Fingland RB, Stone LR, Read EK, Moore RM. Preparing veterinary students for excellence in general practice: building confidence and competence by focusing on spectrum of care. JAVMA 2021;259(5):463-470.
2. Access to Veterinary Care Coalition. Access to Veterinary Care: Barriers, Current Practices, and Public Policy. Available at http://avcc.utk.edu/study.htm. Accessed October 25, 2023.
3. Janke N, Coe JB, Bernardo TM, Dewey CE, Stone EA. Pet owners’ and veterinarians’ perceptions of information exchange and clinical decision-making in companion animal practice. PLOS ONE 2021;16(2):e0245632.
4. Brown C, Garrett LD, Gilles WK, Houlihan KE, McCobb EM, Pailler S, Putnam H, Scarlett JL, Treglia L, Watson B, Wietsma HT. Spectrum of care: more than treatment options. JAVMA 2021;259(7):712-717.
5. Lue TW, Pantenburg DP, Crawford PM. Impact of the owner-pet and client-veterinarian bond on the care that pets receive. JAVMA 2008;232(4):531-540.
6. Benson J and Tincher EM. Cost of care, access to care, and payment options in veterinary practice. Vet Clinics North America: Small Animal Practice 2024;54(2):235-250.
7. Kipperman BS, Kass PH and Rishniw M. Factors that influence small animal veterinarians’ opinions and actions regarding cost of care and effects of economic limitations on patient care and outcome and professional career satisfaction and burnout. JAVMA 2017;250:785-94.
8. Quain A, Mullan S, McGreevy PD, Ward MP. Frequency, stressfulness, and type of ethically challenging situations encountered by veterinary team members during the covid-19 pandemic, Frontiers 2021;8.
9. Galaxy Vets. The emotional toll of financial stress, work environment, and euthanasia (white paper). Published March 2023. Available at https://galaxyvets.com/the-emotional-toll-of-financial-stress-work-environment-and-euthanasia/. Accessed June 2. 2024.
10. Borsiquot NB, Prendergast H, Boudreau L, Niño Cital S, Mages A, Rauscher J, Roth C, Thompson M, Thompson ST, Yagi K. 2023 AAHA Technician Utilization Guidelines. Published September 20, 2023. Available at https://www.aaha.org/resources/2023-aaha-technician-utilization-guidelines/. Accessed June 1, 2024.
11. Driscoll DC. Credentialed veterinary technician intrinsic and extrinsic rewards: a narrative review. JAVMA 2022;260(9):1069-1075.
12. American Animal Hospital Association. Stay, please: A challenge to the veterinary profession to improve employee retention. Published February 16, 2024. Available at https://www.aaha.org/resources/white-paper-factors-that-support-retentionand-drive-attrition-in-the-veterinary-profession/. Accessed June 1, 2024.