Collateral from Outpatient Providers

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Jules A

Jules A

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May I have opinions and practices regarding contacting outpatient providers for collateral information when their patient is on your acute unit. Do you do it? Why or why not? Thanks in advance.
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Armadillos said:
I would be pissed if one of my patients got admitted and someone screwed around with their meds w/o letting me know.
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In addition, whatever we might do acutely is all for naught if we don't have buy-in from the doc who will be overseeing the long-term management.
 
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During residency, we very occasionally contacted the outpatient providers when I was inpatient, but most of the time, the inpatient attending would just do whatever they wanted. Is this the best practice? Probably not, but that's how it was. Many of our inpatients didn't have outpatient providers though, so that could have been a large part of it...
 
I think you should try to contact the outpatient providers in order to:

-Get their opinion about the patient's level of risk (they have probably known the patient for a lot longer than you have) and share any concerning new safety risks.
-Get input about medication changes, or at least notify them that these changes are happening. They will have to take it over after discharge.
-Provide information that can help guide the long-term management of the patient. Let them know if the patient appears to seek secondary gain, or exhibits symptoms that might change the outpatient provider's diagnosis, or had clearly observed dysfunctional interpersonal dynamics, etc.
-Try to make sure the provider prioritizes an appropriate followup appointment. If they don't know about the stay or discharge they can't be expected to make timely followup.
 
That's all well and good, but what if the outpatient provider is screwing up? That's where it gets tricky.
 
SeniorWrangler said:
That's all well and good, but what if the outpatient provider is screwing up? That's where it gets tricky.
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Excellent point and in these cases perhaps even more important to document we called or attempted to call Dr. Feelgood to discuss 2 types of benzos plus Adderall bid and Ambien in a patient with severe alcohol abuse?
 
Jules A said:
May I have opinions and practices regarding contacting outpatient providers for collateral information when their patient is on your acute unit. Do you do it? Why or why not? Thanks in advance.
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I would certainly appreciate it as the outpatient doc, but it never happens.
 
I always call the outpatient provider and let them know just like I would want to know if my patients were admitted and I'm sure most PCP/cardiologist/any other medical specialty would prefer to be alerted.

The problem without patient collateral is that is frequently something along the lines (in my admittedly biased head) of "This is the worst the patient has ever looked ever. I know they deny SI, are functioning at work, and have no prior SA, but if you discharge them I think that's irresponsible and dangerous because you don't know this patient like I do" or "Yeah whatever you want to do is fine" or "Well I wanted to start them on *insert non-indicated medication* for months but never did because I wanted someone else to assume the risk so you now you can do it." So its just frequently not helpful.

Of course it can be super helpful if the patient has a caring, intelligent, rational psychiatrist who also has the time to spend talking about the patient with enough detail to be useful. But those seem to be the exception.

EDIT: I'm also bitter because I had TWO outpatient providers tell me last week in the ED that if I didn't admit their patients I was a horrible, heartless doctor.
 
I'm an outpatient guy and I don't have time to play phone tag with inpatient docs or therapists and have found it to be relatively low yield anyway. My attitude is treat what you see and when they get back we'll go from there. I have found that the competent people in this biz are typically on a similar page and the incompetent just leads to a frustrating and useless phone call. Have your folks send me your notes and we'll send you ours and then we can both get back to work.
 
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Most of my patients are seen as outpatient at their county's public psychiatric clinic, where they are typically seen by the psychiatrist every 3 months. If I need information about the patient, I have the SW or nurse contact the clinic and talk to the "counselor" or nurse there.
 
In training, we tried and it was sometimes useful. Families can only rarely provide any medication history. It was always tricky to make contact though.
Now I'm working with in an outpatient clinic and a residential facility affiliated with an acute hospital. It's kind of maddening; if I find out that one of my outpatients has been admitted, it's more often because the family calls. Discharge med reconciliation form is sometimes sent but because the discharge summary is usually written later and I have to request it. And the medical records department makes me get a ROI, even though they were supposed to send it on their own. Kids at the residential facility are transferred to us without even a day's worth of meds. The wheels of bureaucracy turn slowly.
 
Sometimes they call me back during my work hours. I've only sometimes found it helpful.

I should probably figure out how to use google voice or whatever again. I have a phone at my desk, but I'm probably not at my desk, and calling my pager seems complicated (the receptionists hate writing down the directions to call my pager.)
 
PistolPete said:
During residency, we very occasionally contacted the outpatient providers when I was inpatient, but most of the time, the inpatient attending would just do whatever they wanted. Is this the best practice? Probably not, but that's how it was. Many of our inpatients didn't have outpatient providers though, so that could have been a large part of it...
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This is the major problem with most of our admitted patients to our public hospital: most do not have follow-up, and those that do not have consistent outpatient follow-up thanks to our outstanding public mental health system. Trying to call someone is a pointless endeavor.

For our private patients, one of the problems that I've had is that they just generally aren't helpful. My hope when I call someone's outpatient physician is that I might get a more longitudinal "picture" of a person's presentation. Sadly that doesn't usually happen, and usually I just get information like medications, most recent "picture," etc., which I generally don't find particularly helpful.
 
Jules A said:
May I have opinions and practices regarding contacting outpatient providers for collateral information when their patient is on your acute unit. Do you do it? Why or why not? Thanks in advance.
Click to expand...

I don't do inpatient work any more, but during residency, the biggest difference I could see between the higher tier/higher quality programs vs. the others was the willingness to get collateral, either from family or past providers. I'm not sure how much it objectively improves quality of care (reduced length of stay, impacts on treatment plan, etc.), but it generally takes about 15 minutes (+/- annoying phone tag). Sure, there were times it felt useless, but if the person is receiving bad care outside, that's important information to know.

Some other thoughts:
  1. Echoing the frustration of others, nothing pisses me off more than hearing my patient was in the ED/inpatient unit 2 weeks ago and no one told me. Again, this has only happened at lower tier programs.
  2. Not sure how a court would look at the fact that you thought a person was so mentally incapacitated that they required inpatient hospitalization, but you were willing to take all the information they provided you about their prior care at face value.
  3. Most patients and families appreciate the fact that you're willing to go to outside providers, and that they aren't just locked up away from the rest of the world.
  4. The patients who really DON'T like it when you get collateral (malingering, severe PD, paranoid, mixed manic), are the ones who NEED the collateral the most.
  5. It may not be feasible or necessary to get extensive collateral on every patient that rolls in, but learning who needs it is a good skill to have.
 
Salpingo said:
I don't do inpatient work any more, but during residency, the biggest difference I could see between the higher tier/higher quality programs vs. the others was the willingness to get collateral, either from family or past providers. I'm not sure how much it objectively improves quality of care (reduced length of stay, impacts on treatment plan, etc.), but it generally takes about 15 minutes (+/- annoying phone tag). Sure, there were times it felt useless, but if the person is receiving bad care outside, that's important information to know.

Some other thoughts:
  1. Echoing the frustration of others, nothing pisses me off more than hearing my patient was in the ED/inpatient unit 2 weeks ago and no one told me. Again, this has only happened at lower tier programs.
  2. Not sure how a court would look at the fact that you thought a person was so mentally incapacitated that they required inpatient hospitalization, but you were willing to take all the information they provided you about their prior care at face value.
  3. Most patients and families appreciate the fact that you're willing to go to outside providers, and that they aren't just locked up away from the rest of the world.
  4. The patients who really DON'T like it when you get collateral (malingering, severe PD, paranoid, mixed manic), are the ones who NEED the collateral the most.
  5. It may not be feasible or necessary to get extensive collateral on every patient that rolls in, but learning who needs it is a good skill to have.
Click to expand...

Thank you for such a comprehensive on point reply. In my geographic location we are pretty tight knit and most of us work well together so I usually just send a nonspecific text that "I have one of yours" and they can call me back if they are interested. An instance where I always make the call is when a patient comes in with what appears to be a questionable regimen such as 3 antipsychotics and especially when I know the OP doc isn't incompetent and that there is likely a taper/switch plan or even if the Doc is a ***** contacting them to understand and stay the course if appropriate is helpful for all, imo.
 
Psych NP Guy said:
Every impatient unit I have patients spontaneously admit to do this. Typically, the discharge is some ridiculous, incapacitating regimen.
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michaelrack said:
As is the medication regime the patient came in on
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...and for about 1 in 5 of these patients Borderline PD is probably the most apt dx and the medication regimen from both the inpatient and outpatient is probably ridiculous. That's okay though because meanwhile the MA level counselors with their online degrees are cluelessly fostering so much splitting that the patient will have DID before long.
Don't mind me, I'm just feeling a little cynical this morning.
:shrug:
 
HooahDOc said:
I find it irritating to get calls from inpatient docs without a very good reason. I have enough unbillable useless crap to do every day. I don't want more.


Sent from my iPhone using SDN mobile
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amen to that.....I think we all need to keep in mind that we are all getting screwed and not to bring about more unbillable work on anyone
 
I really hate the process of calling, leaving a message, and talking on the phone. If you guys are pissed off at the inpatient docs for wasting your time, make sure they can text or email you. An overwhelming majority of the time I just send the outpatient docs a message along the lines of "Hey your patient was admitted after an overdose. I'm planning to bump her Prozac and augment with Abilify. Call or text me if you'd like to discuss." Takes 60 seconds and spares a lot of potential acrimony.
 
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