Discharging high need patient in "residential" program

[heyjack70]

I have an outpatient, 19 year old, who is in town living at a "residential mental health" program supporting him while going through college. Parents live in another state and are paying a lot of money for this program. While there are some MSWs on staff at the program, most staff is not mental health trained, and it seems more like a life skills program, but implies heavily it is focused on mental health and brings people in from all over the country to live her while going through school, and everyone in the program has pretty significant mental health struggles.

I've been working with the patient about 6 months. Patient is not very engaged in our appointments. Staff from the program have been inconsistent, hard to reach at times, not calling if patient will no show, and recently rude to one of our clinic nurses about a prescription refill. Parents are also somewhat concern, fairly intense bordering on entitled, and don't seem to get that psychiatric medications are not a cure all. One of my early concerns with this program was the patient did not have a counselor when we started working together. I thought for sure the program would have a counselor, but actually it's not a requirement and the MSWs on their staff don't function as weekly counselors. It took about 3 months before getting established with a counselor when it really should have been about 2 weeks because patient has commercial insurance local counselors accept, and I think parents just ended up paying the cash fee for a counselor.

Anyhow, at this point, I'm feeling uncomfortable continuing to see him. I am not involved with the program in anyway, they outsource his mental health med management to me and I'm billing his insurance. I don't feel a good connection with the patient. I have concerns the program is overselling what it is offering, and I have concerns parents are expecting too much from medications. This is a fairly high risk person, like all of the patients at the program. I am concerned if there is a bad outcome, even if it's something I have no control over, I'll be left holding the bag as the physician and the program will be quick to side step claiming they aren't providing mental health care. I may also be experiencing some counter transference with a patient of very affluent means, or it could be patient is just entitled and doesn't really care about his treatment with me. Either way, I'm considering discharging him and not accepting further patients from this program. Are there any pitfalls to watch out for?

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[Monocles]

Sounds like a liability timebomb. Following to see what other members recommend to get you out of this.

Good luck OP.

 

[wolfvgang22]

Staff from the program have been inconsistent, hard to reach at times, not calling if patient will no show, and recently rude to one of our clinic nurses about a prescription refill. Parents are also somewhat concern, fairly intense bordering on entitled, and don't seem to get that psychiatric medications are not a cure all

Sounds like a typical patient type in many clinics save the unusual housing situation. Set firm limits in a kind manner. Be consistent. Educate about what necessary and sufficient treatment consists of, and don't be surprised if the patient seeks another psychiatrist. If you do decide to terminate care, be sure you follow proper procedure.

 

[Evidence Based]

Sounds like a typical patient type in many clinics save the unusual housing situation. Set firm limits in a kind manner. Be consistent. Educate about what necessary and sufficient treatment consists of, and don't be surprised if the patient seeks another psychiatrist. If you do decide to terminate care, be sure you follow proper procedure.

Definitely agree with this. The clinical situation actually sounds pretty common aside from the living arrangement, and I can't imagine that anyone would hold you responsible for outcomes in a residential treatment setting which you have no formal relationship with.
Is there any reason you can't just treat this patient like any other patient you see with "universal precautions"? Ex. treatment frame, setting limits, no-show policies, etc.
I feel like one can disagree with this program model without terminating with the patient because you're uncomfortable with how it's run.

 

[dl2dp2]

This is the kind of patient that's perfect for a cash psychiatrist who would do combined treatment for $800 an hour. Send him to one. You are not a good fit. Your limited role is insufficient to steer the clinical ship and you are certainly not paid enough to worry about things over which you have no control.

 

[Sushirolls]

This is the kind of patient that's perfect for a cash psychiatrist who would do combined treatment for $800 an hour. Send him to one. You are not a good fit. Your limited role is insufficient to steer the clinical ship and you are certainly not paid enough to worry about things over which you have no control.

Is this sincere or bludgeoning of sarcasm, ... I'm confused...

 

[dl2dp2]

Is this sincere or bludgeoning of sarcasm, ... I'm confused...

LOL, half and half.

 

[Candidate2017]

I've been working with the patient about 6 months. Patient is not very engaged in our appointments.

Employed position? Document and keep seeing like any other patient, or terminate.
Private practice or boutique? Document and terminate.

 

[NickNaylor]

Bad outcomes are inevitable. You're limited in what you can do. Hve discussions with the patient and family about what you think is appropriate from a treatment perspective and why you're making the recommendations that you're making, and they - in particular, the patient - are free to do what they like. As long as you're explicitly documenting a risk assessment and what you're doing to assess that risk I don't think you should be too concerned from a liability perspective. At the end of the day, we have no ability to force people to meaningfully engage in treatment. You do the best that you can and take opportunities for intervention that present themselves, but you can't handcuff someone to a chair and force them to engage in therapy or otherwise make changes in their life that they don't want to make. The sequelae that result from those decisions - including a "bad outcome" - are not your responsibility if the patient and/or family make the choice to not follow your recommendations. This is especially true if there's no symptomatology or pathologic process that clearly impairs the ability of the patient to make rational decisions (e.g., a patient who is floridly psychotic and has no ability to appreciate the consequences of their decision-making). I agree that these patients are difficult. At some point, though, you have to "call it" - you've done what you can to help the patient and their refusal to follow-up your recommendations is on them, not you. Document what you've done, document the ongoing risk, document the response to your suggestions to engage in other forms of treatment, and hope for the best.

Whether or not you want to terminate the patient for other reasons is up to you.

 

[wolfvgang22]

Bad outcomes are inevitable. You're limited in what you can do. Hve discussions with the patient and family about what you think is appropriate from a treatment perspective and why you're making the recommendations that you're making, and they - in particular, the patient - are free to do what they like. As long as you're explicitly documenting a risk assessment and what you're doing to assess that risk I don't think you should be too concerned from a liability perspective. At the end of the day, we have no ability to force people to meaningfully engage in treatment. You do the best that you can and take opportunities for intervention that present themselves, but you can't handcuff someone to a chair and force them to engage in therapy or otherwise make changes in their life that they don't want to make. The sequelae that result from those decisions - including a "bad outcome" - are not your responsibility if the patient and/or family make the choice to not follow your recommendations. This is especially true if there's no symptomatology or pathologic process that clearly impairs the ability of the patient to make rational decisions (e.g., a patient who is floridly psychotic and has no ability to appreciate the consequences of their decision-making). I agree that these patients are difficult. At some point, though, you have to "call it" - you've done what you can to help the patient and their refusal to follow-up your recommendations is on them, not you. Document what you've done, document the ongoing risk, document the response to your suggestions to engage in other forms of treatment, and hope for the best.

Whether or not you want to terminate the patient for other reasons is up to you.

God, grant me the Serenity
To accept the things I cannot change,
Courage to change the things I can,
And Wisdom to know the difference.