Having a court ordered patient?

[futuredo32]

For the last several months a patient has called saying he is unhappy with the treatment he is getting at CMH and he is court ordered for treatment. I referred him to everyone I could think of and no one would take him. He explained that he can pay cash and isn't on probation and states he is compliant with his medications. He requires one supportive therapy session per month with med management. I felt bad for him. Some CMHs are awful. I finally said ok. I have never had a court ordered patient. What all goes into this?

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[PikminOC]

Let us know. We can learn from this.

 

[clausewitz2]

For the last several months a patient has called saying he is unhappy with the treatment he is getting at CMH and he is court ordered for treatment. I referred him to everyone I could think of and no one would take him. He explained that he can pay cash and isn't on probation and states he is compliant with his medications. He requires one supportive therapy session per month with med management. I felt bad for him. Some CMHs are awful. I finally said ok. I have never had a court ordered patient. What all goes into this?

He is going to have paperwork for you to fill out and you may have to talk to his probation officer depending on the circumstances. Probably you will also have to report him to the court if he misses appointments. Are you prepared to say no a lot and be fairly rigid about turning him in if he is less adherent than he claims he is, even if it means he gets jail time?

 

[michaelrack]

Is his court order related to a criminal charge, or is this civil out patient commitment (In which case there may not be much paperwork)

 

[clausewitz2]

Is his court order related to a criminal charge, or is this civil out patient commitment (In which case there may not be much paperwork)

Good point, an important question. I do wonder: how many people on civil outpatient commitments can afford cash pay psychiatrists?

 

[futuredo32]

He said he isn't on probation and has no history of violence. I work in a building with all females and worry about safety not like they would hear me anyway. He sounded maybe developmentally disabled. He said he is his own guardian. I asked what meds he took and he said Abilify. He just said he doesn't like the way he is treated at the CMH and I worked at one for awhile and know that a lot of patients don't get good care. I said he could come for a consult . He's willing to pay full fee.

 

[futuredo32]

Good point, an important question. I do wonder: how many people on civil outpatient commitments can afford cash pay psychiatrists?

I have a few patients with no insurance dirt poor who pay cash. One of the CMH's in the area I work is supposed to be REALLY bad. I work on the border of a really wealthy city and a not so wealthy city, so it's an interesting mix.

 

[futuredo32]

He is going to have paperwork for you to fill out and you may have to talk to his probation officer depending on the circumstances. Probably you will also have to report him to the court if he misses appointments. Are you prepared to say no a lot and be fairly rigid about turning him in if he is less adherent than he claims he is, even if it means he gets jail time?

He said it wasn't anything probation related and he isn't on probation. I am guessing at one time he was noncompliant , he said he is now compliant and just really doesn't like the way he is treated at the CMH. I called it a consult and a let's see how things go, I do that for every patient. Occasionally I end up saying I don't think I am a good fit for you, here is a list of other psychiatrists. In one of the books I read early in residency related to therapy the author I think Paul Watchel? said you shouldn't see patients you don't like and in my private practice I don't see patients I don't like.

 

[clausewitz2]

He said it wasn't anything probation related and he isn't on probation. I am guessing at one time he was noncompliant , he said he is now compliant and just really doesn't like the way he is treated at the CMH. I called it a consult and a let's see how things go, I do that for every patient. Occasionally I end up saying I don't think I am a good fit for you, here is a list of other psychiatrists. In one of the books I read early in residency related to therapy the author I think Paul Watchel? said you shouldn't see patients you don't like and in my private practice I don't see patients I don't like.

Noncompliant with what is the important question to figure out. >95% of people who don't show up for appointments at CMHCs don't get court-ordered to treatment.

 

[futuredo32]

Noncompliant with what is the important question to figure out. >95% of people who don't show up for appointments at CMHCs don't get court-ordered to treatment.

Noncompliant with meds? Im making a lot of assumptions. Ie he has money, and in the past was noncompliant in the hospital? He honestly sounded nice and just desperate it just broke my heart. He was begging.

 

[clausewitz2]

Noncompliant with meds? Im making a lot of assumptions. Ie he has money, and in the past was noncompliant in the hospital? He honestly sounded nice and just desperate it just broke my heart. He was begging.

It sounds like you are going to have a hard time with enforcing limits with him, and while some people certainly get caught up in the legal system through no real fault of their own, there is a significantly higher prior probability that he is maybe not everything he would like you to believe he is. I think you need to be very careful and thorough in your initial evaluation and I predict there is going to be a lot of that circumstantial irrelevance when you ask questions about exactly what led to a judge compelling him to be treated.

I want to be really clear: even people who have done fairly heinous things deserve care if there is anything that can actually be addressed or ameliorated (so almost everyone apart from the sadistic PD/hard antisocial/puppy-torturer types), but at the same time you need to be very clear-eyed and firm in a way that you might experience as excessively rigid.

 

[whopper]

Private practice: It goes like most cases go but the court may be possibly be able to see the records (or not). If the patient still doesn't want the court to see the records you aren't supposed to show the court, even if it's court-ordered unless it's under very specific circumstances, but those have to be detailed to you by the court.

You may get called by the court or other state agencies or employees. You need to enforce boundaries. Some of them might expect you to give out information when you were not given permission. If you are not a state employee you aren't supposed to share information without the patient's permission under usual HIPAA guidelines.

State employee: If you are, however, a state employee, you can share information if there's an actual treatment purpose for it. E.g. during my forensic evaluations, the records in the state forensic unit were open to the court. The court then took steps to shield much of that from the public but that too was at times open depending on the material and the case.

e.g. If I was still working for the state of Ohio and the governor called me up about a specific patient and wanted questions answered that were highly treatment relevant, I can give that information out. After all he's the top guy in the hospital administration of a STATE hospital. The governor never called me, but his office did call 1 person above me on a few occasions such as the judge or the hospital CCO.

I currently have a court-ordered case now and I'm very close to terminating the patient. Wow what a hot-bed cluster B mess. I can't talk about it cause of HIPAA and the circumstances are one of those things where you couldn't believe it otherwise but I got all parties verifying the stuff is true.

The patient in this case is court-ordered but she told them she would see me. I never had any directive from the court, so unless that happens, my part in this issue is no different than any other treatment provider. So, for example, if I terminate her, yeah she's still court-ordered for treatment but now with someone else. The court can't make me treat her.

 

[futuredo32]

I have no problem being firm or terminating patients. I'll see how the evaluation goes and if it seems like too much bother back to CMH HE GOES. he's supposed to bring his CMH records.

 

[OldPsychDoc]

Noncompliant with meds? Im making a lot of assumptions. Ie he has money, and in the past was noncompliant in the hospital? He honestly sounded nice and just desperate it just broke my heart. He was begging.

Get records. Find out why they felt he needed a court order to remain on meds and what the conditions of the order are.
This does vary by jurisdiction. In our state he would have been discharged after the commitment once safe and stable on a "provisional discharge" which would specify the stipulations, how long the commitment runs, etc.

 

[futuredo32]

Get records. Find out why they felt he needed a court order to remain on meds and what the conditions of the order are.
This does vary by jurisdiction. In our state he would have been discharged after the commitment once safe and stable on a "provisional discharge" which would specify the stipulations, how long the commitment runs, etc.

Thanks. I felt clueless but he was just so desperate sounding. Maybe this was a,mistake. If so back to CHM.

 

[watto]

Chiming in with everyone else to request records. Having done a ton of Independent Medical Examinations during which I am privy to the totality of the chart (including reports of investigations and even surveillance videos), I often feel for the community psychiatrists who are going solely off of the patient's subjective report.

I have learned that, even in my private practice, subjective report of symptoms may not be 100% reflective of the patient's experience in many cases. This is a good lesson as sometimes we forget that before making a diagnosis, other possibilities must be ruled out - including obvious external reward.

 

[futuredo32]

End of story- the court ordered patient called to cancel his first appointment and wanted one NEXT month. He said he needed monthly appointments, couldn't come until next month. I said that I think another provider of CMH would be more appropriate and wished him well.

 

[MedMan80]

It's important to trust your gut, if something sounds strange ie: possible ID patient, yet offering to pay cash; keep investigating further..Who know's this patient may be court ordered to treatment for sexual assault/harassment, would you be comfortable treating that? Good call on referring him out!

 

[futuredo32]

It's important to trust your gut, if something sounds strange ie: possible ID patient, yet offering to pay cash; keep investigating further..Who know's this patient may be court ordered to treatment for sexual assault/harassment, would you be comfortable treating that? Good call on referring him out!

A few pay cash . I'm guessing the local CMH is awful. There was something about him something genuine yet "off" , he said it was "his business" keeping him from coming to his appointment yesterday, maybe he's a drug dealer or has a legit business? I wasn't going to tell him to go elsewhere if he was cancelling because he was in the hospital.

 

[MedMan80]

A few pay cash . I'm guessing the local CMH is awful. There was something about him something genuine yet "off" , he said it was "his business" keeping him from coming to his appointment yesterday, maybe he's a drug dealer or has a legit business? I wasn't going to tell him to go elsewhere if he was cancelling because he was in the hospital.

Current behavior is predictor of future behavior, if you cancelled on you last minute what's to stop him doing that in the future and do you want that for your PP?

 

[futuredo32]

Current behavior is predictor of future behavior, if you cancelled on you last minute what's to stop him doing that in the future and do you want that for your PP?

For established patients, they pay full fee What I charge insurance companies) for appointments not cancelled 48 hours in advance, so I TOTALLY don't mind that. It's the first visit appointment cancellations or no shows that I dislike because they haven't signed the patient contract and I can't charge for those.