Outpatient one time consults

[nexus73]

I work in the outpatient clinic of a regional health system. Our clinic is basically understaffed, with nowhere near the psychiatrists or nps to cover the demand, and our panels are essentially full. To increase access I want to offer one time consults to patients whose PCPs are within the system. I've asked for input from our admin/legal team to create a consult consent form for the PCP and the patient so it's clearly a one time only visit and will provide diagnosis and treatment suggestions, but will not take over care and will not prescribe at the visit. The PCP will acknowledge they will continue to manage meds. The admin team's initial reaction was that a special consent is not required, that "a consult implies it could only be a single visit and doesn't guarantee continued care." From a medicolegal and professionalism standpoint I think it is better to be as transparent as possible to prevent anyone from assuming I will be taking over ongoing care for patients. Do you think a unique consent form for one time consults is a good idea?

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[Bartelby]

I think it is, more to ensure clear communication to patients (though it also makes clear who is responsible for ongoing care for legal purposes). There also doesn't seem to be any major downside to asking the patient to review and sign a brief form making the "consult" situation clear

 

[FlowRate]

Our system has "econsults" for the same purpose. I agree that doing full length new patient appointments will lead to more accurate diagnosing and in turn better psychopharm recs but you could probably get 50-75% of the benefit doing 20 minute chart reviews and thereby serve 3x as many pts.

 

[Celexa]

I work in the outpatient clinic of a regional health system. Our clinic is basically understaffed, with nowhere near the psychiatrists or nps to cover the demand, and our panels are essentially full. To increase access I want to offer one time consults to patients whose PCPs are within the system. I've asked for input from our admin/legal team to create a consult consent form for the PCP and the patient so it's clearly a one time only visit and will provide diagnosis and treatment suggestions, but will not take over care and will not prescribe at the visit. The PCP will acknowledge they will continue to manage meds. The admin team's initial reaction was that a special consent is not required, that "a consult implies it could only be a single visit and doesn't guarantee continued care." From a medicolegal and professionalism standpoint I think it is better to be as transparent as possible to prevent anyone from assuming I will be taking over ongoing care for patients. Do you think a unique consent form for one time consults is a good idea?

I think your admin team is probably right that additional paperwork and documentatiok is not REQUIRED, but I agree with you in that situation I think very clear communication and documentation serves a purpose and I would probably pursue implenting it the way you have outlined. To keep it within the consulting role you would want it to be clear that you are prescribing recs only and the final decision to prescribe is with the pcp.

 

[splik]

I do a lot of one time specialist consultations. I don’t have them sign anything I think that’s overkill in a health system (vs if you are in solo private practice) as the health system “owns” the patient as it were. I don’t have a high volume so I call all pts first to explain that this is a one time consultation and their specialist provide them written verbiage that makes it clear that only a one time consult is guaranteed. There is special language you need to put in your note to make it clear it is a consult (especially if you use outpatient consult codes which few payers still pay for). I also end the notes “this was a one time consultation and does not constitute formation of a doctor-patient relationship. A copy of this report was provided to Dr. X who will follow up on my recommendations.”

I wouldn’t worry at all about liability the main issue is only seeing pts who would be suitable for such a consult. Not all patients would be appropriate. It is also important to make sure that patients have no expectation of ongoing care from you. I actually do provide ongoing care to some pts but all pts are told it is a one time consult regardless so I don’t end up with pts I am not a good fit for.

 

[toros102]

It’s interesting you bring this up, New Zealand has a similar model. If you have any psychiatric illness, your PCP is supposed to give a full trial of a medication, if that fails, try another, and if that fails, the patient can get an appointment with a psychiatrist. The psychiatrist starts seeing the patient until the patient is on a stable regimen, then the patient is transferred back to the PCP with that regimen.

 

[NickNaylor]

I do similar one-time consults for interventional/neuromodulation treatment assessment. In general these patients are referred by a psychiatrist, but some do manage to get through without having a current psychiatrist.

As far as I'm aware, we don't have any specific paperwork describing the purpose of this visit in this way. That said, I'm very explicit with patients that I see that our relationship will not persist beyond the appointment and that this is a one-time visit for a specific purpose. This is for two reasons: I don't want patients continuing to contact me after the appointment, and I want to be clear about our doctor/patient relationship. I also document that the patient should return to their primary psychiatrist for ongoing management and additional questions not related to interventional/neuromodulation concerns and discuss this with the patient. So far, this setup hasn't resulted in any issues.

Completing a specific form just for this purpose seems a little excessive, but I can understand the motivation from an administrative/legal perspective. I think that you can probably head off a lot of potential issues by just being explicit with the patient about the nature of the appointment. For patients that don't abide by these boundaries, I will tell them that I am not the appropriate person to contact for general questions about their management and that I will no longer respond to such requests. I'm generally not that black and white, but I'm very uncomfortable with getting roped into an ongoing treatment relationship that I'm not comfortable or interested in being a part of.

 

[clausewitz2]

As far as I'm aware, we don't have any specific paperwork
Completing a specific form just for this purpose seems a little excessive, but I can understand the motivation from an administrative/legal perspective. I think that you can probably head off a lot of potential issues by just being explicit with the patient about the nature of the appointment. For patients that don't abide by these boundaries, I will tell them that I am not the appropriate person to contact for general questions about their management and that I will no longer respond to such requests. I'm generally not that black and white, but I'm very uncomfortable with getting roped into an ongoing treatment relationship that I'm not comfortable or interested in being a part of.

Always worth remembering that even more than actually making terrible decisions the thing that predicts whether you're going to get sued the best is how pissed off people are and/or if they feel they have been treated unfairly or ignored. Harder to sustain that righteous anger if you had a real explicit conversation that this was not intended to be a long-term relationship and remember agreeing to it at the time.

 

[Candidate2017]

Always worth remembering that even more than actually making terrible decisions the thing that predicts whether you're going to get sued the best is how pissed off people are and/or if they feel they have been treated unfairly or ignored. Harder to sustain that righteous anger if you had a real explicit conversation that this was not intended to be a long-term relationship and remember agreeing to it at the time.

The PCP will acknowledge they will continue to manage meds.

PCPs can manage meds on stable patients, and do an ok job. They seem to refer to psychiatry when things get out of hand (they piled on too many meds, substance seeking, constant threats of suicide, difficult personalities etc). What if the PCP keeps punting the patient back to you for consults? And how will you fit them back in if the system is already full?

 

[MedMan80]

Our system has "econsults" for the same purpose. I agree that doing full length new patient appointments will lead to more accurate diagnosing and in turn better psychopharm recs but you could probably get 50-75% of the benefit doing 20 minute chart reviews and thereby serve 3x as many pts.

Our system wanted us to do "Econsults", which were defined as us doing chart review and giving reccs. We would be able to bill and so would the PCP, but we would not be given any face to face time to evaluate the patient, which is why we shot the idea down..anyone doing anything similar?

 

[Mass Effect]

Our system wanted us to do "Econsults", which were defined as us doing chart review and giving reccs. We would be able to bill and so would the PCP, but we would not be given any face to face time to evaluate the patient, which is why we shot the idea down..anyone doing anything similar?

Lots of practices are doing this.

 

[MedMan80]

Lots of practices are doing this.

What are the medicolegal considerations of such?

 

[nexus73]

PCPs can manage meds on stable patients, and do an ok job. They seem to refer to psychiatry when things get out of hand (they piled on too many meds, substance seeking, constant threats of suicide, difficult personalities etc). What if the PCP keeps punting the patient back to you for consults? And how will you fit them back in if the system is already full?

I think the answer is, the one time consult is better than nothing. And nothing is basically what they get now because no one can get in to the psych clinic consistently. PCPs can try to refer the patient back, but we probably won't be able to fit them in for another consult. The PCPs will have to be okay with this. That's why I'm interested in a consent/referral form the PCP signs to acknowledge the limitations. I don't want a PCP to be pissed and documenting in their notes that I'm refusing to take a person on for continued care when the agreement was a one time consult. It would be nice to have the PCP's signature on the referral form scanned into the EHR if/when something like this happens. Otherwise I don't have to do one time consults at all if it's going to create more headache from PCPs.

 

[Mass Effect]

What are the medicolegal considerations of such?

I don't do this set up in my practice so I don't know, but there's lots of information on it.

Electronic consultations (e-consults) to improve access to specialty care: A systematic review and narrative synthesis

We define electronic consultations (“e-consults”) as asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform. E-consults are intended to improve access to specialty ...

www.ncbi.nlm.nih.gov

 

[nexus73]

What are the medicolegal considerations of such?

I'm not aware of any lawsuits stemming from this as of yet. I think a fair argument is an econsult is above standard of care. Because standard of care is the person not getting input from a psychiatrist at all. You'd likely want to stay very close to evidenced based medicine and for more complex patients recommend psych referral.

 

[UTsksk]

This is something interesting to me that my boss has brought up to us with CAP. What happens after you make your recs and there is later another issue? Do they come see you once again and provide additional recs?

 

[Merovinge]

This is something interesting to me that my boss has brought up to us with CAP. What happens after you make your recs and there is later another issue? Do they come see you once again and provide additional recs?

Depends on the setup, when I was doing this it could be a message or phone call with you providing a quick rec, could be a f/u consult. I was doing a different model where most patients were seen 3-6 times in an effort to stabilize before return to peds but with the understanding that patients would not be long-term with me (of course this involved a traditional patient/doctor relationship while they are seeing you). I found most PCPs appreciated this and have come to understand that even large academic centers are not able to keep patients in CAP indefinitely except for particularly difficult cases. I had a patient w/ bipolar d/o (actual bipolar) be transferred out of one of the biggest academic centers because they simply do not have the capacity to keep patients long-term these days (due to taking medicaid and so few PP docs taking this OP).