Potential liability of a clinic policy

[psyduck1990]

I wanted to get feedback from you guys about a recently implemented policy at a clinic I work at. Admin has started pushing PHQ-9s electronically to all patients on the mornings of their appointments and CSSRS screeners to all intakes on the mornings of their appointments. My worry is that these ask about suicidal ideation but that a proper risk assessment might not happen until much later in the day. Is this a potential liability risk?

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[HemeOncHopeful19]

Sounds like a nightmare if someone fills it out and then no shows later that day

 

[psyduck1990]

Sounds like a nightmare if someone fills it out and then no shows later that day

We were told if that happens to call the patient after they no show, do a risk assessment, and document it

 

[calvnandhobbs68]

We were told if that happens to call the patient after they no show, do a risk assessment, and document it

😆😆 lol this sounds even dumber. The perceived liability if the patient no shows is more what I would be concerned about.

Just tell them the patient can fill out the PHQ9 when they actually show up for the appointment. All this requires is an iPad or a piece of paper. It takes like 30 seconds to fill out. If they push back about it, tell the admin THEY can call the patient then and do the risk assessment over the phone if they want to keep this policy….or they can just change it to have it happen when the patient checks in for the appt.

If their system can recognize what day the appt is and push the questionnaire then, it almost certainly has the ability to delay pushing the questionnaire until they’ve checked in to their appt.

Even if you have to manually input the results from the paper form I’d prefer that over this idiocy.

 

[comp1]

I'm not as concerned about liability. I think we way overestimate liability in general and are horrible predictors of risk. I've found people are often very surprised at what they ultimately get sued regarding. Obviously if they fill it out, report concerning SI and then no show you call them when you are reviewing it at the time of their appointment. If you can't reach them, you send out a welfare check. That's clear standard of care. However, I do think this is a poor flow practice. Have patients fill it out when they show up (if there is some metric from on high that is forcing them to fill it out in general). They might be a completely different person from the morning, particularly if on the Cluster B spectrum. I'm not highly supportive of measurement based care in general for mental health. I think they can work okay as pure screening in a primary care practice, but are pretty useless and occasionally distracting/harmful in a psychiatric practice.

 

[Sushirolls]

I send PHQ/GAD to my patients in my solo practice 1-2 days ahead of the appointment.
Not concerned about liability.
PHQ is just a pseudo science number. A data point to help me trend patients.
I (and we all) have patients that consistently have high numbers but their MSE and self report don't match up.
Or the SI isn't plan/intent, but merely some variant of passive SI that has been chronic.
We know which patients are of concern when they no show - and that doesn't correlate at all with PHQ scales.

I also do the scales to bill for them.

 

[aim-agm]

I also do the scales to bill for them.

What billing code do you use?

 

[Sushirolls]

96127
search on the forum, and you'll find a whole thread I started on this code.

 

[ObsequiousAplomb]

I'm not as concerned about liability. I think we way overestimate liability in general and are horrible predictors of risk. I've found people are often very surprised at what they ultimately get sued regarding. Obviously if they fill it out, report concerning SI and then no show you call them when you are reviewing it at the time of their appointment. If you can't reach them, you send out a welfare check. That's clear standard of care. However, I do think this is a poor flow practice. Have patients fill it out when they show up (if there is some metric from on high that is forcing them to fill it out in general). They might be a completely different person from the morning, particularly if on the Cluster B spectrum. I'm not highly supportive of measurement based care in general for mental health. I think they can work okay as pure screening in a primary care practice, but are pretty useless and occasionally distracting/harmful in a psychiatric practice.

I agree. Isn't the Columbia cutoff something like a 2% chance of completed suicide in a year?

 

[Bartelby]

Obviously if they fill it out, report concerning SI and then no show you call them when you are reviewing it at the time of their appointment. If you can't reach them, you send out a welfare check. That's clear standard of care.

I think this idea perfectly sums up why this is so concerning.

I don't think I have ever sent out a welfare check for a no-show. In some clinics a significant portion of my panel experiences chronic suicidal thinking. If there was a very compelling reason, such as a family member calling concerned earlier in the day and a no-show later that day, then sure I would call a welfare check. But if the person is chronically high risk (the kind of person who very well might screen positive on these brief screeners) I would need more than a no-show where I could not immediately reach them to call a welfare check. It's worth keeping in mind that a welfare check is not really benign. You are sending police out to check on someone they will understand to be mentally unstable and suicidal. This can lead to upsetting interactions for the patient or to unnecessary forced hospitalization (not to mention wasting the police department's time). In very rare cases it can lead to worse than that, like a violent interaction that really wasn't needed.

You mentioned "concerning SI," and by that I presume you mean that in cases like chronic SI you would document why you do not view the person as an imminent risk. But when such a patient does eventually complete suicide or make a seriously injurious attempt, there are plenty of experts who would make the case that the suicidal expression they had just sent in to you was obviously concerning and, as you just said, the "clear standard of care" is a welfare check. And do we really want to add the documentation burden of regularly explaining away positive screeners where we could not then conduct an actual risk assessment?

The bottom line is that I think it does open up potential for liability that otherwise may not have been present, and opens up the potential for people sending routine police welfare checks out as a form of CYA for no-shows. It reminds me of the saying about ordering labs without a clear indication: it's kind of like picking your nose in public, if you find something you don't know what to do with it!

 

[calvnandhobbs68]

I think this idea perfectly sums up why this is so concerning.

I don't think I have ever sent out a welfare check for a no-show. In some clinics a significant portion of my panel experiences chronic suicidal thinking. If there was a very compelling reason, such as a family member calling concerned earlier in the day and a no-show later that day, then sure I would call a welfare check. But if the person is chronically high risk (the kind of person who very well might screen positive on these brief screeners) I would need more than a no-show where I could not immediately reach them to call a welfare check. It's worth keeping in mind that a welfare check is not really benign. You are sending police out to check on someone they will understand to be mentally unstable and suicidal. This can lead to upsetting interactions for the patient or to unnecessary forced hospitalization (not to mention wasting the police department's time). In very rare cases it can lead to worse than that, like a violent interaction that really wasn't needed.

You mentioned "concerning SI," and by that I presume you mean that in cases like chronic SI you would document why you do not view the person as an imminent risk. But when such a patient does eventually complete suicide or make a seriously injurious attempt, there are plenty of experts who would make the case that the suicidal expression they had just sent in to you was obviously concerning and, as you just said, the "clear standard of care" is a welfare check. And do we really want to add the documentation burden of regularly explaining away positive screeners where we could not then conduct an actual risk assessment?

The bottom line is that I think it does open up potential for liability that otherwise may not have been present, and opens up the potential for people sending routine police welfare checks out as a form of CYA for no-shows. It reminds me of the saying about ordering labs without a clear indication: it's kind of like picking your nose in public, if you find something you don't know what to do with it!

This basically sums up what I would have said. I do think people freak out too much about liability in general but this opens up liability for no reason.

Basically, yes absolute risk is low but IF one of these patients checks anything for SI, then no shows and dies from suicide in the short term or has a significant suicide attempt, you’re basically hosed. So now you have to followup on every no show that checks off anything for SI which may or may not actually mean anything. It’s turning a non issue into a potential issue. Just wait to give them the PHQ9 when they check into the appt and now you have a whole clinic note/face to face appt as your assessment even if they check off the SI question

 

[psycho-matic]

I understand everyone has different opinions on "measure-based care," as someone put it. I prefer a PHQ-9 and GAD-7 be completed before every visit. I don't base my treatment decisions on the scores or adjust medication to chase the numbers. It simply provides a slightly more 'objective' way of quantifying the patient's response to treatment. The score trends are very helpful in tracking response to treatment. If scores plateau and are not decreasing, that could indicate the treatment is not working. It may even help me to determine if a particular domain or symptom(s) is not improving.

Sometimes the patient is not a good historian. If there is a large discordance between how the patient is saying they feel and the screening scores, this allows for an opportunity to discuss that incongruence with the patient. That conversation often leads to additional insights because it prompts the patient to reflect more deeply on aspects of their mood they perhaps were unaware of or had not given much thought to. I find the scores are pretty accurate at letting me know when the patient has a departure from their baseline, such as when the patient experiences a mood exacerbation. Discussing the increase in scoring with the patient often leads to additional insights.

Lastly, some concern was expressed over the liability of a patient providing a positive answer to question #9 and not showing up for their appointment. Although no-shows are not common at my shop, they happen as they do at any clinic. We added a question that appears when a patient provides a positive answer to question #9 on the PHQ-9 with 2 possible answers.

Would you describe these thoughts as:
-vague: A vague or general thought or feeling
-specific: Something I have made specific plans for

Patients almost always select "A vague or general thought or feeling." We do not follow up on those. We only follow up if they select "something I have made specific plans for." These are normally completed by the patient on their phone the day before the visit. If they select the second option, we follow up on that ASAP. We do not wait until they come to the appointment, so whether they show or not doesn't affect the decision to reach out to them. A patient selecting the second option is rare, so it doesn't significantly impact our workload. Most of the time, when the patient selects the second option, we can reach the patient and clear up the issue. If the patient can't be reached and we can't reach their emergency contact, a welfare check from the police would be arranged. Again, this is pretty rare.