Special Report
MIEC Claims Alert
Number 37A
June 2005

Challenge for psychiatrists:
collaborative treatment with nonphysician co-treaters

• Frequent questions
• Protecting your patients
• Other suggestions
• To reach MIEC
• Loss Prevention resources
• Psychiatry progress note template
• Charting essentials
• Patient information brochure
• Co-treater form
• Informed consent: Medication
• MCR

With increasing frequency, psychiatrists share patient care with nonphysician therapists. In these cases, responsibility is split between a psychiatrist, who is responsible for medication management, and a nonphysician therapist, responsible for the patient’s ongoing psychotherapy. This article addresses some of the liability issues related to this type of collaborative care, and recommends ways psychiatrists can protect themselves and their patients when co-treating with a nonphysician.*

*This article does not address the risks for psychiatrists who provide consultative services to non-physician therapists (who then choose to follow, partially follow, or disregard the consultant’s recommendations); nor does it address psychiatrists’ supervision of non-physician therapists (in which case the therapist must follow the physician’s advice in managing patient care).

Here are two of the most frequent collaborative care-related questions posed by psychiatrists:

1. An agency with which I work has asked me to prescribe medications for patients they want me to see for 15-20 minutes, between two and four times per year. Common sense medical standards and my own ethics require that I see patients at clinically sound intervals if I’m going to prescribe medications. There’s no guarantee that agency-determined intervals will be safe for each patient even if they are seeing a midlevel therapist as an adjunct to his/her medication management. I also know that ordering drugs without a good-faith evaluation (which takes more than 15-20 minutes) is unethical and is probably illegal. I need the work. What should I do?
   
   
2. I manage medications for a number of private patients who are seen for ongoing therapy by a mid-level therapist. I suspect that because I don’t know these nonphysician therapists, and therefore have no meaningful collaborative communication with them, I may be increasing my own liability. I’m afraid that there is potential for patient injury when the right hand doesn’t know what the left hand is doing. I don’t know if these nonphysicians can diagnose properly, understand the psychopharmacology and its related problems, recognize medical conditions, assess a patient’s potential for harming self or others, or manage suicidality. The therapist, the patient and I are all at a disadvantage because the therapist and I don’t know one another. What can I do to decrease my risks?

How to protect your patients and you

If you are a psychiatrist who is considering a collaborative care arrangement to manage medications, or currently manages medications for patients who see nonphysician therapists, consider the following recommendations: 

Don’t compromise yourself or your patients: If a third-party payer is involved in the collaborative care plan, don’t sign an agreement that compromises your professional integrity. Consider whether the authorized intervals for patient examination and treatment are sufficient; whether the psychopharmaceutical selection available to you is broad enough; and whether the delineation between the duties of the psychiatrist and the duties of the nonphysician therapist is clear. Do not allow yourself to be persuaded to provide care that is less than clinically or ethically appropriate for your patients. 

Knowledge is power. Know your co-treater: Get acquainted with the nonphysician therapist with whom you share responsibility. Establish scheduled and as-needed communication guidelines and satisfy yourself that the therapist is competent in his or her discipline, adequately experienced, appropriately certified or licensed, and insured. Discuss with the co-treater what you believe is essential about diagnosis, treatment, the options and goals of treatment, on-going practical issues, boundary issues, the indications for medication, medication efficacy and side effects, and how to detect early signs of instability or suicidality. Develop agreements about who is responsible for what aspects of care, what you need to know and when you need to know it, what the therapist needs to know and in what time frame, and how to handle emergencies. 

Encourage the patient’s cooperation: Clarify the three-way relationship with the patient—in writing. Educate the patient about the therapist’s, the patient’s and your responsibilities in the three-way relationship. Although co-treaters can legally communicate with one another about their mutual patient under certain circumstances, in the interest of openness, you must obtain the patient’s written agreement for ongoing mutual communication with the therapist. Ascertain that the patient knows when to call the therapist and for what concerns, and when the patient should call you, and for what purposes. Send a copy of the signed agreement to the co-treater. (See Figure 2 for a sample psychiatrist/therapist/patient agreement.)

Other liability-reducing suggestions:

• Communicate with your patients: Inform patients about yourself, your practice, your policies, and your patients’ responsibilities in a patient information brochure. Patients are less likely to profess surprise at or deny knowledge of your policies if they are informed in advance of your hours; how and when they may contact you; their responsibilities in the doctor-patient relationship; under what circumstances, when and how they can obtain medication refills; and what they should do if you are not available when they call. (See Figure 3 for a sample patient information brochure; the brochure was designed for psychotherapists, but may be adapted for medication-management-only.)
  
  
• Obtain the necessary information for a thorough evaluation, diagnosis and treatment. Psychiatrists reduce their liability by obtaining baseline medical information to rule out clinical pathology related to presenting symptoms. Ask about each patient’s medical, social, family, and psychiatric history; allergies, medications and other physicians the patient sees; and drug and sexual histories, when appropriate.
  
  
• When it is clinically appropriate to do so, inform patients about their diagnosis, treatment, and medications. Provide written information about medications, including why the medication is prescribed, the directions for use, the possible side effects, and when to call you about medication reactions. Document that you have done so.
  
  
• Make certain that patients are adequately informed prior to making decisions for which they must give you their consent. If patients fail to follow your advice, inform them of the likely consequences of their refusal. (See Figure 5 for a sample form to document informed consent for medication use. For further information on informed consent and refusal, see MIEC’s Claims Alert #17.) 
  
  
• Document all important aspects of patient care and related communication. Make certain that your progress notes justify the medication(s) you prescribe, support the fees you assess, and distinguish between the patient’s (and co-treater’s) actions, statements, and responsibilities—and your own. If your care deviates from that usually indicated in similar situations, document the rationale for your decision. (See Figure 1 for a Psychiatric Progress Note Template form.) 
  
  
• Include in patients’ charts: (1) patients’ consent to treatment; (2) the substance of significant telephone calls to and from patients, other doctors, managed care plans, and co-treaters; (3) all patient education, oral and written; (4) unambiguous referral information; and (5) patients’ noncompliant behavior or patients’ refusal to follow recommendations. (See Figure 4 “For Complete Psychiatric Medical Records ...”)
  
  
• Include in progress notes the indications for medications; their efficacy and/or indications for continued use; and test results of drugs that must be monitored. Prescriptions and subsequent refill documentation should include the medication name, the dose, the directions for use, the amount prescribed, and the number of refills allowed, if any. Keep in mind that a complete record of a patient’s medication treatment is the best defense of medication-related allegations of negligence. Use a Medication Control Record (MCR) for accessible and readable documentation of prescriptions and refills. (See Figure 6 for a prototype of an MCR.)

If in doubt about a situation in which you provide--or are asked to provide--collaborative medication management, call MIEC for advice about your particular circumstances.

We thank Ann H. Larson, Esq., of McNamara, Dodge, Ney, Beatty, Slattery & Pfalzer, Walnut Creek, California, for her review, and advice for this edition of Special Report Claims Alert.

How to reach MIEC

Resources from MIEC’s Loss Prevention Department

Answers to professional liability questions. The Loss Prevention Department responds to a wide range of general questions about malpractice liability, and obtains legal advice for policyholders when indicated. Sample questions: How long must a physician keep medical records? How does a doctor properly withdraw from a patient’s care? What is the best method to obtain informed consent and how should consent be documented? (Direct questions about specific patients to an MIEC claims representative.)

Medical Records text. MIEC’s booklet, Medical Record Documentation for Patient Safety and Physician Defensibility, offers practical advice for maintaining defensible medical records and avoiding documentation deficiencies that can compromise a medical defense. The book includes useful chart forms, answers to questions about medical records, and a self-assessment form to review documentation quality. The book is free to MIEC policyholders.

Forms, templates and letters. MIEC’s Sample Forms, Templates and Letters , offered free to MIEC policyholders, is a packet that includes ready-to-use forms and templates that help physicians and staff organize medical charts, find data easily, and document important information that protects patients and physicians. Camera-ready forms can be reproduced for office use.

Extensive resource library. Policyholders can request sample medical record chart and consent forms; patient education materials; articles on medical-legal topics; lists of resources for practice guidelines; vendors of electronic and voice recognition medical records systems; and more. 

On-site loss prevention survey. MIEC’s loss prevention specialists conduct complimentary individual or group practice surveys in which record-keeping, office procedures and practice policies are analyzed. Surveyors meet separately with physicians and their office staff to discuss liability issues relevant to the practice and specialty, and offer practical advice for reducing liability exposure. A written report summarizes the survey findings and provides constructive suggestions for improvements.

Newsletters and alerts: MIEC publishes the Claims Alert; Special Report; We Get Letters...; New Law Alert; and Managing Your Practice newsletter series, and other publications that offer helpful and timely solutions to practice problems and answers to policyholders’ questions. Contact the Loss Prevention Department or visit our website for a list of titles and ordering information.