Thank you for joining us for today's educational program, Risk Management Considerations with Supervisory, Collaborative, and Consultative Relationships. Content in this presentation is intended solely to provide general information concerning developments in the area of risk management. It is not intended as legal or medical advice, nor does it offer or solicit for offers with respect to any insurance product. Legal or medical advice should be obtained from qualified legal counsel or other professionals to address specific facts and circumstances and to ensure compliance with applicable laws and standards. And listeners should consult their own insurance advisors for information pertinent to the purchase of any insurance product. This content may not be reproduced or redistributed in whole or in part without the prior written consent of Allied World. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the American Psychiatric Association and Allied World. The APA is accredited by the ACCME to provide continuing medical education for physicians. The APA designates this enduring activity for a maximum of one AMA PRA credit category one credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity. There's no disclosures to be disclosed. My name is Kara Staus and I will be your speaker for today. I am an Assistant Vice President in the Risk Management Group for AWACS Services Company, a member company of Allied World. I provide risk management consulting services to Allied World's medical professional liability policyholders and insured psychiatrists, psychologists, psychiatric nurse practitioners, and physician assistants. I work directly with policyholders to develop individualized action plans to mitigate potential loss based on their unique exposures and risk management needs. Additionally, I assist these clients with ongoing medical education programs, as well as policy and procedure review and development. The terms consultation, collaboration, and supervision currently convey different and sometimes overlapping meanings to healthcare professionals. So today we will review each of these roles and at the conclusion of the presentation, you will be able to describe the types of roles in split treatment, supervisory, consultative, and collaborative relationships with other professionals, and the liability issues involved, identify the potential malpractice issues associated with each of these three types of roles, discuss case examples when working with other providers in the care and treatment of patients, and apply risk reduction strategies with each of these three roles. So let's get started. A doctor-patient relationship is generally formed when a doctor affirmatively acts in a patient's case by examining, diagnosing, treating, or agreeing to do so. Once the physician consensually enters into this relationship with a patient in any of these ways, essentially a legal contract is formed in which the physician owes a duty to that patient to continue to treat them or to properly terminate the relationship. The relationship will be situational specific and some factors that the court may consider is what was the relationship between the consulting physician and the facility required of the consultant to give advice and what degree to which the consultation affected the course of treatment, and can the requesting physician choose to take or leave the advice. So since we're talking about potential liability issues, let's start with an overview of the elements needed for claims against physicians. It's important to note that most claims involve a claim of negligence. And so to prevail, a plaintiff would have to essentially prove the following, that there was a duty owed through a doctor-patient relationship, there was a breach in the standard of care, and that there was a causal relationship or link to the alleged damages. Claims are brought when there is a real or perceived deviation from the standard of care. And it's important to note that the standard of care varies from state to state. And generally the standard isn't what an expert might have done, but rather whether the actions as a physician who in a similar situation with a reasonable and same degree of care and knowledge practiced under the same circumstances. So let's begin to review these three shared roles, also known as split roles. So we'll start by talking about consultative roles. Consultation occurs between two professionals who are licensed or credentialed to provide patient care. Typically, liability related in consultation roles depends on the type of consultation the physician provides. Keep in mind, there's two types of consultations, a formal consultation and also an informal, which may also be known as a curbside consultation, which we'll talk about on the next slide. So let's talk about formal consultations. They occur when a treating physician or licensed clinician directly requests the written or verbal opinion of a consulting physician. A formal consultation results in the creation of a physician-patient relationship, and therefore that legal duty to the patient exists. Formal consultations can be provided through face-to-face assessments and interviews, by telephone, or even through telemedicine and telepsychiatry. In a formal consultation, the consultant provider typically knows the patient's identity. They're going to perform a potential physical or mental status exam. They're going to review records, studies, test results, provide a diagnosis. They may even prescribe medications. They're also going to document in the medical record, provide a written report that included their evaluation, recommendations, and any planned follow-up. And that consulting psychiatrist typically can charge and gets paid for the consultation. Now curbside consultations are the most informal type of specialist consult. They occur when the physician consultant does not see the patient or review the patient's chart or document the consultation. So it's considered to be informal advice where the patient identity is not known, there's no compensation for services, and the treating physician is in charge of the care and treatment of the patient. So let's talk about an example. Let's say a family practitioner bumps into you leaving the office one evening and proceeds to ask for your opinion concerning one of their elderly patients who they believe may be suffering from depression. The patient has a number of other medical issues and is contemplating beginning treatment with an antidepressant. You do not know, nor have you examined this patient, and you have not reviewed their record. You give your friend an opinion on treatment options. Psychiatrists often encounter similar curbside consultation requests, but could an informal conversation expose them to liability? So liabilities and issues arise with this type of scenario. They may not be well-defined, yet they occur frequently in all types of medical practice, including psychiatry. So the physician's liability may depend on whether or not the physician engaged in a formal consultation rather than an informal consultation or conversation, often referred to that curbside consultation. So there's going to be gray areas since the courts and juries look at so many factors when determining, really, does liability exist? So it's important to understand that liability may attach to a physician's actions, especially when using their clinical expertise to advise a colleague on a recommended course of treatment. And so typically, an informal curbside consult is informal advice, as mentioned, the patient identity is not known. There's no interview or exam of the patient or medical record review or documentation. There's no exchange for compensation or billing of services, and the treating physician is in charge of the treatment. So in the consultative role, there's typically less exposure to liability in the consultative role, because treatment is dictated by someone other than the psychiatrist. The psychiatrist who provides the consultation will most likely not be continuing that duty to the patient. So how do you reduce risk? Be sure that the roles between you and the referring physician are clear. When providing a formal consult, explain your role to the patient so that they understand your role as the consultant. Another reason there may be less liability exposure is that there is no supervisory relationship involved. So the psychiatrist offers advice, and the referring physician really can use it as a take it or leave it advice, which means they can choose to follow or not follow the advice given by the consulting psychiatrist. So this leaves the consulting psychiatrist outside the decision-making chain of command and not directly involved in the care and treatment of the patient. So risk management considerations with consultations. You know, when asked to provide a consultation, it's really important for you to consider these key risk management questions. Is there a contractual relationship? So think about supervisory, facility, clinic, or agency relationships. Be sure you know this information ahead of time before you're considering. So is there anything within the contract that discusses the supervisory role or liability for patients? Is there a hold harmless agreement incorporated within that contract? Do you need to negotiate the contract with the clinic or agency or healthcare facility to provide liability coverage? And make sure that there's details of the terms of expectations, such as the necessary information to be shared in order to provide a consult. Who is responsible for decision-making for the patient's clinical care? Make sure that these roles are clearly defined and be sure to confirm all physicians and clinicians involved know who's involved in the care and who may be prescribing. What is the process for addressing patient emergencies? Again, who's handling it? Do we know who's responsible and who's taking the lead? It's important for you to know if there is a procedure in place when consulting, who's responsible for handling and communicating any patient emergencies. And then lastly, who is owning the patient's plan of care? Who's responsible for all other aspects? If you are obligated by contract, be sure to know the role of each of the providers involved, who's responsible, who's covering, and understand what your duty and obligation is. So as we've concluded our dialogue on the consultative role, we'll now move into the supervisory role. So it probably goes without saying that liability can arise when a psychiatrist employs or supervises another individual. So within the supervisory role, it often carries the highest risk for the psychiatrist because in this role, you can alter treatment, you can make clinical decisions regarding the care and treatment of the patient. Psychiatrists who are supervising other providers remain legally and ethically responsible for the patient's care, even when you may not be directly delivering the care. So there are a lot of theories of liability for which holds a physician liable for the acts of others, which is known primarily as vicarious liability. So vicarious liability is the legal theory that is used to hold a person liable for negligent acts, omissions, or wrongful acts of another person because of the relationship that you had with them. So in this case, if you are supervising psychiatrists overseeing the care of other clinicians within your practice or by nature of a supervisory arrangement or agreement, you could be held responsible through vicarious liability. So one type of vicarious liability is a theory of respondent superior, which is the common law doctrine, meaning let the master answer. So this theory is often used in medical malpractice to hold a physician liable for his or her employees' negligent acts or omissions. It's also often used to hold a physician responsible for the acts of an advanced practice provider, and this can even apply when the physician did not personally treat the patient. Another theory or liability issue is a parent agency. So a parent agency can be used to hold a physician vicariously liable if it appears to the public that the agency relationship existed between two individuals. So the best example is that an advanced practice professional may work in a practice as an independent contractor but have a written collaborative or supervisory agreement with a psychiatrist, which makes it difficult to avoid that vicarious liability by claiming the nurse practitioner is an independent contractor. So again, that a parent agency is that it appears that that independent contractor actually works for your clinic or agency. So there also may be direct liability for negligent supervision when a physician allows an advanced practice provider or resident to provide care beyond their scope or license, power for inadequate supervision, negligent hiring and credentialing when you own a practice, and practice owners can be liable for failing to ensure that their staff is qualified, properly licensed and supervised. So it's important for practice owners to consider how they can reduce their liability by prescreening applicants, conducting background checks, and checking references. It's also important for you to understand the risks of, you know, signing off on documentation of others in your practice. Even if you aren't the supervising physician, if you sign off on a subordinates documentation, essentially you may be on the hook, which means that when you sign off on a case, you're taking responsibility for the contents of the documents you sign. So it's always recommended that you review the documentation before signing off on it or have an appropriate policy and procedure in place within your practice so that it is clear as to what the role is and the procedures for signing off on documentation. The supervisory role and advanced practice providers. So it's important to understand the scope of practice of those you supervise and how much oversight is needed. So supervision for advanced practitioners varies from state to state, and there are more states allowing for the independent delivery of care for PAs and APRNs. So again, it's important to know your state statutes and regulations when it comes to supervision and what that role of that advanced practitioner is allowed or isn't allowed to do by state statute. So keep up to date. They do change frequently, and be familiar with the board of oversight for the level of practitioner you're supervising. State statutes also have statutory requirements that may involve chart reviews, a written supervisory agreement. They might limit the number of supervisees an individual is supervising. They might have requirements for direct on-site supervision, require regular meetings, co-signing of medical notes. So it's important to define your roles clearly and set expectations up front and keep communication lines open when engaging in a supervisory role. That way, it is understood at the start of the arrangement, the frequency, how often you're going to meet, how is an adverse event to be elevated or escalated, what do you want to be notified of. You know, establish those parameters with the person you're supervising so that it is clearly understood at the start of their role and your role as supervisor as to how they are to act in the role, in the practice, and what the expectations are. Primary roles and split treatment. So now we're going to finish off by talking about the collaborative role. So the collaborative role is most likely the most complex of the three roles. You may also refer to this as co-treatment, dual, or split treatment. This is traditionally when two or more licensed professionals share ongoing responsibility for the patient's treatment. So split treatment refers to that arrangement whereby the psychiatrist is responsible for medication management, while psychotherapy is provided by another mental health provider, such as a psychologist, social worker, or a nurse specialist or counselor. So the American Psychiatric Association has issued guidelines for psychiatrists on the consultative, supervisory, and collaborative relationships. So these guidelines can be found directly on their website at www.psychiatry.com. So I do encourage you, if you're not familiar with those guidelines, to go to the website to take a look at those. Collaborative care, a lot of times, is also going to involve a primary care physician, may involve advanced practitioners, other mental health providers, as well as maybe even another psychiatrist. As an example, the collaborative team will come together. The psychiatrist may be managing the medications while the psychologist administers therapy, and the primary care may prescribe the medication as a continuation and collaborate with the therapist. So the role is going to be different from the consultative role because each clinician is acting independently and responsible for their portion of the treatment plan and the care that they deliver. So communication is absolutely critical and essential and it must exist. And the sharing of information related to patients and their treatment plan has to happen for a successful collaborative plan. So it's important that each involved provider understands their role and ideally should have it written into an agreement which details the plan of care, who's exactly managing the medication, what are the responsibilities, as well as that communication plan amongst the care team. Is there care team meetings? What is the frequency? What is the approach? So it's also important as the clinical team communicating together, but equally as important to communicate clearly with the patient so that they understand what exactly the collaborative approach is amongst providers and how that information is shared. So be aware under HIPAA for care continuation and collaboration that information sharing is acceptable unless the patient explicitly refuses. And so it's always recommended when entering a relationship with a patient that at the start of care, you explain that as part of your practice, that it's important for you to have open dialogue with other medical professionals that may be treating the patient that you would need to have conversations with. So again, be transparent with them so they understand the importance of the care team communication. The collaborative role. Physicians must agree really on the following, the basis of the patient's diagnosis, anticipated therapies, and any risks from the treatment or diagnosis. Communication. Communication is essential, as I mentioned, for a successful collaborative treatment relationship. The psychiatrist should maintain an open line of communication with the other treatment providers on a routine basis instead of only communicating during a change in the patient's condition. Always address patient safety. It's important to address that at any time. Changes in the patient's condition are very important and need to be discussed timely and documented. So again, we wanna make sure that there's communication and routinely communicating, consistently communicating, and also documenting all of these as part of the collaborative treatment relationship. You wanna document and communicate any changes in the treatment plan, change in diagnosis. Is there change in the psychotherapeutic strategy? Is there any changes to the medication management? Again, it's important for these changes to be communicated timely, as we know that in the event there was an urgent question or a patient need, that each provider involved in the collaborative care plan was aware of these changes timely. Communication regarding any patient onset of suicidal ideation or any risks for violence or threats of violence does require that collaborative team discussion and appropriate planning and documentation. Should you consider medication? What are the frequency of refills? Do we need to look at it? Should it be 30 days versus 90 days? Is there a concern if there's a greater availability of medication on hand? Is there a concern for self-harm? Does the individual have access to weapons? Is there a safety plan in place? What is the level of treatment required? Is inpatient level of care something that should be considered or an intensive outpatient program or partial hospitalization? Again, these are all of the considerations that should be discussed as part of the collaborative approach. So we've covered a lot of information here, and so let's review situations where you may be faced with potential liability while acting in one of these three roles, the consultative, supervisory, or collaborative role. So consider the on-call physician and have they been consulted about a patient? Are you on call? Is there consulting requirements? Are you covering for a colleague? And have you been asked about a colleague's patient? You know, what do you do about that? Are you prepared to respond from a coverage standpoint? Are you supervising medical or non-medical staff at your practice? So there's vicarious liability considerations. Have you been asked to give an informal or curbside consult about a patient? Maybe not having the full picture. Does that curbside informal consult inquiry turn into a patient diagnosis and treatment without providing a formal consult? Take a pause, really consider that as these consultations appear throughout your day. Are you billing for services? Again, billing for services is going to show that a patient-physician relationship exists. Make sure you're communicating, you're examining, personally examining the patient and you're communicating directly with the patient. Establish that physician-patient relationship for certain roles. If you need to review or document in the patient record, you are doing that. Again, you wanna make sure that you are clearly identifying what role you have in order to reduce the risk to reduce the liability that may or may not exist in a certain circumstance. Failure to define your role and responsibilities when working in that collaborative or consultative role should be concerning. So you wanna make sure that it's clearly defined. With the physician you may be consulting with, with the patient that you're involved with, again, make sure that those individuals clearly know your role and make sure you understand what the ask is, what the scope of your role is before agreeing to engage in a collaborative or consultative role or supervisory role. Be mindful of collaborating, supervising of an advanced practitioner that may fall outside the scope of practice. So watching what those advanced practitioners are practicing, making sure you're aware of the statutory requirements of the guidelines within the practice and scope of the individual that you are supervising. Again, following or not following state regs is a potential liability concern when you are supervising. So again, be aware of the statutory and regulatory requirements, especially if you're engaged in the age of technology where we've seen a lot of telemedicine and potential cross-state supervision, make sure you're licensed in the state where this advanced practitioner is licensed and you also know those regulations required for those states. Because again, as we indicated, they do differ from state to state. So this list is not an all-inclusive list. It's really the most common risks and so we want you to be familiar with where the courts and jurors and attorneys will most likely look to examine the records in the event there was a claim for malpractice or negligence, that these are the areas that they're going to look at to determine where liability exists and who it falls upon. And so that's why we're taking particular attention to really drive home the importance of defining your role and looking at the differences in the roles and making sure it's understood the uniqueness of each one of these three roles of split treatment. And lastly, it goes without saying, communicating changes in the patient's diagnosis or condition is something that would weigh heavy on the courts, because again, they're going to be looking at those situations. We reviewed a lot of information here. So what are some risk reduction strategies? So understanding your state and federal laws and regulations. State and federal laws tend to change quickly. So be familiar with them. If you are a part of a professional association, such as the American Psychiatric Association or your state district branches, they would be a great resource for you to stay up to date and informed on these legislative changes. In addition, there are other resources regarding regulations state specific for going for licensure. You can look at the Center for Connected Health Policy and other sites that are listed in our list of resources at the end of this presentation. It's always important to adhere to your profession's ethical guidelines, take pause and consider in the event, something may not feel right. You may need to talk to somebody, talk to a peer, get guidance or consultative support to run through a situation. Be very cautious when an informal inquiry turns into a patient diagnosis or treatment situation. Again, understand what that role of that informal relationship is, because in the event that provider who owns the plan of care documents that they discussed with a colleague and they might even mention your name, you wanna be mindful of that. So make sure that those informal inquiries don't turn into a informal doctor patient relationship. So be aware that that curbside informal consultation does not necessarily make you immune from a lawsuit or litigation. There are steps that we've talked about today to mitigate the risk. And by all means, we're not looking to, you know, make this, you know, a daunting task for you to remember all of these strategies. But again, it's important to know that some of these consultations can result, you know, in some situations that you might not wanna find yourself in from a legal and liability standpoint. Defining your roles with consultations is very important, again, for you and then the person who may be referring to you or you're supervising. So again, clearly defined roles is an important component to risk reduction. Talked about delineation of responsibility in supervision and collaboration. So when you're supervising, again, keep in mind what the expectations are. Some levels and some states do require that collaborative agreement for supervision that does outline by statute certain requirements. So again, be aware of what that responsibility is before agreeing to that supervision. Make sure you have the time and the ability to properly supervise and have oversight over that clinician. Be aware of your employment contractual obligations. So again, if you're working for a hospital system or facility by contract or contracted services out elsewhere to a clinic, be aware of those contractual obligations and what they're holding you to. So it's important to keep that contract, read it thoroughly and understand your roles. Be aware of organization's policies and procedures. Again, working for larger health systems, clinics and other agencies, they will have policies and procedures. You want to be familiar with those policies and procedures. If you are in private practice, you should consider developing policies and procedures for these types of roles. And then lastly, communication and documentation. You know, ultimately patient care involves communication and documentation are two essential and critical elements in delivering quality patient care. So make sure you're effectively communicating with the patient, with your staff, with any other collaborative or consulting or supervising clinician involved in the plan of care and make sure where appropriate you are documenting, documenting those conversations, documenting those collaborative care agreements with the care team, documenting, you know, responsibilities, documenting action plans. You know, again, keep in mind when we talked and we started this presentation and we talked about the elements, the four elements of a claim and how often negligence is a part of claims that when litigation or lawsuits are brought to court, it's typically three to five years. And so again, your documentation is going to be really that one complete record of what took place regarding the care and treatment of the patient that you're taking care of. And that is what you're going to reference when and if you ever need to. So again, by documenting in the record and having thorough contemporaneously, keeping those documents, you're well on your way to having rate risk reduction strategies. Here are some of the resources that we've mentioned today. The consultative approaches to leveraging the psychiatric workforce, talked about integrating primary care and behavioral health and then cross state lines, consultative, we've talked about liability issues. These are excellent resources for you to take a look at when you have time and follow up to the presentation. So we thank you for your time today. If you have any follow-up questions or insurance needs, please contact the APA Endorsed Professional Liability Program American Professional Agency at 1-800-421-6694. You can email at psychiatry at americanprofessional.com and also visit their website at www.americanprofessional.com. Thank you.

Risk Management

Supervisory Relationships

Collaborative Relationships

Consultative Relationships

Liability Issues

Clear Communication

Ethical Guidelines