Handling unsolicited phone calls from family members

[liquidshadow22]

I have had a few patients in my outpatient practice where I receive phone calls from family members regarding the patients mental health.

Sometimes it is unclear if there is an emergency that would warrant breaking hippa to warrant having a discussion with the family member.

Ie. Family's concern that patient is alienating family and isolating, becoming more depressed and family requesting to speak to me without the patients consent.


Family is concerned that a patient is acting bizzarely, possible police charges, even though no history of psychosis. Again without the patients consent.


I understand you can say "I cannot confirm or deny that patient is under my care" and listen to the information provided. But I am really bad at even having these phone calls without divulging some information about the patient and most of the time I feel justified because I am concerned that there is an acute decompensation that warrants breaking hippa but sometimes it requires some level of discussion to understand whether there is an actual imminent threat to the patient or others.

Any advice on how I should handle these phone calls going forward without fear of breaking hippa inappropriately but also trying to provide the safest possible care?

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[clausewitz2]

I have had a few patients in my outpatient practice where I receive phone calls from family members regarding the patients mental health.

Sometimes it is unclear if there is an emergency that would warrant breaking hippa to warrant having a discussion with the family member.

Ie. Family's concern that patient is alienating family and isolating, becoming more depressed and family requesting to speak to me without the patients consent.


Family is concerned that a patient is acting bizzarely, possible police charges, even though no history of psychosis. Again without the patients consent.


I understand you can say "I cannot confirm or deny that patient is under my care" and listen to the information provided. But I am really bad at even having these phone calls without divulging some information about the patient and most of the time I feel justified because I am concerned that there is an acute decompensation that warrants breaking hippa but sometimes it requires some level of discussion to understand whether there is an actual imminent threat to the patient or others.

Any advice on how I should handle these phone calls going forward without fear of breaking hippa inappropriately but also trying to provide the safest possible care?

I am struggling to identify under what exemption you could possibly justify releasing PHI to a family member who isn't an already agreed upon health representative of some kind in this situation. This is not really a scenario where even serious clinical concern allows you to do this, especially if you haven't even talked to the patient to figure out if they are incapacitated or some such.

Maybe read up on HIPAA? This is a good start: Summary of the HIPAA Privacy Rule

Nothing stops you from asking factual questions about whatever they are telling you but that should be enough to figure out if there is a serious threat to someone's safety, or at least so crystal clear a threat that you're on safe legal ground. Even then, i don't see how you justify telling the family stuff unless maybe a family member is the target of the threat. Appropriate disclosures seem like they would be to law enforcement/crisis response folks.

 

[splik]

I don't recommend responding to such messages. Delete them. If someone calls you and you answer, just say you cannot get involved without a release of information and hang up. do not allow yourself to be triangulated.

 

[Crayola227]

I mean I would probably say the disclaimer about how I can't confirm or deny, and receive the info, and just make it clear that's all I can do. If I was worried about the patient I might ask questions the way clausewitz said, essentially asking about HI/SI and signs of psychosis or serious acute decompensation.

OTOH, your post is giving me the feeling that it's very difficult for you to engage in these conversations and set these boundaries so you might be better served by splik's advice.

 

[robellis]

I don't recommend responding to such messages. Delete them. If someone calls you and you answer, just say you cannot get involved without a release of information and hang up. do not allow yourself to be triangulated.

Wow this seems pretty ballsy…patient family calls saying the patient is gonna kill him self..you then listen and delete the message..the patient then kills himself and you did nothing about it..the family has evidence they called you and you ignored them…hmm

 

[Bartelby]

My take has been:

1- if it seems like an emergency I tell them I cannot confirm or deny whether I am caring for anyone without a release, but they can tell me whatever they would like.

2- if not I let my patient know who called and discuss with the patient whether it is worthwhile to respond. If so I sign a release and let the collateral source know that I will discuss what we talk about openly with the patient.

If you do call back keep it brief and remember your call is solely to obtain information relevant to your patient's treatment. If you want to involve family in treatment as part of your treatment plan that is a different matter.

 

[comp1]

The OP did not say that the family is calling and saying the patient told them he/she is going to kill themselves or someone else. Families are rarely so direct in outpatient work. They usually want to vent and express their own frustration in living with or caring for someone with a mental illness. Of course if the family calls and is direct about threats, then your voicemail should literally say to take the person to the ED. Your voicemail should also clearly state that you can legally only return calls about patients to designees on signed releases. You might have some sort of obligation to return the phone call if they are leaving very direct messages just to repeat that they need to take the person to the ED or call the police (if you don't call the police yourself), but for your average venting voicemail, I think Splik's advice is pretty darn good. If the OP is feeling such strong emotions about this, there may be significant personality pathology issues at play in their panel (and more specifically the families of their panel) and I agree that triangulation is likely happening. Remember, first do no harm... If the OP really feels the need to engage with these family members, they should at least be recommending that the family member is in their own therapy focusing on the stresses they are experiencing and ideally not seeking free therapy via voicemail.

 

[NickNaylor]

Disclosing information that you receive suggestive of imminent dangerousness is a permissible disclosure under HIPAA. That said, I will often listen to information that families provide even without a consent, but I can also maintain that boundary pretty firmly. Something along the lines of "I cannot confirm or deny that that person is currently in this facility, but I am happy to take any information that you would like to provide in the event the person does arrive here." Many times, families are very well aware that the patient is in the facility I'm working in and get the gist of what I'm saying.

If you cannot maintain that boundary firmly, then I agree with what others have said as you may quickly get yourself into significant medicolegal liability. I also think things are different in the outpatient setting... I work exclusively in inpatient/ED settings, so situations are typically more acute and collateral is often critical, even if the patient does not consent to sharing information about the patient. I think you will struggle to make an argument that violating HIPAA or other privacy protections is appropriate in the outpatient setting unless there is something clearly awry, and what the OP describes doesn't fit that criterion IMO.

As an aside, my father has well-controlled bipolar disorder. I know who his psychiatrist is but I am otherwise not at all involved in his care. If something went off the rails, you bet I would be calling the psychiatrist's office and providing whatever pertinent information is necessary, and I would expect the psychiatrist to take that information even if there is no consent to speak with me about his care. Then again, I wouldn't be calling about non-acute issues.

 

[Evidence Based]

Mostly in agreement with folks above. I work with a lot of patients with SMI and if I never returned a call to a family member who was worried about decompensation, then I would be putting my patients in danger. HIPPA only governs what we disclose and not what others say to us, and there's a lot more flexibility about PHI disclosure if you have reasonable concern someone is in danger than some people think. The HHS HIPPA FAQ section is very helpful here: HIPAA FAQs for Professionals

For instance, on the question of whether an MD can disclose PHI to family or friends:
"Where a patient is not present or is incapacitated, a health care provider may share the patient’s information with family, friends, or others involved in the patient’s care or payment for care, as long as the health care provider determines, based on professional judgment, that doing so is in the best interests of the patient. Note that, when someone other than a friend or family member is involved, the health care provider must be reasonably sure that the patient asked the person to be involved in his or her care or payment for care."

Obviously this is different in an ED or inpatient setting where someone may be clearly incapacitated by florid psychosis or mania vs outpatient where things are not always as acute, and if someone has capacity but refuses contact with collateral, then you have to respect their wishes. However, HIPPA affords more leeway to professional judgment than is commonly understood.

 

[liquidshadow22]

Mostly in agreement with folks above. I work with a lot of patients with SMI and if I never returned a call to a family member who was worried about decompensation, then I would be putting my patients in danger. HIPPA only governs what we disclose and not what others say to us, and there's a lot more flexibility about PHI disclosure if you have reasonable concern someone is in danger than some people think. The HHS HIPPA FAQ section is very helpful here: HIPAA FAQs for Professionals

For instance, on the question of whether an MD can disclose PHI to family or friends:
"Where a patient is not present or is incapacitated, a health care provider may share the patient’s information with family, friends, or others involved in the patient’s care or payment for care, as long as the health care provider determines, based on professional judgment, that doing so is in the best interests of the patient. Note that, when someone other than a friend or family member is involved, the health care provider must be reasonably sure that the patient asked the person to be involved in his or her care or payment for care."

Obviously this is different in an ED or inpatient setting where someone may be clearly incapacitated by florid psychosis or mania vs outpatient where things are not always as acute, and if someone has capacity but refuses contact with collateral, then you have to respect their wishes. However, HIPPA affords more leeway to professional judgment than is commonly understood.

based on professional judgment, that doing so is in the best interests of the patient

In particular one piece of information I shared related to some information that was provided to me in the visit in which I was unsure if it was a paranoid ideation. I wanted to confirm with the family member to see if it was reality based. To me this was helpful, to determine if the patient was psychotic or not..

 

[clausewitz2]

For instance, on the question of whether an MD can disclose PHI to family or friends:
"Where a patient is not present or is incapacitated, a health care provider may share the patient’s information with family, friends, or others involved in the patient’s care or payment for care, as long as the health care provider determines, based on professional judgment, that doing so is in the best interests of the patient. Note that, when someone other than a friend or family member is involved, the health care provider must be reasonably sure that the patient asked the person to be involved in his or her care or payment for care."

I think it is really hard to argue that you were confident the patient was incapacitated or not able to make decisions about this if you don't make any attempt to contact them or speak with them before making the disclosures. Gotta satisfy the first clause before the second one is operative. If someone calls you up and says your patient Uncle Bob is talking about Soviet agents everywhere like he always does before he gets hospitalized, seems like you would have to make some attempt to determine whether Uncle Bob is okay with you talking to this person who claims to be their nephew before talking about the contents of your appointments.

I'll leave aside the idea that you can confirm someone is delusional by asking a single other person who may have their own interests at stake whether or not their belief is true for...another time.

 

[Evidence Based]

I think it is really hard to argue that you were confident the patient was incapacitated or not able to make decisions about this if you don't make any attempt to contact them or speak with them before making the disclosures. Gotta satisfy the first clause before the second one is operative. If someone calls you up and says your patient Uncle Bob is talking about Soviet agents everywhere like he always does before he gets hospitalized, seems like you would have to make some attempt to determine whether Uncle Bob is okay with you talking to this person who claims to be their nephew before talking about the contents of your appointments.

I'll leave aside the idea that you can confirm someone is delusional by asking a single other person who may have their own interests at stake whether or not their belief is true for...another time.

Right, certainly I would make a good faith effort to contact the patient in question before just sending the police to their house or revealing to Uncle Joe every medication trial they've ever been on or what the patient said to me in the last session.

However, if I can't reach the patient, I would certainly call family to ascertain more about the situation, and would not disclose any PHI aside from the fact that I am in my care (which they clearly already know if they're calling me) unless critically important to keep the patient safe (ex. it sounds like the patient has orofacial dystonia and is having trouble breathing, that the patient had called me and sounded really psychotic and wandering through the streets, etc).

But circling up to the question that prompted this thread, there's nothing in HIPAA to prevent us to "speaking with the family without the patient's consent," especially if there is no disclosure happening from our end. There's explicit guidance about what represents incapacity 2/2 mental illness where you do not need to obtain consent from a patient and can use the "best interests of the patient standard." To whit:

"This permission clearly applies where a patient is unconscious. However, there may be additional situations in which a health care provider believes, based on professional judgment, that the patient does not have the capacity to agree or object to the sharing of personal health information at a particular time and that sharing the information is in the best interests of the patient at that time. These may include circumstances in which a patient is suffering from temporary psychosis or is under the influence of drugs or alcohol. If, for example, the provider believes the patient cannot meaningfully agree or object to the sharing of the patient’s information with family, friends, or other persons involved in their care due to her current mental state, the provider is allowed to discuss the patient’s condition or treatment with a family member, if the provider believes it would be in the patient’s best interests. In making this determination about the patient’s best interests, the provider should take into account the patient’s prior expressed preferences regarding disclosures of their information, if any, as well as the circumstances of the current situation. Once the patient regains the capacity to make these choices for herself, the provider should offer the patient the opportunity to agree or object to any future sharing of her information."

2090-When does mental illness or another mental condition constitute incapacity under the Privacy Rule?

www.hhs.gov

I think there's probably some interesting hairs to be split here re: psychosis (what is "temporary" and a departure from patient's baseline vs a chronic psychosis where patient's baseline capacity is limited, and obviously a voicemail from a family member is very different than seeing a floridly manic patient in the ED. However, not all disclosures are the same- returning a voicemail and saying "Yes I'm your father's pscyhiatrist, what's going on?" is a minimal disclosure that would pretty easily clear the "best interests of the patient" standard if you have clinical concerns and are acting in good faith.

This is a bit of a hobbyhorse for me so forgive me for the prolonged response, there are just many myths on how HIPAA works that are largely driven by freaked out hospital lawyers (which still may affect our practice to be fair) not based on the law. For instance:
-Can hospitals disclose the location and general condition of a hospitalized patient for family and friends without a release? Yes unless patient has expressed preference against this: 483-Does HIPAA permit health care facilities to inform visitors about a patient’s location
-Is a written release needed to discuss the patient's care with family or friends? No (this is mostly a CYA thing for hospitals, verbal agreement is fine and per HIPPA does not even need to be documented). 525-Do I have to give my health care provider written permission to share my information
-Do you need a release or a patient's authorization to talk to the patient's other doctors about their care? No. 261-Are health care providers restricted from consulting with other providers about a patient’s condition without the patient’s written authorization

481-Does HIPAA permit health care providers to share information for treatment purposes without authorization

www.hhs.gov

Not forensically trained here so may be missing some subtleties of the law, but I think it's important to realize the circumstances under which the law frequently defers to our clinical judgment

 

[NickNaylor]

I’ve found that many outpatient docs are overly concerned about HIPAA protections to the point where it’s difficult to even talk with them about the care of their patients. I’ve had multiple cases where a community psychiatrist will send a patient to our hospital and then refuse to talk with me until I have the patient sign a ROI and fax it to them. Like wtf, you sent them here, obviously the patient is allowing me to talk to you by virtue of me giving me your name, and continuity of care is a permitted exception to HIPAA.

Utterly frustrating.

 

[hallowmann]

I’ve found that many outpatient docs are overly concerned about HIPAA protections to the point where it’s difficult to even talk with them about the care of their patients. I’ve had multiple cases where a community psychiatrist will send a patient to our hospital and then refuse to talk with me until I have the patient sign a ROI and fax it to them. Like wtf, you sent them here, obviously the patient is allowing me to talk to you by virtue of me giving me your name, and continuity of care is a permitted exception to HIPAA.

Utterly frustrating.

Well that's just stupid. Its literally the one situation in which no one would be worried about HIPAA violations. I wonder if its a hospital/clinic policy thing written up by management. Even then, I would struggle to abide by it in a case where HIPAA clearly doesn't apply.

 

[Stagg737]

Well that's just stupid. Its literally the one situation in which no one would be worried about HIPAA violations. I wonder if its a hospital/clinic policy thing written up by management. Even then, I would struggle to abide by it in a case where HIPAA clearly doesn't apply.

It's a policy at most of the places I've rotated through despite HIPAA's irrelevance to the subject. No med organization I've dealt with is willing to release info about the patient without their informed consent.

 

[hamstergang]

This is a bit of a hobbyhorse for me so forgive me for the prolonged response, there are just many myths on how HIPPA works

Then why do you keep spelling HIPAA incorrectly?

 

[NickNaylor]

Well that's just stupid. Its literally the one situation in which no one would be worried about HIPAA violations. I wonder if its a hospital/clinic policy thing written up by management. Even then, I would struggle to abide by it in a case where HIPAA clearly doesn't apply.

This would be unsurprising if this was occurring with docs working at Big Box shops, but these are docs working in solo private practices!

 

[Evidence Based]

Then why do you keep spelling HIPAA incorrectly?

FML I'll never be an attending now

 

[hallowmann]

It's a policy at most of the places I've rotated through despite HIPAA's irrelevance to the subject. No med organization I've dealt with is willing to release info about the patient without their informed consent.

It's one thing to release documents and records, it's another to have a conversation with the treating outpatient psychiatrist. You're telling me that beyond verbal consent you had to create a document signed by the patient before you could talk to an outpatient psychiatrist about their patient whom you were treating? Ridiculous. It actively discourages collaboration, which is very much not "patient-centered".

Talking to hospital legal, although "ideally" it's recommended to have a formal consent on file, it is not required in my institution in this type of situation. People here (other residents/attendings) incorrectly assume it's required, but it is not.

 

[whopper]

Over 95% of the time I've found the family's involvement very helpful, but this doesn't by any means deny the 4% that are extremely intrusive, inappropriate, and causing a problem for you and the patient.

1) Discuss with the patient and clarify how much involvement the patient (and perhaps you as the clinician) want with friends and family. In many cases the patient will welcome the family's involvement. Do not take any steps to put barriers between the family and the patient until you have reason to do so because you may alienate or make an enemy out of a potential and valuable treatment ally. Obviously have the patient sign a release form.
2) If the patient doesn't want the family/friends involved-still make no steps to alienate them. Again they could be invaluable later on down the road for you and the patient. From a purely seflish viewpoint should a bad outcome occur it's often times initiated by friends or family against the provider. Being on good terms with them can save your ass (if you are looking at it from only that viewpoint which if that's the case you're likely not good for this profession or any healing profession).
3) If the family/friend is attempting to talk to you, you are allowed to take information but not give it out. Tell the person to write a letter. I'd avoid communication on the phone or in person unless it's abrupt and with a very small time limit because they could try to draw information out of you and in a moment of weakness you might violate HIPAA.
4) If the friend/family member continues to try to communicate with you, keep it on the receiving end only, keep the patient up to date on what the friend/family member is doing, and you feel the friend/family member's involvement is not worth it write them a letter saying that due to HIPAA you recommend not communicating with them unless it's an emergency.
5) If you really want to take it a step further and the friend/family member is intrusive have a lawyer send the person a cease and desist letter. I've already retained a lawyer for this if need be.

 

[whopper]

Adding to the above I've had a few patient's family intrusively bother my office in a manner that was not helpful and that patient was clear he or she didn't want the family involved.

After literally hours of intrusive behavior I contacted my lawyer and he had a cease and desist letter written up with a plan of what to further do if the family member did not comply, that was very diplomatically written citing that the his client (me) is only trying to follow the HIPAA law, that continued communication of the type that was being done was disrupting my place of business, and that further requests for information is literally asking me to break the law and in doing so the family member is breaking the law. The letter was very carefully written to make it out as if it's about following the law and to only communicate with us if there's an emergency.

If the family member continued the persist the next step would be to start a restraining order, but it never went to that degree after the C&D letter. In another case the family member asking me to violate HIPAA was a physician himself so the lawyer said he could contact the state medical board, but the doctor in that case stopped the inappropriate communication.

 

[splik]

Wow this seems pretty ballsy…patient family calls saying the patient is gonna kill him self..you then listen and delete the message..the patient then kills himself and you did nothing about it..the family has evidence they called you and you ignored them…hmm

this is a fallacious scenario. No patient ever killed themself because a psychiatrist didn't return an unsolicited call from a family member who didn't have permission to contact said psychiatrist. We have no obligation to respond to such messages. every psychiatrist that I know has an "if this an emergency, please hang up and dial 911" on their voicemail.

because of the nature of my practice, I frequently talk to family members who are very involved in the care of the patient (and may be the primary contact point for me or the one paying the bills) as I see pts with TBI, neurodevelopmental disorders, dementia etc. But no good ever comes of communicating with random people who the patient has not chosen to involve in their care. when this happens, the person in question usually asks you not to say anything to the person or not to mention they were the ones who said anything. I don't see any good in getting involved in that. I really hate it when family members contact me without permission and expect me to collude with their nonsense (which for me seems to happen with patients I am seeing for weekly or more frequent psychotherapy and this has the potential to poison the relationship). The best way to respond is not to respond at all.

 

[clausewitz2]

because of the nature of my practice, I frequently talk to family members who are very involved in the care of the patient (and may be the primary contact point for me or the one paying the bills) as I see pts with TBI, neurodevelopmental disorders, dementia etc. But no good ever comes of communicating with random people who the patient has not chosen to involve in their care. when this happens, the person in question usually asks you not to say anything to the person or not to mention they were the ones who said anything. I don't see any good in getting involved in that. I really hate it when family members contact me without permission and expect me to collude with their nonsense (which for me seems to happen with patients I am seeing for weekly or more frequent psychotherapy and this has the potential to poison the relationship). The best way to respond is not to respond at all.

I'd wager the chances of someone in more than once a week therapy coming from a family background where all communication and ways of relating were totally healthy and unproblematic is close to nil.

 

[MedMan80]

My stance is that I'll be happy to take info without providing any, including saying "i can't confirm nor deny anything", IF there is a safety concern. I won't return the call if some vague reason for a call. I'm also sure to bring the matter up with the patient to have them confront the family member.

 

[erg923]

I'm not sure why this is so controversial here. lol. Geez!

Don't take calls from people you don't know directly. Have staff screen calls or your professional voicemail screen calls. They can/will leave a message if concerned/urgent. And even then, they are made aware of contact/resources for emergent safety issues if they are needed. If John Q. is a danger to himself or others they will say that. Follow up from there.

Taking calls from rando collateral for an adult outpatient without needing or asking for it is just infantilizing your patient and their care and/or asking for more headache (triangulation?) than you or the patient need.