Posted By Sandy Rose,
Thursday, December 8, 2011
| Comments (2)
accuse me of being a closet-lawyer-wanna-be. I vehemently deny these
charges. My obsession over ethics statutes has far more to do with my
anxiety disorder than any career ambition (although Lord knows, I
certainly would not mind the money).
one who transitioned from specialty care to a fully integrated FQHC
setting, I was bound to get nervous in uncharted waters. It was not the
role change or frantic pace that got me going. It was confusion: How
could I integrate into a medical world that was held to different
ethical standards and licensing laws? No medical colleague I ever knew
was required to provide the specific language for informed consent
prior to starting treatment that is mandated in our licensing law. In
NH, we have very specific language, amounting to pages of information,
which licensed psychologists must provide prior to mental health
treatment, in addition to informed consent requirements that apply to
all health workers. Nor did my medical colleagues appear to do much
beyond securing the HIPAA general consents for release of PHI prior to
collaborating outside the practice: They routinely picked up the phone
and talked with their colleagues using only general releases. Unlike
HIPAA’s provision for exchange of information for health purposes, the
ethical standards for mental health providers require specific releases
rather than general consents before communication to external providers.
get me wrong: I harbor no masochistic tendencies and do not relish
the response of the medical records and front end staff faced with endless releases and four page consents that were so (relatively) easy at
my former specialty practice site. Most importantly, I would not be
here at an FQHC if I did not wholeheartedly believe in the need for
full access to my records by the primary care providers and operational
efficiency of my center. I also know that our viability as a profession
requires us to be on par with the healthcare providers in optimizing
efficiency and accessibility of our practice. I just wasn’t sure that
the laws and ethics caught up to this need. If I did "behavioral
intervention” vs. "mental health” care, how much do I have to comply
with my state laws and regulations intended for "mental health
practice?” How much is "enough” informed consent for a warm handoff? Do
behavioral interventions, even if billed using H&B codes vs. the
CPT therapy codes, make me immune from having to provide full informed
consent as mandated by my state licensing law? Do patients expect more
privacy from us, and does this set us apart from our medical colleagues
in all the above? Am I a covered "program” under 42CFR Part 2 because I
diagnose and treat alcohol and drug problems in the health center, but
do not "hold myself out” as a specialist?
out that I found little clarity or even discussion of these topics in the
integration literature. And, not many really wanted to talk much about
this either. I used to take the unanswered emails personally, but have
since concluded that few like to talk about something so messy. Go
figure. It was also clear that there were different approaches to this
vacuum--As one successful administrator responded, "It is better to
ask forgiveness than permission” when practicing in areas of ambiguity.
Alternatively, one could simply stick one’s head in the sand until
policy, at least in my state, catches up with integration.
there were others confused just like me, and we bonded over our drinks
and questions at last year’s CFHA conference. These colleagues (Cathy
Hudgins, Pete Fifeld, and Steve Arnault) came from various aspects of
integrated care—education, service provision and administration. We
decided to see what we could learn collectively through a systematic
course of study, from all our perspectives. Our goal was to develop a
research base to guide practice relating to informed consent and
confidentiality in integrated settings: Our plan of attack was as
presented a manic overview of our findings at a 20 minute presentation
at last month’s CFHA conference in Philadelphia. We are preparing a
full report of our findings and analysis for an upcoming article on
this topic. It will include a compilation of state and federal laws
impacting confidentiality and informed consent for comparison and
analysis. We have been most interested in how these laws and
regulations are different for BH providers than for medical providers,
and what this means for integration. Can we truly have one informed
consent that covers all disciplines, and are there differences in the regulations (rather
than theory) that set us apart when it comes to chart entries? We have
drafted a "best practices” protocol based on our findings and will
include this in our discussion next week in part 2 of What A Conundrum: Confidentiality And Integrated Care.
all the federal and state statutes, regulations, and
discipline-specific ethical guidelines for psychological interventions
that we could find on informed consent and confidentiality for
behavioral health service provision.
key national agencies and stake-holders including the National Council,
NACHC, LAC, SAMHSA for guidance and interpretation of ambiguous laws.
- Survey the literature (books, articles), provider list serves, and practice manuals to identify patterns of practice.
- Consult with lawyers we knew who could assist in interpretation of any remaining ambiguities.
|Sandy Rose is a psychologist and Director of Behavioral Health for Goodwin Community Health, an FQHC in the Seacoast area of NH. She is past president of the New Hampshire Psychological Association and served two terms on the Council of Representatives of the American Psychological Association. She is currently a Psychology Advisory Member of the New Hampshire Board of Mental Health Practice.|
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