General Clinical

1. Messaging through Tebra, Google Voice, Gmail are all HIPAA compliant and Google services are the most secure, therefore best for patient treatment via clinician-patient correspondence is to communicate through Google Voice or Gmail.

2. If a patient cancels two times or more without there being an affiliated emergency then the clinician should consider having the patient "step down" in their level of care to a less frequent schedule (twice a month, once a month), or remove the patient from their schedule until they have an availability. If a clinician decides to remove the patient from their schedule, the clinician will contact the patient to inform them and also let the patient know they will be notified when the clinician has an opening. These steps should be taken only if it is clinically safe and appropriate to do so.

3. A clinician is only beholden to wait ten minutes for a patient during a scheduled therapy session. While waiting the clinician should call and email the patient as well as notify their coordinator to contact the patient. Once the ten minutes has expired it is the clinician's prerogative whether or not they will wait longer or not.

4. If a clinician has tried to contact their patient three times using any combination of methods (phone, patient portal, email) the clinician should ask their coordinator to contact the patient. If the patient doesn't reply to the coordinator, the clinician can then discharge the patient by first documenting these steps and outcomes using a "Memo to Record" note in Tebra and then completing a discharge summary. 

5. If there is a cancellation the clinician needs to reschedule the patient for the same week. However, if this is not possible they should use their clinical judgment and if they have an availability they can reschedule the patient for the following week. It is important to note that, in order to meet weekly session minimums, a clinician can add a new patient intake. As long as it is clinically indicated and appropriate, the clinician can see this new patient once a month or two times every month until they have an availability one time per week (or as clinically indicated for that patient).

• Cancellation Policy:
  For cancellations made less than 72 hours (unless due to illness or an emergency) or a scheduled appointment that is completely missed and not rescheduled, the patient will be charged a $100 late cancellation fee. 

  • This policy above should be added to your Lucet Profile settings as well. 

• Clinical Boundaries  VS Cancellations
  -If the patient cannot attend every session (unless it is an emergency) then it clinically indicates that they can step down to every other week from being seen every week. Having this conversation with your patient is important because it also helps them with their own boundaries with their schedules.
  -When a patient says that they do not need a session due to personal issues or a holiday this is a clinical indication that they may need to step down to every other week and at that time you can add a new intake in their place (even if it's biweekly). The patient can cancel due to an emergency however, even in an emergency we can usually reschedule them within that week. This also helps us to hold the clinical boundary as well and process with the patient why they need to cancel their sessions and what the reason is they are cancelling. Our patients are only with us until they meet their goal and episode of care so we need to let them know that the appointments are important to attend every session due to a high volume of patients who are on the wait list and need to be seen ASAP. This help our patients understand the importance and value of the sessions and why it is important for them not to cancel their appointments. When we suggest to our patients that they may be able to step down to every other week or once a month they usually say that they do not want to this and are not ready to step down so they end up not wanting to cancel their session. This really helps with preventing cancellations. Also, you should let every patient know this information at the time of your first session so if they need to cancel or reschedule then they need to either email you in the patient portal or chat you by Google Voice which are both HIPAA compliant. This way you receive the message right away and can reschedule them. For a ligitimate cancellation you can add an Intake session into Lucet and complete an Intake only.

• Reminders
  -Remind your patients of the clinical boundaries and have a conversation with them because they may need to step down to every other week due to canceling appointments because this is showing that they are doing well enough to skip sessions.  It is important for clinicians to hold the clinical boundary with our patients regarding attending sessions every session.

• Rescheduling
  -It is easier to reschedule clients with online sessions because they can have the sessions anywhere such as in their car, etc. which makes it really convenient for them to have their sessions and not need to cancel. This is helpful for you and your patients to know so that they do not cancel their appointments anymore and you can meet your minimum sessions for the week.

• Making Up Sessions
  -To make up the cancellations from a previous week, for the next week and following weeks you will need to add 5-7 additional sessions in your calendar to make up for the deficit. This will ensure that you will be able to make up your deficit and meet you session minimums every week. Also, please let your PCC know that you need to make up sessions for a few weeks. You can add intakes into Lucet so that they are aware of what is going and can help you make up your deficit and meet your weekly minimum as well as add Patient Availabilities into your Tebra calendar to have transfer patients added to you calendar. 

• Preventing Cancellations
  -What helps to prevent cancellations is to call every current or new patient 1-3 days before or on the appointment day. With new intake patient you should contact and introduce yourself if confirm that they will be there beforehand. We've noticed this helps remind the patient that they session is scheduled because sometimes they forget that they had an appointment. After 3 months or so they attend every session or contact me to reschedule if necessary.

• Holidays
  -For upcoming holidays it’s best to start confirming with all of your patients 2-4 weeks in advance so that they will keep their appointment and if they need to reschedule their appointment during the holiday week then you can reschedule the appointment and also call to confirm that week so that they show up. 

Each clinician is required to partner with their coordinator to schedule their patients 2-4 weeks in advance, on all calendars including Tebra.  There are many reasons that we hold this requirement to schedule 2-4 weeks in advance.  One significant reason is to provide consistent patient care by adding recurring events on our calendars as well as reminders to patients that they are upcoming. Another is to allow our administration team to have ample time to set up each session for insurance verifications, intake documentation etc.  Finally, we are also required by Kaiser to maintain regular frequent appointments to current patients otherwise we are out of compliance. 

The only time a patient should be seen twice a week or more is for crisis stabilization.

A patient satisfaction survey will be sent to all patients seen in Tebra in order to provide good patient care as well as to meet necessary accreditation requirements.

Clinicians and coordinators need to review the Documents section in Tebra and make sure that all intake documents and screen assessments have been filled out and signed by the patient before the session is conducted. If the Intake Documents have not been submitted by the patient, then the Clinician must ensure that each intake documents are in the Documents section in Tebra, by either collecting the documents from the patient themselves or partnering with a coordinator.  These documents include but are not limited to:

• Informed Consent - Patients are required to resign a new Informed Consent 1 time a year, sent by clinicians).

  • The Kaiser Release of Information is located in the contents of each provider's Informed Consent. 

• Minor Custody Agreement - Along with all required custody agreement documents.

*Filling out and signing the intake documents are a clinical responsibility of the clinician. It is included as a part of the intake initial evaluation assessment that is needed in order to make sure that the clinical history has been gathered and any possible referrals needed have been provided to the patient. Clinicians must use the intake therapy session to help assist and ensure that their patients have received all of the intake documents necessary and have completed them all. The PCC’s are available to help assist the patients and clinicians to complete the necessary intake documents before the session. However, if the patient does not complete the intake forms before the first intake therapy session then it is the clinician’s responsibility to make sure that the forms are all completed, reviewed and any potential referrals are provided to the patient. The clinician can use the therapy session to assist the patient in completing the forms with the patient. 

• Treatment Plans must be created during the BPS for every patient. 

• Tx Plan Reviews are required to be completed every 6 months at a Minimum: 

  • The Progress Note includes a section at the bottom titled Treatment Plan which provides the abilty to create SMART Goals and update SMART Goals.  SMART Goals are the Treatment Plan and must contain a current value a goal value and a date that the patient is trying to attain the goal. Collaborate with your patients to create SMART Goals and Review your SMART Goals within 6 months to maintain your Treatment Plan. 

Notes are required to be signed within 24 hours. 

Quality Reviews are performed by Quality Assurance Reviewers randomly. Each chart review will be sent to the clinician being reviewed via email.  It is the responsibility of the clinician being reviewed to acknowledge and respond to the email being sent to them, so that there is confirmed receipt of the changes required. The clinician is required to review the material sent to them and incorporate feedback and necessary changes to improve the quality of the treatment and meet a baseline of expectations for treatment.  These are changes that are required by the insurance company we are in contract with, Forward Wellness and the Board of Behavioral Science for the state of California to prevent negligence.

When a patient is at high risk (in crisis and/or suicidal) we conduct the following: when a patient is in crisis then we increase contact with the them as needed, increasing to two sessions or more a week if appropriate, we conduct ongoing follow up and monitoring of the patient, conduct a suicide screen, follow up assessment at every session, review changes to risk and protective factors, and review and update the clients safety plan.

If a patient scores 3 or more on a Suicide Risk Screen the clinician is required to complete a Suicide Risk Assessment - Long note. This note is a more comprehensive assessment for evaluating suicide risk.  The note includes a standard Columbia Suicide Risk screen as well as other factors to have a more rounded understanding of patient's risks.  

1. Open a Release of Information note in Tebra

2. Click in the Release of Information section to reveal the "Template" button

3. Select the most recent ROI Template

4. Check off all the items with an asterisk (*) to ensure you have all the items included on the ROI note when the template populates

5. If one of the items on in the template list opens another menu, add in the appropriate information

6. Select the "Close" button on the template to populate the information into the note

7. Read the information populated and fill in all asterisked items: Clinician contact name, Clinician contact number, Clinician email, Name of person and/or agency to release or obtain information from, etc

8. Read the "Filing and Instructions for Staff" section on the bottom

9. Save and sign the note

10. Open the Release of Information note again (if you sign a note in Tebra, it will automatically close the note so you have to reopen it again)

11. Superbill or Capture Charge for the note: include the CPT code "00000 Release of Information"

12. Select the "Send to Billing" or "Submit to Biller" button

13. Select the "Actions" button on the upper right of the screen and select "Print" 

14. Download the document to your computer

15. Email the document to the patient for them to sign and email back to you

16. Once the patient signs the document and returns it to you, then upload the document into the "Documents" section of the patient's Tebra chart

17. Make a freeform note in Tebra called "Memo to Record" or update the patient's "Progress Note" to document that the Release of Information was completed 

When sending Records to any Patient:

• For Minors: In this case, we have the minor patient's consent for the clinician to release medical records or information to themselves or someone else.  The patient must sign the Release of Information (ROI) form in order for us to provide any records or information to the patient or anyone else.  Consent is given by a minor patient, who is anyone 12 years old or over, who can or could have consented to treatment. A minor who is able to consent to a release information, must sign an ROI before the clinician sends any information.

• For Adults and Minors: The clinician must ask the therapist if it is alright to send records and get an ROI signed first. If the clinician thinks that it would be detrimental to the patient or any other person/agency by providing records to them, by causing either harm to the patient therapeutic relationship and/or harm to the patient's psychological or physical wellbeing then this must be documented by the clinician and they must inform the patient to be aware of potential clinical detriment. 

A patient who's primary diagnosis is substance use diagnosis, then their treatment track is Substance Use Disorder (SUD). Patient's with a mental health diagnosis as their primary diagnosis are on the Mental Health Disorder (MH) treatment track.

We can diagnose for ADD/ADHD when the following apply:

We are familiar enough with the patient's symptoms and psychosocial history, and the patient does not need formal testing in order to diagnose.

In order for the patient to be formally tested for ADHD/ADD we must refer them to either their primary care physician or psychiatrist.

If a patient is an adult they must have been diagnosed with ADHD/ADD in childhood or we cannot give them that diagnosis.

If the patient is a minor, either their school psychologist, primary care physician or psychiatrist can test them.

The Ask Suicide-Screening Questions (ASQ) tool is a brief validated tool for use among both youth and adults. The Joint Commission approves the use of the ASQ for all ages. Additional materials to help with suicide risk screening implementation are available in The Ask Suicide-Screening Questions (ASQ) Toolkit, a free resource for use in medical settings (emergency department, inpatient medical/surgical units, outpatient clinics/primary care) that can help providers successfully identify individuals at risk for suicide. The ASQ toolkit consists of youth and adult versions as some of the materials take into account developmental considerations. The ASQ is a set of four screening questions. In an NIMH study, a “yes” response to one or more of the four questions identified 97% of youth (aged 10 to 21 years) at risk for suicide. Led by the NIMH, a multisite research study has now demonstrated that the ASQ is also a valid screening tool for adult medical patients. By enabling early identification and assessment of medical patients at high risk for suicide, the ASQ toolkit can play a key role in suicide prevention. SAFE-T Pocket Card: Suicide Assessment Five-Step Evaluation and Triage for Clinicians This resource gives a brief overview on conducting a suicide screen.

Providers have access to the Forward Wellness letterhead however providers need to email the Program Director at Info@forwardwellness.org for approval to use it before they do so.  Also a Release of Information is required to be completed, signed by the patient and a final signed copy uploaded to the patient's chart in the EHR, before sending out a letter.
***Link to Letterhead Template***

There is a Release of Information note available in Tebra to be customized at any time.  There is a requirement to have an ROI signed by patients in order to see any Kaiser patient.  It is also legally required for the patient to fill out an ROI in order to have a collateral session.

Clinicians will be provided a template copy of the Emotional Support Animal (ESA) letter. The following are things to know before completing and sending and ESA letter.

1. Ask yourself if you have any formal training, education, and experience on the subject matter to offer a professional opinion or knowledge on this subject that will benefit the patient. For example, "Based on my professional opinion, the patient may have some kind of emotional condition that impacts their daily life, and their animal/animals help them function much better and feel more safe.

2. Most clinicians do not feel that they meet this criteria to write an ESA letter, so in this case, they should inform their patient that they cannot write the letter because they fail to meet the necessary criteria.

3. I have added the following sentence to this ESA letter template, which highlights that the clinician is not responsible for the animal's or animals' behavior. “This letter represents nothing about the overall safety or appropriateness of the animal in any setting.” 

4. Ask yourself, does the presence of the animal(s) help ease the patient's distress, anxiety, loneliness, etc.? If this is the case, there may be rationale for drafting an ESA letter as clinically indicated, ex: due to loss of job, family issues, MDD disorder, etc..

5. If the emotional support animal described in the letter is a dog the clinician must have had a client/provider relationship for at least 30 days before the clinician can consider writing a letter. Though, if the patient is verified to be homeless no established clinician/patient relationship is necessary.  The word "dog" must be used in the letter at least one time to indicate that the animal(s) is a dog.

6. If the animal is not a dog, then the patient does not have to be an established patient for at least 30 days.

7. Keep in mind what the patient needs to be addressed in the letter so that their requirements are being met. For example, is the patient's landlord/school/workplace asking for the number, types and sizes of the pets? If so, add this information into the letter. This will help ensure that the clinician only needs to write one letter without any future edits or additions.

***Link to to the ESA Letter and checklist instructions: LINK ***

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