Guidance for Dismissing Patients from Primary Care Practice

Guidance for Dismissing Patients from Primary Care Practice

Guidance for Dismissing Patients from Primary Care Practice

Relating to Chronic Pain and Opioid Use

Please note UCHa has no formal policy related to dismissing patients specifically related to chronic pain or opioid use/abuse. What follows is guidance to assist providers who are considering dismissing a patient from their practice.

  1. Introduction:

Many possible reasons exist fordismissing a patient from primary care, none of which should be taken lightly. Consequences of dismissal can be severe for patients on opioids, including withdrawal, self-treating with heroin, overdose, death, and/or suicide. Unless a patient is clearly engaged in criminal activity or violent/threatening behavior, a differential diagnosis for observed aberrant behavior should be explored carefully. In all cases careful specific documentation should be made in the medical record to describe relevant behaviors, their differential diagnosis and evaluation, and relevant communications with patients.

  1. Potential reasons for dismissal:
  2. Habitual low-to-moderate riskaberrancies/violations of the patient agreement, including:
  3. Lost or stolen prescriptions
  4. Unauthorized dose escalation
  5. Appointment cancellations/no shows
  6. Early refill requests or asking to replace a visit with a refill
  7. Using opioids for reasons other than pain (sleep, anxiety, etc)
  8. Unexplainable urine drug testing results
  9. Soliciting opioids from other prescribers, including unauthorized ER visits
  10. One or more instances of high-riskaberrancies/violations of the patient agreement, including:
  11. Prescription forgery
  12. Drug diversion
  13. Altering route of administration (e.g. Injecting oral formulations)
  14. Non-iatrogenic overdose
  15. Violent/threatening behavior
  16. Unwillingness to participate in care plan or maintain a therapeutic alliance
  1. Colorado State Medical Board Policy:

Colorado State Medical Board policy for any dismissal must be followed:

“Policy: It is the policy of the Colorado Medical Board (“Board”) that the proper discharge of a patient from a provider’s practice includes the following elements:

  • The discharge is done in writing, via delivery that confirms receipt to the patient, such ascertified mail or hand-delivery.
  • In the discharge letter the provider agrees to provide 15-30 days of emergencycoverage while the patient obtains a new provider.
  • If possible, the provider provides referral information to the patient regarding possiblenew providers.
  • Notification in the letter to the patient that patient records will be sent to the newprovider upon receipt of written authorization from the patient.”
  1. LEGAL / RISK MANAGEMENT CONSIDERATIONS IN ADDITION TO BOARD POLICY:
  2. Toavoid charges of medical abandonment, discrimination, civil rights or Americans with Disability Act violations, etc., dismissals must be non-discriminatory and should not jeopardize patient well-being.
  3. If appropriate, dismissals should include referral to addiction therapy as well as new primary care practices if not already done.
  4. Typically dismissal from a UCH primary care practice means dismissal from all our primary care practices. This is now considered a “qualifying life event” for patients on the CU Health Plan, so they may change insurance prior to open enrollment.
  5. Exceptions exist for threatening/violentbehavior
  6. ANY DISMISSAL ACTIVITY MUST GO THROUGH RISK MANAGEMENT. If you are considering a patient dismissal call the risk management office at 303-724-7475 (“4-RISK”)
  1. OPERATIONAL GUIDELINES:

The following is operational guidance from existing UCHa termination guidelines related to habitual cancellations/no-shows. Please follow this guidance for any patient dismissal.

  1. “If discharge is agreed upon, the patient will be sent/given a termination letter…This letter will be generated via EPIC, and must be signed by the Provider and Practice Manager with a copy to the Practice Director. These should be sent as certified mail, return receipt requested, restricted delivery in compliance with HIPAA.”
  2. “If the patient refuses the certified letter:
  • Document the patient’s refusal to accept the certified letter in Epic.
  • Scan and keep a copy of the unaccepted letter, including the return receipt.
  • Forward the actual unaccepted letter including the return receipt to HIM for inclusion in the patient’s hard copy record.
  • Make a copy of the letter. Resend the copy to the patient in a plain envelope with no practice identifiers. (Note this in Epic.)”
  1. “Please Note: If a patient is terminated from one primary care practice, then the patient is considered to be terminated from all of the UCH primary care practices”
  2. “When a patient is terminated from a practice the following steps must be completed in EPIC:
  3. FYI tab:
  4. EPIC > Appts > Patient Options > Patient FYI > Flag Type, select “Discharged from Practice”> Accept > Enter in comments section “patients discharged from xxxx practice(s) effective xxxxdate > Accept
  5. Dismiss Patient tab:
  6. EPIC > Appts > Patient Options > Dismiss Patient > Dismiss by Center, Enter service (Primary Care) and/or Department, enter individual department as appropriate > Reason, select from drop down list > > Date of Dismissal, enter effective date (30 days after letter is sent to the patient) > Accept
  7. If it is a discharge from a UCH PCP:
  8. EPIC > Appts > Patient Options > PCP/Care Teams > Delete PCP name
  1. SAMPLE DISMISSAL LETTER

Below is a sample dismissal letter. It can be altered slightly as needed to meet underlying circumstances, such as whether the 30 day requirement is waved due to threatening behavior, whether refills will be provided during this time, whether addiction referral is appropriate in addition to a PCP referral, etc.

Sample Primary Care Practice Termination Letter

Send certified mail, return receipt requested

Date

Patient Info

Dear Mr/Ms. xxxx,

Your primary care provider has determined that we can no longer continue to be your health care provider.

This dismissal applies to all of the University of Colorado Hospital Primary Care Practices including:

  • University Internal Medicine at Lowry
  • University Internal Medicine at Anschutz
  • University Family Medicine - A.F. Williams
  • University Family Medicine at Boulder
  • University Family Medicine at Westminster
  • Women’s Integrated Services in Health (WISH)
  • University Family and Internal Medicine at Lone Tree Health Center
  • Seniors Clinic

This termination does not apply to any UCH specialty practices where you may be a patient.

You will need to identify and establish care with a new Primary Care provider. Please contact your insurance plan or your local medical society for the names of other providers who can assume your care.

During this transition, we will continue to provide care for the next 30 days. We will not be able to continue prescriptions renewals or refills if you do not establish with a new provider.

Attached is a summary explaining your medical condition, your current treatment plan, and recommendations for follow-up care. In the event of an emergency medical situation, you should go to the nearest emergency room to receive care.

We will forward your medical records to your new provider when we receive written authorization from them. Please contact Medical Records at 720-848-1031 for questions about this process.

Sincerely,

xxxxxxx, MDxxxxxxxxx

Practice Manager

cc: Vice President, Ambulatory Services

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