Navigating the intersection of psychiatric care and physical health is an increasingly important skill for physician associates (PAs) in every field. There’s an immense need for more mental health care support in the United States, and PAs are trained to support all patient care needs. “PAs are well-suited to provide psychiatric care for patients because our training promotes an integrated approach to care delivery, which is what current research recommends is needed to improve mental health and substance use outcomes,” says Chris Cannell, DMSc, MPAS, PA-C, DFAAPA
Mental health care carries a significant overlap for PAs in all areas of medicine, particularly in primary care and emergency medicine, but it even applies to specialty practices. Dr. Cannell works in emergency medicine and orthopedics and says mental health is a factor in patient management and decision-making in both areas of medicine he practices.
For example, when a dementia patient has a hip fracture, they’ll need support for follow-up treatment. “A patient’s psychiatric condition impacts your treatment protocols and managing that patient, so it’s important for you to understand the full picture,” says Dr. Cannell.
In healthcare today, PAs must balance patients’ mental health needs together with their overall health while also protecting themselves from potential legal and professional risks. Dr. Cannell works as an administrator, clinician, educator, medical legal and healthcare consultant as well as an expert witness for PAs and NPs, explains the reality of practicing medicine as a PA and how to support patients’ mental health needs while mitigating associated risks.
The overlap of mental health and physical health
In emergency medicine or urgent care, many visits involve patients with limited access to the healthcare system in general, especially mental health and psychiatric care. Patients are sometimes unhoused and struggle with substance use disorders, making mental health a pervasive concern in their treatment.
Patient care as a PA doesn’t always include such apparent examples of mental health needs, but more patients, in general, are struggling with mental health. Over one in five American adults experience some type of mental illness each year, according to the National Alliance on Mental Illness (NAMI). Of those, 5% experience a more serious mental health concern.
Despite the increased need for mental health care in the U.S., access to psychiatric care remains a significant treatment barrier. Many mental health providers opt out of insurance networks due to administrative burdens and compensation issues. Those who do accept insurance often have long waitlists.
Mental health needs often go untreated, which puts every PA in a position of needing to consider mental health care in patient management. “The ER is the downstream effect of a broken system, so we have to have the infrastructure to support crisis intervention,” says Dr. Cannell.
When Dr. Cannell did his PA training over two decades ago, mental health was not given the same priority as physical health conditions like diabetes or heart disease. The medical field, in general, has increased awareness that mental health is health, especially since the pandemic.
PAs graduating today receive more mental health care training, and seasoned PAs participate in more continuing education programming to meet patients’ growing mental health care needs. Mandatory training and protocols for handling substance use disorders and psychiatric emergencies are becoming more common in institutions.
Risk management strategies for mental health care as a PA
With the additional mental health care that many PAs are treating comes more risk. Dr. Cannell offers risk mitigation strategies based on his work in emergency care and orthopedics and as a consultant to other PA practices.
Reconciling charts and comprehensive documentation
One of the most critical risk mitigation strategies is to reconcile patients’ medical charts so that you’re aware of their medical history and any current medications. Then, be sure to maintain thorough and accurate documentation. Detailed records should include timestamps, discussions with colleagues, patient understanding, decision-making capacity, treatment options and the chosen plan’s rationale. Using electronic medical records (EMRs) effectively, such as the Epic system’s Care Everywhere function, allows PAs to access and reconcile patient information from various sources, enhancing patient safety and care continuity.
This requires enough time spent on patient visits, which can be limited in many healthcare organizations. “Negotiate adequate time to see patients safely to allow for appropriate documentation, consultation with physician colleagues and to generate adequate and safe plans,” says Dr. Cannell.
Preventing risks:
Ensure your documentation entries are precise and comprehensive. Missing details can be construed as negligence. Include timestamps, people you spoke to and note any changes in condition or unusual vitals. Click here to read Dr. Cannell’s checklist on documentation.
Informed consent
It’s paramount to clearly explain any treatment protocol and ensure the patient understands it. This includes obtaining informed consent. Proper documentation of providing informed consent can protect providers from legal repercussions.
“Many of the medications used in psychiatric care may contribute to undesirable side effects that has to be weighed with the risks of not being on the medications,” says Dr. Cannell.
Preventing risks:
Document fully that you explained a treatment protocol and that the patient understood. When a patient is not fully capable of understanding and following through on treatment, coordinate with family members or caretakers and document this, too.
Managing polypharmacy
Polypharmacy is a significant concern, especially when psychiatric medications are involved. Patients with psychiatric disorders often have comorbid conditions requiring multiple medications. This means different providers may prescribe medications without full awareness of a patient’s existing prescriptions. Meanwhile, patients may request additional medicines based on their research, experience or interests.
“Patients often present with complex polypharmacy concerns and at times unrealistic expectations of their treatment trajectory,” says Marc McManus PA-C, PsyD, a psychiatric PA.
Preventing risks:
Collaborate with a pharma technician to carefully reconcile medications for patient safety and mitigate risks. Pharma techs can access prescriptions not included in a patient’s EMR.
Suicidality risks
Suicidality is a significant area of medical malpractice risk for PAs working in psychiatric care, emergency care or urgent care settings –– especially when it comes to discharge decisions. PAs must assess whether a patient meets the criteria for possibly requiring hospitalization by using a suicide assessment tool and then following standards of practice to determine if a patient is at risk of suicide or if they are having chronic passive thoughts. “These patients cannot legally leave the hospital until evaluated, which sometimes involves restraints and chemical sedation due to aggressive responses directed toward staff, leading to safety events,” says Dr. Cannell.
The most common cause of malpractice complaints against psychiatric providers is suicide or a suicide attempt, says Michael Asbach DMSc, PA-C. “It’s critical that psychiatrists properly document care provided, including lethality assessments,” he says.
Preventing risks:
Suicide risk is a significant liability in lawsuits against PAs. Mitigate risks by including others in decision-making, staying within the scope of practice, following standard protocols, using evidence-based assessment tools and documenting the decision-making process.
Privacy and access to records
Privacy is critical to adhering to HIPAA laws. However, limited access to a patient’s full medical history can lead to safety concerns and impact patient care and management. Ensuring compliance with privacy regulations while maintaining comprehensive patient records is vital for patient care and legal protection. Privacy concerns have crossover implications with informed consent, suicidality, polypharmacy, and other areas of patient care. All of them are top concerns for litigation.
Preventing risks:
EMRs often include safeguards like the “break the glass” feature, where you must document your access to a patient’s chart. This demonstrates your effort to access the necessary health history. When you need access to records, ensure you have HIPAA-compliant signed permission from the patient.
For PAs, managing psychiatric issues in their practice involves navigating a complex landscape where mental health often intersects with physical health. By adhering to rigorous documentation practices, obtaining informed consent, managing polypharmacy and staying updated through continuing education, PAs can protect patients while minimizing risk.
If something adverse occurs, professional liability insurance for PAs includes malpractice coverage for all methods of patient care delivery, including telemedicine/telehealth services, as long as they are within the scope of practice according to relevant laws.
