Care Coordination and the Patient Centered Medical Home Neighborhood page 3. Counsel s Corner page 4

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1 Issue 6 September 2015 Nevada Issue O Care Coordination and the Patient Centered Medical Home Neighborhood page 3 Counsel s Corner page 4 Case History: Documentation Issues Complicate the Defense of a Lawsuit page 6 PROVIDING MEDICAL PROFESSIONAL LIABILITY INSURANCE IN ARIZONA, COLORADO, NEVADA AND UTAH

2 About us Our mission is to protect and defend the practice of medicine in Arizona, Colorado, Nevada and Utah. Executive Staff: James F. Carland, III, M.D. President & Chief Executive Officer Ronald E. Malpiedi, Vice President & Chief Operating Offi cer Edward G. Marley, MBA, Vice President & Chief Financial Offi cer Darren J. Palmer, Vice President & Chief Information Officer Robin L. Charles, MBA, CIC Vice President, Marketing & Corporate Communication Walt Davis, Vice President, Claims Mary K. Hedin, MBA, RPLU, Vice President, Underwriting Leon W. Kochan, M.C.Ed, Vice President, Human Resources Julie A. Ritzman, MBA, Vice President, Risk Management Service Board of Trustees: James F. Carland, III, M.D., Chairman Marc L. Leib, M.D., Vice Chairman Joseph W. Hanss, Jr., M.D., Secretary Douglas P. Jensen, M.D., Treasurer Phyllis I. Biedess James G. Leiferman, M.D. Steven P. Matteucci, J.D. Jeffrey W. Morgan, D.O. Karen J. Nichols, D.O. David A. Pedersen, M.D. J. Greg Rula, M.D. Amy A. Silverthorn, M.D. Walter K. Sosey, M.D. Charles W. Swetnam, M.D. Michael A. Trainor, D.O. MICA was founded in 1976 after the largest medical professional liability (MPL) insurance carrier announced it was no longer underwriting MPL insurance coverage for the physicians of Arizona. MICA offers stability through the peaks and valleys of the insurance cycle. Our mission is to protect and defend the practice of medicine in Arizona, Colorado, Nevada and Utah. Our vision is to be the insurance company of choice for physicians and their groups, medical facilities and nurse practitioners. Our values include outstanding service to our members, affordable insurance coverage, prudent underwriting principles, relevant risk management programs to educate and protect our members, aggressive defense against claims, and paying dividends to our members when fi nancial conditions warrant. In fact, over the past ten years, we have paid $337 million in dividends to our members*. * Dividends declared in a given policy year refl ect the Company s fi nancial performance during that year. Past performance does not guarantee future dividends. 2 MICA Risk Rundown November MICA Risk Rundown September 2015

3 Care Coordination and the Patient- Centered Medical Home Neighborhood M ost patients and families have no understanding of the complexities involved in the coordination of care across a fragmented healthcare delivery system until they are left to navigate the system on their own. All too often the responsibility for conveying information is shifted to patients or their families as they transition from physician to physician or from out-patient to in-patient care. The Patient-Centered Medical Home (PCMH) model conceptualizes the delivery of comprehensive, coordinated care that places greater emphasis on the needs of the patient. The PCMH model expands the role of the primary care clinician (PCC), physician, nurse practitioner or physician assistant, to include coordination of care and managing the flow of information across and between healthcare practitioners, institutions, community resources, families and patients. Considering that many patients have multiple complex encounters during the diagnosis and management of their health needs, it is unrealistic to believe the coordination of care and communication can be managed solely by the PCC. The PCMH will only reach its true potential when it functions in the broader context of the medical neighborhood. The concept of the Patient-Centered Medical Home Neighborhood (PCMH-N) recognizes the range of specialists, hospitals, ancillary professionals and others who provide episodic care to patients. The PCMH-N requires basic communication and coordination functions to ensure patients transitions across the healthcare continuum are timely, appropriate and safe. The involvement of stakeholders, such as specialists, hospitals, out-patient facilities, home health agencies and health plans, is fundamental for establishing and maintaining an effective neighborhood. For example: PCCs need to make appropriate referrals and provide background information, clinical data and expected goals for the referral. Specialists need to communicate to the PCC what routine care the patient will need following a surgery or course of treatment. Hospitals need to communicate with the primary care team when their patients are hospitalized or have visited the emergency department. Community organizations and social services are important, especially for low income, frail or elderly patients. Ideally, patients with complex medical conditions would have an opportunity to partner with community resources through the PCMH-N to support their clinical and nonclinical needs, such as personal care services, accessible transportation and home-delivered meals. This suggests that PCCs will recognize the mix of patients in the PCMH, know about the resources available in the patient s community and make appropriate referrals. Primary care teams with case managers or social workers are better able to assist with these types of referrals. Unfortunately, very few primary care teams include these members. Coordination Continued on page 6 September 2015 MICA Risk Rundown 3

4 Counsel s Corner QI was recently on an airplane flight and the attendants asked if there was a physician on board to assist a passenger in distress. I was hesitant to respond for fear of being sued if the person had a bad outcome. Do I have to respond? If I do respond, do I have a potential legal liability? A In this situation, assuming that the fl ight is over American airspace, there is likely no duty for an off-duty physician or healthcare professional to respond to the emergency; international fl ights, however, are subject to the laws of the country of origin for the fl ight, resulting in widely-differing obligations. In the event that a healthcare professional chooses to respond to a medical emergency on board a fl ight, the Good Samaritan laws in effect likely shield that professional from liability relating to that response. A physician without a pre-existing duty can expect to be provided immunity from liability in the event that he or she does respond in good faith and gets sued because of a bad outcome. In the United States, there is no defi ned federal burden that requires a physician or other healthcare professional to render aid in the event of a medical emergency on board an airplane. Though a number of states have enacted laws purportedly requiring citizens to assist strangers in peril (including Florida, Ohio, Massachusetts, Rhode Island, and Vermont), these laws are not generally or broadly enforced. The safe assumption is that, at least within the United States, there is no affirmative obligation to respond to a medical emergency on board an airplane. Healthcare professionals should check the relevant laws and regulations of the appropriate country if they choose to fl y internationally and want the most accurate information concerning the different obligations. However, if a healthcare professional opts to render aid in an emergency, they are likely shielded from liability for their aid. In 1998, the Aviation Medical Assistance Act of 1998 established that [a]n individual shall not be liable 4 MICA Risk Rundown September 2015

5 JUSTIN SHIROFF, ESQ. Law Offices of Snell & Wilmer for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-fl ight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct. 1 Given the considerably higher threshold for fi nding gross negligence, it is unlikely that a medical professional using their best judgment in an emergency situation would be held liable for that care. That does not, however, mean that they couldn t be named in a lawsuit merely that any lawsuit brought under those terms would likely be unsuccessful (at least against the healthcare professional). The fear of being subjected to litigation may be a powerful deterrent to a health care professional responding in an emergency situation on board an airplane. Though there is likely no formal obligation to respond, a medical professional who chooses to exercise his or her professional skill and training is likely shielded from liability for that intervention. Justin A. Shiroff Snell & Wilmer L.L.P. Hughes Center 3883 Howard Hughes Parkway Suite 1100 Las Vegas, NV Office: jshiroff@swlaw.com 1 The Aviation Medical Assistance Act of Pub. L , 49 U.S.C : Apr. 24, Federal Register: April 12, 2001 (Vol. 66, No. 71). September 2015 MICA Risk Rundown 5

6 Coordination Continued from page 4 The PCMH-N has the potential to improve patient outcomes, patient satisfaction and the safe delivery of care. However, there remain barriers to the development of a highly functioning PCMH-N which include lack of financial incentives, lack of staff and time for coordination of care and limited IT infrastructure to facilitate quality measurement and performance reporting. These barriers may be mitigated with the following: Develop written operating procedures which delineate who will perform specific coordination of care tasks. This requires the primary care team to discuss and agree on how to handle key components of coordination, such as referrals or diagnostic testing. This will help improve efficiency by reducing confusion within the office, promoting appropriate delegation of tasks and identifying essential roles that need to be filled. Refer patients to specialists who are good neighbors. This refers to specialists who actively coordinate and collaborate with the PCMH. This includes timely access, communication with patients and better coordination of care with the PCC. Establish care coordination agreements that formalize how the clinicians will work together. In 2010, the American College of Physicians proposed the following principles for developing care coordination agreements: define the types of referral, consultation and co-management arrangement available, specify who is accountable for which processes and outcomes of care, address how secondary referrals will be handled, and regular review of the agreement s effectiveness. Collaborate with hospitals to routinely: inform the PCC when a patient has been hospitalized, notify the PCC when patient is discharged, and provide copies of discharge status and plans, including discharge medication instructions. Educate patients regarding the medical neighborhood and how connections with neighbors allow PCCs to provide more comprehensive and informed care. Case History Documentation Issues Complicate the Defense of a Lawsuit A healthy 59 year old male underwent a laparoscopic sigmoid colon resection for diverticulosis. Six days post-operatively the patient experienced a temperature spike, increasing abdominal pain and distension. A CBC with manual differential and CT scan with contrast were ordered. The surgeon saw the patient later in the day, but did not document the visit. The laboratory results indicated a left shift and the CT scan was interpreted as showing extensive free air anteriorly in the abdomen, greater than to be expected five days post-op. Later that evening a nurse called the surgeon with an update on the patient s condition. Early the next morning the surgeon evaluated the patient and scheduled the OR for a re-exploration later in the day. The patient was transferred to ICU and antibiotics administered. Surgery was performed and a three mm opening in the surgical anastomosis was found, but the opening had been walled off by the omentum overlapping the perforation. The anastomosis was repaired and a temporary colostomy created. The patient experienced a prolonged recovery spending two months in the hospital and three months in a rehabilitation facility. Complications of his recovery included acute renal failure, sepsis, abscesses and fistulas, and three additional major abdominal surgeries. The patient and his wife filed a lawsuit naming the hospital, surgeon, and several other consultants involved in the patient s care. The allegation against the surgeon was negligent sigmoid colon resection resulting in a 6 MICA Risk Rundown September 2015

7 ˮ Consistently review dictated notes to ensure accuracy and completeness of the record. ˮ breakdown of the anastomosis and failure to timely follow up on the patient s deteriorating condition. The lawsuit against the surgeon was settled before trial in the mid-six-figure range. Problems with this case An error in the operative report resulted in the surgeon contradicting his own documentation. Following the second surgery, the surgeon s dictation stated stool was found in the pelvis. However, the surgeon testified there was no stool in the pelvis because the leak was walled off by the omentum. The medical record is often referred to as the best witness for the defense because it is written contemporaneously with the event, at a time when the author s memory is fresh. An uncorrected error can have significant consequences for the patient s care and treatment, as well as destroying the credibility of the medical record and placing the defendant in the position of discrediting his own documentation. In this case, the plaintiffs alleged the surgeon did not timely respond to the patient s deteriorating condition. The surgeon did not document his second visit the day before the patient was returned to surgery. Additionally, the nurse s phone call to report on the patient s condition was not documented and her recollection of the details she provided varied substantially from the surgeon s recollection of the information he received. These gaps in the record provided the plaintiff s attorney with an opportunity to argue the surgeon was not adequately monitoring the patient s progress. Discussion An anastomotic leak is a recognized complication of this type of colon surgery and can occur absent any negligence. Timely recognition of the complication and appropriate steps to treat the patient are critical to ensure an optimal outcome. Careful documentation of the details of the patient s deteriorating condition, the sequence of events, and the communication among the caregivers provides a clear picture of the care rendered to the patient. To improve patient outcomes and minimize your liability risk, consider the following risk management strategies. Consistently review dictated notes to ensure accuracy and completeness of the record. Telephone conversations with other members of the healthcare team should be documented, especially when information is shared regarding the patient s condition or additional orders are provided. Document in the hospital record when patients are seen or diagnostic results are reviewed. September 2015 MICA Risk Rundown 7

8 2602 E Thomas Rd Phoenix, AZ PRSRT STD U.S. POSTAGE PAID SALT LAKE CITY, UT PERMIT NO Mutual Insurance Company of Arizona The information contained in this publication is intended to provide general information for review and consideration. The contents do not constitute legal advice and should not be relied on as such. If you need legal advice or assistance, it is strongly recommended that you contact an attorney as to your specifi c circumstances.