Therapists are required to have 24 hour coverage for their private practice. They need to be available to their clients if a client has a crisis or an emergency. But you obviously can’t be available at any hour. There will be times when you are sleeping, out-of-town or just don’t have service on your cell phone. Learn the solution to 24 hour coverage.
24 hour coverage is something that many private practice therapists worry about. Insurances seem to be moving toward requiring that you be available to clients in crisis. I used to think the standard voicemail message that directed a client to a crisis number, 911 or an emergency room would be enough. But I’m not so sure now.
I recently had a colleague tell me a new contract with an insurance panel required that she be available within one hour for a client in crisis. I checked and one of my contracts specifies the standard for outpatient care is to be available for emergency within one hour, urgent within one day and routine within 7 days. One hour? What if you are on vacation? What if you are sleeping? What if you live an hour from your office?
How can you have 24 Hour Therapy Coverage?
I know the thought of 24 hour coverage can be scary to think about. I know I don’t want to have to run to my office in the middle of the night. And I need to have days off and the occasional vacation. It may not be fun but you need to be available to your clients if they have a crisis. You don’t want to end up sued because a client couldn’t reach you and committed suicide.
But don’t worry. If you take a few simple steps, you can decrease liability over 24 hour coverage. You can show that you took every precaution against death or disability when you weren’t available. These precautions are for extreme circumstances. Don’t worry that it will happen often. I have known people in private practice for years that haven’t had an emergency happen. I have only had a couple of clients contact me after hours. And each situation was able to be resolved over the phone without an emergency visit to my office.
Note:These steps are for therapists in private practice who work on their own. If you are in a group practice or a partnership, the practice should have policies in place for 24 hour coverage. If you are starting a group practice, be sure to have a policy about 24 hour coverage.
Follow these steps to limit your liability:
- Document everything.
- Have a cell phone number you can be reached at in an emergency.
- Have a colleague who can cover for you.
- Have a voicemail message or answering service.
- Don’t take clients with serious mental health issues.
I don’t know how much I can stress this. If you don’t document it, it didn’t happen. I’m sure you know the things you need to be doing and are doing them. It’s just a matter of writing them down in the client’s notes and including them in the treatment plan.
Cell Phone Number for Emergencies
Since you need to be reached if a client has a crisis, the easiest way to do this is to have a cell phone number where you can be reached anytime. It isn’t necessary to give your cell phone to clients. You can have a land-line that forwards call to your cell phone. If you have a profile in Psychology Today, you get a phone number to track your calls which you can use. Google offers a service called Google Voice that can forward calls to one phone.
You can find a colleague to help you with 24 hour coverage. There are many therapists in solo private practice. They need help with 24 hour coverage too. You can have an arrangement with them to be available for each others clients if an emergency happens. Make these arrangements before a situation arises. If a client contacts you who is suicidal, needs to be seen in an hour and you cannot get there, call your colleague to meet them. It’s a good idea to have more than one person to call in these situations. That way if one person can’t be reached, you can call the second person.
Voicemail Message or Answering Service
A voicemail message can help you at those times when you can’t answer the phone immediately. The key points that you want to cover in a therapists voicemail message are your name, credentials, and where clients can get help when you are not available. You can direct your clients to the nearest emergency room or to call 911. You can include a number for a crisis hotline too. While a voicemail can help, you may still need to return calls for emergencies within an hour.
An alternative is to hire an answering service. It may cost extra money to hire people to handle calls but it will be added protection against liability. There are answering services that specialize in medical and mental health calls. An answering service can take your normal calls for appointments and route any calls for emergencies. Some options for answering services are Concorde Communications, Answer Center or Specialty Answering Service.
Don’t take Clients with Serious Mental Health Issues
Another option is to not take clients with serious mental health disorders. Some disorders are more prone to suicidal tendencies which can lead to a need for crisis intervention. I know it can be hard to turn away clients when you are just getting started. But you have to realize the limits of your practice and your limits as a therapist. You probably won’t get many calls from people with more serious disorders like schizophrenia but there are some clients who may call you that you don’t want to take. I have received special instructions for Bipolar, Schizophrenia, ADD/ADHD and Major Depressive Disorder from one insurance panel I am contracted with. Let’s consider some disorders and the issues they could lead to.
People with Bipolar disorder often need medication management. If you aren’t working closely with a Psychiatrist, you might want to refer someone with Bipolar disorder to another provider. Of course, you can work with them on tools for emotional regulation but many insurances want them to be treated with medication. The client can refuse to take medication but this is something that you have to document and continue to document. If you see a Bipolar client, take precautions by documenting that you asked if they wanted a referral for medication often, perhaps at every visit. Document that you checked mood symptoms and suicidal ideation at every visit.
Personally, I wouldn’t take any schizophrenic clients. But if you do, take some precautions by documenting a few things. Document that you assessed them for signs of psychosis like delusions or hallucinations at every session. You need to work closely with their Psychiatrist for medication management. Document any consultations with their Psychiatrist and that you are checking for medication side effects like dystonic reactions, akathisia or akinesia. Involvement with their primary caregiver and/or family should be documented.
I have often seen insurance panels that have different instructions for ADD/ADHD. I think the reason is that children are often diagnosed with it and take medication for it. An adult client who does not want medication and only wants to learn some tools to cope with the disorder may be treated differently. But if you take children with ADD/ADHD, document that you are assessing effectiveness and side effects of medication and coordinating care with a Psychiatrist. Document that family or a primary caregiver is involved in their treatment. And that you have educated the client about their disorder.
Major Depressive Disorder
The risk with major depression is suicidal ideation. You need to assess them at every visit for their mood and suicidal ideation. Medication needs to be coordinated with their prescribing Psychiatrist or PCP. If they aren’t on medication, document that you are talking to them about it. I think if the disorder is mild, then you don’t have to worry as much but moderate and especially severe depression needs to have special precautions.
Borderline Personality Disorder
While I haven’t had any special instructions for Borderline Personality Disorder (BPD), I do have experience with this disorder and I know precautions need to be taken. BPD clients are known to have problems with boundaries. These clients will try to reach you at home if you allow it. It’s important to make the boundaries of the therapeutic relationship clear to BPD clients. If they have suicidal ideation, document that you are addressing it each session. Document coordination of care for medication management with their Psychiatrist.
In addition to the particular disorders above, any client with suicidal ideation should have assessment at every visit for suicidal thoughts or plans. A safety plan will show you are addressing it. Any client on medication should have documentation that you have made attempts to coordinate care. If the client does not sign consents, document this. If they do not want medication but have a disorder that is often treated with medication, document it. Assess a client’s mood and any other symptoms at every session and document it. I know a lot of this is standard procedure and you do it already but the key is that you are documenting it.