22 July 2011

Capital Health Mental Health Program

Guidelines for Information Sharing within the Triangle of Care

A collaborative approach to information sharing

The Capital Health Mental Health Program is committed to a collaborative approach to the care and recovery of Persons living with mental illness. This approach includes the Person living with mental illness; the individuals they identify as supporting them, their Circle of Support; and Mental Health service Providers. Together they form the collaborative Triangle of Care.
A core component of a collaborative approach is information sharing.
  • Persons living with mental illness need information about their illness, their options for treatment and support, and the advantages and disadvantages of sharing information with the individuals who support them. This information is essential to making an informed decision about which recovery goals and treatment course they will choose to follow.
  • Individuals in the Circle of Support, who provide practical and emotional support, need information about the Person’s illness, treatment, and support needs in order to provide helpful and effective support.

Providers listen to the Person living with mental illness and advise them of their right to confidentiality of personal health information. They help the Person to understand that those who support them need information about their mental illness and treatment in order to provide them with effective support. Providers also listen to and provide appropriate information to those who support the Person living with mental illness.

The following guidelines reflect an approach to information sharing that supports collaboration within the Triangle of Care. The guidelines follow the provincial Personal Health Information Act*, the provincial Hospitals Act, and the United Nations Convention on the Rights of Persons with Disabilities.

Definitions

►  Person living with mental illness –a person who has a mental illness and who receives, or is being considered for, service from the Mental Health Program (referred to at times simply as ‘Person’).

Circle of Support – individuals, identified by the Person living with mental illness, who provide practical and emotional support.

►  Providers – staff and physicians of the CDHA Mental Health Program.

►  Triangle of Care – care based on three-way collaboration among Persons living with mental illness, their Circle of Support, and their Providers.


Health Information

  • Personal Health Information − all information relating to a specific Person’s mental and physical health, health care, family health history, and all other information collected by a Provider in their assessment and care of a Person living with mental illness.
  • Publicly available information about health that does not identify, and is not related specifically to any Person, is not regarded as personal health information and therefore does not require consent for sharing.
  • General information is personal health information relating to a Person’s presence in a hospital, location in the hospital or clinic, or condition on the day the information is shared.
  • Restricted information includes all other personal health information and is only shared with consent except in situations of risk to self or others.

General Information

1. The Personal Health Information Act allows Providers to share general information with members of the Circle of Support without consent. General information may not be shared with individuals outside the identified Circle of Support.

General information may not be shared where the Person has expressly requested that general information not be shared with a particular individual or with any individual.

Persons who wish to not share information with particular or all individuals can request a communications block under CDHA policy.

2. General information is limited under these guidelines to the following information at the time it is shared:

General location is limited to stating the hospital unit or outpatient clinic where the Person is currently receiving treatment (not where they live or are staying).

General Presence is limited to stating whether or not the Person is in the stated hospital unit or clinic at present.

General condition is limited to describing the Person’s current condition using one of the five following phrases, or equivalent wording, without giving further detail:

o Acute – the Person is acutely ill and unstable
o Same − the Person’s condition has not changed
o Getting worse − the Person is showing increasing symptoms
o Getting better – the Person is recovering; their symptoms are decreasing
o Better – the Person is in remission, or otherwise recovered, or stable

Restricted Information

3. Restricted information may only be shared with members of the Circle of Support with the explicit consent of the Person living with mental illness.

Public Information

4. Providers are encouraged to support members of the  Circle of Support by sharing publicly available information with them. This includes information about mental illness, treatment, services, coping, support, and communication strategies (in order to support the Circle of Support).

Recommended practice regarding information sharing

Mental Health Providers are strongly encouraged to initiate discussion regarding sharing of health information early in care and regularly throughout the care process with the Person experiencing mental illness and their Circle of Support. The following principles and practices are vital to this approach.

1. The Provider informs the Person living with mental illness of their right to confidentiality of personal health information.

2. Members of the Circle of Support need some personal health information about the Person’s illness and treatment in order to better help the Person and to better cope themselves. Research shows that good support improves outcomes (see bibliography in Appendix).

3. The Provider has a discussion with the Person regarding what information might be shared with members of the Circle of Support, what might be the advantages and disadvantages of sharing information, and then asks whether the Person consents to share specific information with specific individuals in the Circle of Support.

4. Where a Person living with mental illness has expressly requested that no personal health information of any kind may be given to a particular individual, then no personal information at all may be shared with that individual.


5. The Provider advises the Person of their right to change their mind at any time and makes plans to review information sharing on an ongoing basis. Consent is a process, not an event.


6. Wellness plans and personal directives should include the Person’s directions as to what information may be shared, and with whom, in the case of acute illness or incapacity.


7. Consent to share information has several requirements. It must be:

• Free − consent is given freely without undue pressure from others.
• Informed − the Person understands the nature of the information to be shared, and the advantages and disadvantages of sharing and of not sharing.
• Specific − consent is specific as to what information is to be shared and to whom.
• Capable − the Person appreciates and understands the nature of the decision and the consequences of the decision. Otherwise, a substitute decision maker is appointed.

8. Where the Person living with mental illness has been declared by a physician to be incapable of consenting to sharing of information, then personal health information may be shared with the legally appointed substitute decision maker (SDM) in the absence of consent as the SDM requires information in order to make informed decisions about the Person’s care.

9. A Person living with mental illness may retain capacity to consent to information sharing when they lose capacity to consent to treatment. All individuals are deemed capable unless found legally incapable by a physician.

Sharing Information with the Circle of Support without consent

1. Providers may share relevant personal health information with others without consent when the Provider believes on reasonable grounds that sharing information will help avert or minimize an imminent and significant danger to the health or safety of the Person living with mental illness or to the health and safety of others.
 
2. Providers may initiate contact with members of the Circle of Support without consent to request collateral information regarding a Person living with mental illness when the provider believes on reasonable grounds that the information will help avert or minimize an imminent and significant danger to the health or safety of the Person living with mental illness or to the health and safety of others.

3. The Provider may listen to members of the Circle of Support when a member of the Circle of Support initiates contact to provide information without obtaining the consent of the Person. The Provider advises the Circle member at the beginning of the conversation that the information will be shared with the Person living with mental illness except in special circumstances (as outlined below).


4. In crisis situations, when members of the Circle of Support indicate there is violence or a threat of violence as a result of the information shared, then the information shared from the Circle of Support will be withheld from the Person at the request of the Circle member.
When a member of the Circle of Support shares information that there are significant behavioral changes, such as increased verbal abuse or paranoia, and it appears that informing the Person of the conversation will likely disrupt support, the Provider will delay sharing this information with the Person until the Person has begun to recover sufficiently to be able to reflect on the crisis. This decision is made collaboratively with members of the Circle of Support where feasible.

5. The Provider documents all decisions and conversations regarding sharing of information.
 

 

* Footnote: the Personal Health Information Act has been passed by the Legislature but is not yet in force.


APPENDIX  -  CASES FOR REFLECTION ON INFORMATION SHARING


Case 1 − A social worker asks whether the patient’s information should be kept confidential

A social worker sees a new patient for assessment. He is 27 years old and has schizophrenia. He lives with his mother who provides him with support. The social worker asks him at the end of the interview whether he would like to have his information kept confidential or not.
What would be a better way for the social worker to approach information sharing?

Case 2 − A mother calls to find out how her daughter is doing in hospital
A 22 year old woman is admitted one night to the Short Stay Unit after going on her own to the Emergency Department with complaints of severe depression and suicidal thoughts. The mother calls the next morning to find out how she is doing.
What should the nurse tell her? What should the nurse not tell her?

Case 3 − A mother calls to find out how her daughter is doing (after taking her to hospital)
A mother takes her 22 year old daughter to the Emergency Department one evening with severe depression and suicidal thoughts. The daughter is admitted later that night to the Short Stay Unit. The mother calls the next morning to find out how she is doing.
What should the nurse tell her? What should the nurse not tell her?

Case 4 − A man calls his brother’s psychiatrist to get advice on how to help his brother
A man has a brother with bipolar disorder. His brother has been up most of the past two nights and is restless and irritable. The man does not know what to do and so calls his brother’s psychiatrist at the mental health clinic for advice. The psychiatrist calls back that morning and explains that he does not have consent to share personal health information with the man.
What can the psychiatrist tell the brother?

Case 5 − A man calls his wife’s psychiatrist to report she is getting paranoid
The husband of a woman with schizophrenia calls his wife's psychiatrist to report some disconcerting things his wife is saying and doing as a result of her paranoid delusion about their neighbours. He worries that she might "run away" to hide. The husband informs the psychiatrist about the changes in the hope that will help the psychiatrist understand what is happening and that changes in treatment are needed.
How should the psychiatrist respond?

Case 6 – A woman presents to the Emergency Room
A 25-year old woman is brought to the Emergency Department by a friend. The friend said that he "talked her into coming because she seemed unusually depressed” and that “she said she was going to end it all”. He also said he knows she has seen a therapist for mental health issues. The psychiatric nurse notes inconsistencies in the woman's description of her recent mood, immediate plans, and details about her support network. The woman refuses to give any information and refuses to give consent for the provider to contact anyone from her support network.
Are there other ways for the nurse to collect information?

CASE COMMENTARY
Case 1 − A social worker asks whether the patient’s information should be kept confidential
Information sharing should not be regarded as an all or none issue where the patient’s information is confidential or not confidential. Rather, the Provider should encourage the patient to explore what information would be helpful to share with some members of the Circle of Support while keeping other information confidential.
So the social worker might have said something like, “Let’s discuss what health information you might agree to share with your mother so that she can better understand your illness and treatment and therefore be able to support you in ways that are more helpful to you.” The social worker should document the conversation and the decision regarding information sharing in accord with the consent given.

Case 2 − A mother calls to find out how her daughter is doing in hospital
The staff confirm the caller is the patient’s mother. They then release general information, confirming that her daughter is present on the unit, and advising her, when asked, that her daughter is “getting better”. The staff might ask for collateral information without consent . The staff provide no further information about the daughter. They let the patient know that she called and what was said.
The staff should discuss information sharing as soon as possible on admission. If consent to share information with the mother has already been obtained on the unit or in the emergency department then staff can provide the information the patient consented to share. The staff document any consent and sharing of information.

Case 3 − A mother calls to find out how her daughter is doing (after taking her to hospital)
If the patient is able to manage a discussion of information sharing, the Psychiatric Emergency Service (PES) team discusses sharing particular information with her Circle of Support about her illness and treatment and gets consent to share particular health information with the mother.
When the mother calls the Short Stay Unit the next morning, the staff confirm she is the mother and check that they have consent to share clinical information with her. They then give the mother some details as to how the patient did overnight and is doing this morning. The staff might ask for some collateral information. They let the patient know her mother called.
If consent to share clinical information with the mother or other members of the family was refused in PES or could not be obtained, then staff should review with the patient the benefits of sharing information with her mother and her wishes in regard to doing so.
If the patient is incapable of making decisions regarding her treatment and the sharing of information, the staff should work with her mother to determine who is the legal substitute decision maker (SDM) and engage the SDM in the informed decision making process.

Case 4 − A man calls his brother’s psychiatrist to get advice on how to help his brother
The patient has not consented to his psychiatrist disclosing personal health information to anyone. Nor has he expressly requested that general information be withheld from anyone. Therefore, the psychiatrist can tell the brother some general information, e.g. “he is getting worse”, but nothing more specific than that. She can also listen to the man’s description of his brother and advise him on how to handle the situation using the information the brother gives him, e.g. “if this or that happens, bring him immediately to the Emergency Department or call Mobile Crisis”, “do your best to avoid aggravating him”, “try and coax him to sleep”, “try to bring him to see me this afternoon at 3 PM.” The psychiatrist also advises the brother that she will let the patient know of the conversation.
The psychiatrist informs the patient of the conversation at the next visit, discusses the advantages and disadvantages of sharing some information with the brother, and reviews the patient’s position on releasing personal health information to his brother.
Case 5 − A man calls his wife’s psychiatrist to report she is getting paranoid
The psychiatrist thanks the husband for letting her know, offers general advice as to how to handle the situation, and asks if he would feel comfortable if she were to inform his wife of their conversation. The husband asks her not to share the information with his wife. In the past, his talking with others about his wife led to her having paranoid thoughts about him which then led to threats to leave him and his support.
The psychiatrist agrees to defer informing the patient of the conversation until she recovers sufficiently to be able to reflect on the crisis.

Case 6 – Woman presents to the Emergency Room
The nurse obtains the name of her next of kin, her father, and his contact information from the health record. The nurse informs the woman that she will be calling the father as a member of her circle of support  for collateral history due to the level of concern she has for her safety, reviews the advantages and disadvantages of making this contact with the father, and describes what information she is seeking. The woman still refuses consent; however due to the level of risk, an imminent and significant danger to the health or safety of the Person living with mental illness, the nurse proceeds to contact the father. This information is shared with the psychiatrist. The psychiatrist and nurse meet with the woman and the friend to collaborate on the treatment plan which is informed by collateral information from the father.

BIBLIOGRAPHY

Provided by Dr Graïnne Fadden, Meriden Programme, Birmingham, UK

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