Immediate Discharge From Practice

Discharge from practice is the most common topic of inquiry received through the Coverys Risk Management Consultation Line. By the time practitioners call to discuss the possibility of discharging a patient from practice, they are stressed and frustrated from dealing with disruptive or problematic patient behaviors. While patient discharge may seem like the only option, many practitioners are concerned about the potential for an allegation of abandonment or an escalation of an already volatile situation.
 
Discharge from practice for failure to pay bills, disagreement over the treatment plan, or missed appointments is a process, not an event. In most cases, the process begins with several attempts to resolve the behaviors and progresses to sending the patient a written 30-day notice and the provision of treatment for urgent conditions during the notice period. Although rare, some patient behaviors or actions are so serious that they justify immediate discharge without notice. Those behaviors include:

• Uncontrolled hostility, violence, or threatening behavior.
• Repeated verbal abuse.
• Threats or commission of violent acts against the staff or other patients.
• Commission of criminal acts on the premises, such as theft, stalking, vandalism, or assault.

While practitioners and organizations have a duty to the patient, they also have a duty to protect the staff and other patients. Healthcare workers have a right to work in a safe atmosphere and to be treated with respect. When a patient’s actions are egregious enough that they violate those rights or compromise the safety of the staff or other patients, practitioners have the right to immediately terminate the professional relationship and discharge the patient from practice. Consider the following when reviewing your organization’s policies regarding discharge from practice:

• Set expectations up front. A collaborative patient-practitioner relationship begins with setting expectations. A well-crafted patient brochure and a patient-friendly website that clearly outlines behavioral expectations can establish ground rules at the outset and help avoid misunderstandings later. By the time a patient comes to their first appointment, they should clearly understand their responsibilities as a patient of the practice and which behaviors are not acceptable.
• Provide clear guidance for practitioners and staff. Ensure that policies and procedures clearly state which patient behaviors or situations require immediate discharge from practice. Outline specific steps to take in the discharge process and how to document that process. Be sure to include specific instructions for removing the patient from the premises, when to contact law enforcement, and how to manage persistent or menacing post-discharge behavior.
• Notify the patient verbally. When a patient demonstrates verbal aggression or abuse, warn them that they will be discharged if the behavior continues. If the behavior persists, or if the patient threatens or exhibits violent behavior toward a practitioner or staff member or commits a criminal act on the premises, notice of immediate discharge may be delivered verbally if it is safe to do so. Advise the patient that they are no longer a patient in the practice and ask them to leave immediately. When necessary, enlist the help of law enforcement to remove the patient from the premises or to protect other patients and staff. If the patient has left the premises, notice of immediate discharge can be delivered by telephone, email, or via the patient portal. Thoroughly document all communications with the patient and any interventions taken in the medical record.
• Confirm the discharge in writing. Even when making a decision to terminate the patient without the typical 30-day notice, send the patient written confirmation of the discharge and the reason for the termination. Notify the patient of resources that can help them find another practitioner, such as the local medical society or their health insurance carrier. Ensure that recent/pending test results, consultation recommendations or other important clinical information requiring follow-up by the patient is clearly outlined in the letter. Offer to send medical records to their new practitioner and enclose a blank Permission Form to Send Medical Records. Send the notice by both regular and certified mail, and keep a copy of the letter and return receipt for your files. If you cannot locate the patient to provide verbal or written notice, consider hiring a process server to hand-deliver the written notice to the patient.
• Have a plan. If the patient’s menacing behavior persists after discharge, seek assistance from local law enforcement, or consult with an attorney to explore other remedies available under state law, such as serving a Notice of Trespass or a restraining order. Even though the person is no longer a patient, persistent aggressive or threatening behavior may be relevant in future legal proceedings, so be sure to document these behaviors thoroughly.
• Don’t reschedule the patient. Ensure the front office staff are aware of the discharge. Establish a process to prevent staff from inadvertently rescheduling the patient for an appointment. 

Patients who enter the healthcare system have rights, but so do practitioners and staff! Healthcare workers have the right to feel safe and respected at work. When patient actions compromise those rights, healthcare practitioners have the right to immediately terminate the professional relationship.