Top tips for telephone assessments

The COVID-19 pandemic has changed the way mental health services are being run. In view of the government’s restrictions, mental health care providers have had to come up with innovative ways to use technology to provide patients with appropriate and safe care in a timely fashion.

In mental health trusts, face to face assessments have been replaced with telephonic consultations due to government’s guidelines regarding social distancing and reducing non-essential contact. Telephonic assessments have been relatively easier to conduct as compared to the use of other applications due to everyone having an access to a phone and being able to use it usually without the need of a good internet connection.

On performing a literature search for guidance about telephonic consultations in psychiatry, most studies showed guidance which was more GP centred in the United Kingdom and internal medicine based in the United States.

I found this rather alarming, as services like IAPT (Improving Access to Psychotherapy) have been conducting telephonic consultations for their clients. Furthermore, it also highlighted the “developmental delay” psychiatry is often criticised for in keeping up with the latest innovations in medicine and public health.

When the lockdown first started, I must admit I was quite excited about not having to dress up every day and commute to work. The idea of rolling out of bed and just going downstairs to do my afternoon clinic and attend MDTs in the comfort of my dining room felt amazing.

However, this also gave me the opportunity to reflect upon how quickly we are forced to adapt in the face on constant change. As I write this, I am working as a ST4 in the Rotherham Assessment and Formulation Team and I must commend the resilience, flexibility and innovation each member of the team has shown in adopting to this new way of working, which all the more motivated my consultant, Dr Arthita Das and myself to develop a quick how to guide for carrying out mental health reviews over the telephone.

We understand that each trust has its own local policies and procedures and also that some aspects of this guide may not be applicable to a certain specialty or area of work, but it’s a humble attempt to provide a quick desktop guide for psychiatry trainees when carrying out their next psychiatry clinic remotely, without feeling too much out of their comfort zone.

 Before the phone call

• Identify your aims for the phone call. Is it for a diagnostic review? Medication change? Or just a follow up call?
• Is this appropriate to be done over the telephone? Consider your patient for any cognitive impairment, their access to technology along with levels of risk and engagement. How well do you know the patient?
• Speak to a member of staff who knows the patient well to gauge the above information.
• Have access to the patient’s records and a pen and paper.
• Is your phone charged?
• Do you need any accessories to make the consultation easier – headphones, mic?
• Know the technology you are using.

During the phone call

• Be empathetic and supportive with a welcoming attitude, which is reflected in your words and tone of voice.
• Identify yourself clearly – “My name is Dr ______, a psychiatrist calling from  _____.
• Identify your patient- Can you please confirm your full name and date of birth?
• Ensure they are in the appropriate environment to speak to you – Can I check you are okay to speak to me? Where are you now? Pay attention to subtle cues - background noises, what the patient is doing, don’t hesitate to ask for clarification if in doubt.
• Ask who else is with them? And whether they could be spoken to for collateral history.
• Check their expectations from the appointment- this helps break the ice.
• Acknowledge that phone consultations can get difficult to absorb and retain, therefore they can ask for breaks and/or ask questions at any point during the conversation.
• Chunk and check- frequently pause to summarise and check understanding on both sides of the line.

• Assessing Risk:
  

        Consider-

  • likelihood of a behaviour or event occurring
  • frequency with which it may occur
  • whom it will or may affect
  • the extent to which that behaviour will cause harm.

• Leave time for final thoughts and questions.
• Summarise your assessment and management plan.
• Provide explicit safety-netting – (important phone numbers and other information)

After the phone call

Documentation

• Be sure to record signs and cues that may not necessarily be documented in a face-to-face consultation. For example, often speech isn’t very thoroughly explored in face to face assessments.

Practicalities

• Medicolegal: Each trust has its own policies regarding this. There are some very useful webinars by different indemnity organizations, which you can refer to for more information.
  

• DNA: Treat the phone call as you would a face to face, if someone does not attend it may be considered a DNA. If someone doesn’t attend twice, it could be a discharge. However, if there is any reason to be concerned, use your clinical judgement. Remember to document your concerns so specific information can be added regarding risk and further contact with GP/other agencies. Again, speak to your line manager and team to keep yourself up to date with your trusts appointment and engagement policies.
  
  
• Prescriptions: These can be arranged through the patient’s GP or pharmacy. Alternatively, these can be posted directly to the patient. You can also enclose relevant patient information leaflets to provide information about mechanism of action, side effects, monitoring etc.
  

Face to face assessments (following government guidelines for screening/PPE) may still be needed in cases where telephonic reviews do not allow for a complete assessment to take place, especially in cases where patients may have difficulty speaking on the phone due to cognitive or sensory difficulties.

Other factors that may prompt need for a face to face assessment are severe or unclear symptomatology, age of the patient (children and elderly), the patient’s ability to talk about their experiences, and their level of debilitation and ability to access technology (phone/laptop etc).

The pandemic has been a testing time for everyone, requiring us to perform our day to day tasks in new and unprecedented ways.

However, it has also given rise to innovative ways of working, which I’m sure we can continue to benefit from even after return to usual business. I would like to take this opportunity to thank everyone for their hard work, resilience and dedication during these times! I’m confident that we have come out stronger as a workforce from this experience.