KEY ACTIVITY #12C:
Embed Develop and Implement Standing Orders
This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction.
Overview
A standing order is a preapproved provider order to perform a specific intervention for any patient who meets the criteria for the order and is used when the step in the workflow specifically requires the order of a qualified provider. Like protocols or standardized workflows, standing orders can help maintain consistent and systematic practices by clearly describing what team member is best suited to perform which important clinical activities. The following section offers guidance on how to use this suite of tools – protocols, standardized workflows, and standing orders – to make behavioral health screening a reliable part of care.
Standing orders describe the action to be taken and identify who on the care team is authorized to complete the order. Standing orders are designed to enable care team members other than the primary care provider (PCP) to initiate specific clinical actions to provide timely screening and care as long as specific criteria are met.
Implementing standing orders for BH treatment could support integrated care teams to provide holistic, effective and potentially lifesaving care to every patient who experiences a behavioral health crisis. The most common mental health crises are opiate overdose and suicidal ideation.
Examples of behavioral health standing orders could include:
- Any positive screens on BH-related screening tools, such as a patient endorsing suicidal ideation during routine screening.
- Next steps for any patient who asks for BH services.
- Naloxone administration to patients experiencing an opiate overdose.
While a standardized workflow around universal behavioral health screening does not necessitate a standing order, in practice the distinction between a standing order and a protocol can mean different things to different teams, so there are instances where practices find it useful to create standing orders for behavioral health screenings as a way to support the care team to provide evidence-based care.
Standing orders and other standardized workflows, in concert with other key activities, allow care team members to work to the full scope of their license and provide scaffolding to support care team members as they work to greater autonomy. They promote workflow efficiency and effectiveness by standardizing who gets what care while freeing up time for the prescribing clinician.
Standardized workflows help promote equity by ensuring that every patient who meets the criteria for an intervention under the standing order is provided with appropriate services, limiting variation that could occur in interpersonal encounters. Care team members must train and practice their response to ensure that individual biases do not prevent them from taking action when time is of the essence. Leveraging standardized workflows as an opportunity to train and practice responding to mental health crises may diminish the discomfort that many of us feel when faced with patient disclosures of sensitive topics, including suicide or drug overuse.
Most EHRs can enable the creation of order sets that can be used to create standing orders. Order sets are particularly effective for managing a group of standard adult screening orders for a population. See Appendix D: Guidance on Technological Interventions for more details on implementing order sets in a commercial EHR. Depending upon the health center’s workflows, these order sets can be placed on the chart by providers or can be drawn down by responsible designated staff according to protocols.
Relevant HIT capabilities to support this activity include electronic access to care guidelines, registries, care gap reports, and clinical decision support. The effectiveness of standing orders can be tracked through registries and care quality reports.
Action steps and roles
The table below outlines the actions and steps required to create standing orders and is adapted from the University of California, San Francisco (UCSF) Center for Excellence in Primary Care.[1]
1. Review and understand the latest clinical guidelines and your practice’s already established workflows.
Suggested team member(s) responsible: Quality improvement lead and panel manager, data analyst or medical director or equivalent.
See the latest guidelines for depression screening here: USPSTF Depression and Suicide Risk in Adults: Screening.
Develop and implement standardized workflows for behavioral health screening. At a minimum, this includes using the PHQ-2 with a standing order for completion of the PHQ-9, based on the results and suicide risk assessment. Other appropriate screenings should be determined by the practice. Many clinics use standardized workflows for SBIRT screening and follow-up.
2. Translate the appropriate clinical guidelines into a standing order or workflow.
Suggested team member(s) responsible: Panel manager or data analyst.
The standing order or standardized workflow will follow the relevant clinical guidelines and be updated whenever clinical guidelines are updated. It will generally allow the following:
- Medical assistants or community health workers with proper training may initiate the agreed-upon next steps when patients meet criteria when there isn’t a concern that requires the PCP’s involvement.
- This may include initiating a referral, leveraging needed care team members, or notifying the PCP or behavioral health staff of the need for further evaluation.
See the example workflow in this article by the American Family of Physicians for opioid-associated emergencies, which details when naloxone should be considered and given.
For a standing order to be valid and in effect, it must be approved by clinical leadership at the practice, signed by a designated valid signatory (e.g., CBHO or CMO), and dated, and it must include the effective date for the standing order. Practices should consider including an expiration date and flagging this date in their system to help ensure that the standing order or workflow is reviewed and updated regularly. As the clinical guidelines change or other components are updated, the workflow should be signed and dated again by the appropriate party with an effective date for the revision.
3. Train the practice’s staff on the workflow and include this training in clinical onboarding of new staff.
Suggested team member(s) responsible: Medical director or equivalent.
The practice’s staff should receive training in the use of standing orders and other standardized clinical pathways. Include any additional materials related to the workflow, such as patient education or instructional materials and nuances that the care team will need to understand.
Training should be provided at least annually, retraining should be provided before the effective date of any revisions to the work, and training should be part of the orientation for all new members of the practice care team.
The process of implementing updated workflows for BH treatment are opportunities to train and educate staff in how best to respond to both potential and unexpected situations, including responding to reports of suicidal ideation and other mental health crises and identifying and responding to opioid overdose. Training creates opportunities for open dialogues around topics that are associated with taboos and fears, such as suicide and drug use.
4. Assess and institute mechanisms to ensure the effectiveness and safety of the standing order.
Suggested team member(s) responsible: Clinical director or equivalent or their designee.
It is likely that one or more aspects of the standardized workflow will not work as planned. For example, the practice’s workflow may not fully support the standing order, the wording may be confusing to one or more staff members, or it may not be regularly followed exactly (e.g., staff are using workarounds). Look out for these and other common challenges, and revise and update the workflow as needed to ensure that it works for the practice and meets all applicable regulations and guidelines.
Implementation tips
Common pitfalls of standing orders:
- Standing orders are not updated when screening guidelines are revised and reflect an outdated practice. The remedy is to assign the task of updating the protocols to a member of the team who is responsible for at least annual review and modification.
- New staff are not instructed on the clinical protocols. The remedy is to include review of standing orders as a core element of orientation for all roles named in the standing order.
- A workflow includes the signature of a clinician who is no longer with the practice. The remedy is to workflow orders at least annually as well as any time a clinician responsible for setting the standing order has changed roles.