Clinician Demographics

Agreement to Participate in the

PEACE for Moms Program

Georgia Perinatal Psychiatry Education Advocacy and Community Engagement

For Clinical Providers

Introduction

To educate and train providers about  the psychiatric and behavioral health needs of women located within the State of Georgia during pregnancy and the postpartum, the Georgia Department of Public Health  approved funding for a perinatal psychiatric program to provide teleconsultation to you as a Georgia licensed physician, physician assistant, nurse midwife or nurse practitioner ("You" or "Your") called the GA PEACE for Moms program (the "Program"). 

The Program will be staffed five (5) days per week by physicians, specifically trained in women's mental healthcare, who are current faculty members at the Emory University School of Medicine Department of Psychiatry (the "Psychiatrists").  These Psychiatrists will provide remote teleconsultations, as well as educational material and didactics to You, throughout the State of Georgia in order to improve the knowledge of those clinicians caring for this vulnerable perinatal population.  In addition, the Healthy Mothers and Healthy Babies Coalition of Georgia ("HMHBGA") will be available to assist You, as you care for  Georgia moms in need  , by assisting with finding appropriate local social services and support that will further alleviate Your patient's  mental health symptoms. 

Agreement

Before continuing with enrollment, please read this Agreement to Participate. You must agree to the following terms of participation prior to enrolling and utilizing the Program's psychiatric teleconsultation educational services. The Program will provide educational support for You, as a  Georgia  licensed provider to assist in the management of Your perinatal women patients with psychiatric or substance use disorders and to provide linkage/referral support for those patients who are considered beyond the scope of Your practice.

You, the provider, agree to the following

1. The Program's psych teleconsultations are available Monday through Friday from 8-5 pm by contacting the HMHBGA Call Center (the "Call Center").  The Call Center and the Psychiatrists are not be available after hours on weekdays, on weekends  or New Year's Day, Martin Luther King Jr. Day, Memorial Day, Independency Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving and the day following, Christmas Eve and Christmas Day
2. The Program is not an emergency referral service; we cannot provide emergency evaluations over the phone or in person. If You call about a case requiring emergency services, the Psychiatrist will make efforts to refer You to an appropriate local service. 
3. Teleconsultation is a provider-to-provider service. The Program's Psychiatrists do not provide teleconsultations directly with patients/clients. In situations in which a woman needs ongoing psychiatric care; efforts are made to identify an appropriate local referral. Teleconsultation with a Program Psychiatrist will be limited to discussions with You. 
4. Participation in the Program is available to You, if You are a Georgia licensed clinician with prescriber privileges within the State of Georgia.  
5. The Program psychiatrists are not available for ongoing treatment of referred cases.
6. Phone support will be provided by GA PEACE for Moms team, which consists of psychiatrists, nursing and a triage coordinator during business hours. 
7. Before calling the Program, You should make Your patient aware that the call is being made and the reason for the call. 
8. When You call about a case, our triage coordinator will answer the call and when appropriate, referrals to community services will be shared with the provider. 
9. In order to best serve You and your perinatal women patients, the Program team members will request identifying information in case You request future teleconsultations. The Program will maintain HIPAA compliance through our secured database. 
10. In responding to Your questions about a case, the Program team members may respond with "In cases such as this...." or similar language. We are not trying to be evasive but do wish to emphasize that we have not evaluated your patient, will not issue prescriptions and, as a result, our recommendations must be tempered and are educational in nature.
11. There will be no written communication following teleconsultation calls with You. You remain responsible for the medical care and treatment of Your patient. 
12. As a part of the on-going Program evaluation process, you may receive surveys periodically to measure the impact of, and satisfaction with, the Program's services.  Your participation in these surveys will help improve and grow the Program.