Psychiatry’s role rising in hospital care



BALTIMORE – A team of physicians and mental health experts at Johns Hopkins Hospital is trying something new: combining mental health services with medical ones. Hospital leadership hopes the experiment will pay off in shorter lengths of stay, lower readmission rates, and better overall patient care.

“We’re still collecting that data,” Melissa Richardson, the hospital’s director of care coordination, said in an interview. “We also will look at the impact on staffing ratios on the units. For example, has the number of patient observers gone down? Has the overall severity of certain cases on the unit been reduced by embedding mental health workers there?”

The medical-surgical mental health team debuted in April, and is separate from the hospital’s other psychiatric services. Comprised of a social worker, a nurse practitioner, a nurse care coordinator, and an attending psychiatrist, the team typically works a regular day shift, beginning each morning with patient chart reviews prepared by medical-surgical personnel. They discuss which patients will be seen by whom, since all team members are trained to do psychiatric evaluations.

Dr. Patrick T. Triplett Whitney McKnight/Frontline Medical News

Dr. Patrick T. Triplett

Not all medical patients require psychiatric care, but according to the program’s clinical director and attending psychiatrist, Dr. Patrick T. Triplett, up to 38% of all medical admissions have a psychiatric comorbidity. Addressing those comorbidities while patients are in the hospital often leads to improved outcomes.

The team’s social worker connects patients with the appropriate outpatient mental health services in the community, and the team’s nurse care coordinator arranges any necessary transfers from the medical-surgical units to the inpatient psychiatric unit. Dr. Triplett and the psychiatric nurse practitioner are the only two team members who can diagnose and prescribe. Dr. Triplett’s time is billed as consultation services, and the hospital absorbs the cost of the rest of the team, according to Ms. Richardson.

‘Complex medically ill’ patients

As some procedures and medical treatments have shifted to the outpatient setting in recent years, and joint replacements or acute conditions such as myocardial infarctions can be managed successfully in shorter stays, more complicated patients, such as joint replacement patients who develop delirium, have been left on the medical-surgical unit, said Dr. Constantine G. Lyketsos, the Elizabeth Plank Althouse Professor at Johns Hopkins Bayview, Baltimore.

“Also, these days, up to 20% of our admissions are linked to opioids. Then, there are the chronically mentally ill. They tend to be a population with high rates of obesity, smoking, and diabetes, so they end up in the hospital with higher-level, more complicated conditions, that because of the disintegration of the mental health system, receive neither good psychiatric nor outpatient medical care,” Dr. Lyketsos, also chief of psychiatry at Johns Hopkins Bayview, said in an interview.

This surge in the number of complex medically ill patients has led to a growing number of hospitals nationwide calling upon psychiatrists for help in improving overall care. Hopkins is only the latest to join the ranks of other institutions such as Massachusetts General Hospital in Boston, State University of New York Downstate Medical Center in Brooklyn (N.Y.), Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and New York–Presbyterian/Columbia University Medical Center in New York City.

The progenitor of this collaborative inpatient care model is Yale New Haven (Conn.) Hospital. The behavioral intervention team (BIT) at Yale New Haven includes nurses, social workers, and psychiatrists who proactively screen for and address behavioral barriers to care for medical patients with a co-occurring mental illness, said Dr. Hochang B. Lee, one of the psychiatrists who helped created the model in 2008. Dr. Lee is Yale’s psychological medicine section chief and director of the school’s Psychological Medicine Research Center. He also is an associate professor of psychiatry and an associate clinical professor of nursing.

“The goal was to create a proactive model of care, not the reactive one that is traditional consultation-liaison psychiatry,” Dr. Lee said in an interview. “Before the BIT model, medical teams often missed behavioral issues or made consultation requests too late in the course of hospitalization to avoid psychiatric crisis.”

LOS, costs reduced

A study

Dr. Philip R. Muskin

Dr. Philip R. Muskin

“The hospital is not making money off of us, but they’re losing less money because of us. That’s good!” Dr. Philip R. Muskin, chief of consultation-liaison psychiatry at New York–Presbyterian/Columbia, said in an interview.

Patients at New York Presbyterian have been comanaged since 2004 when, according to Dr. Muskin, a donor gift specifically intended for such a purpose was matched by the hospital’s department of medicine. The unspent money was enough to cover the cost of a consultation-liaison psychiatrist to round full time as an attending with the medical team.

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