Psychiatry’s role rising in hospital care



“We were lucky at NYPCH, because someone gave us the gift to hire a full-time psychiatrist we could embed into the medical team,” Dr. Muskin said. “But there is no one right way to deliver collaborative care in the inpatient setting.”

The NYPCH program has grown to include a second full-time and one part-time psychiatrist, serving about half of all medical services at the campus, with plans to hire more. There is also a social worker to assist with outplacement services. Dr. Muskin said he is currently looking to hire a psychiatric nurse practitioner.

‘Nurses love us’

Maureen Lewis Whitney McKnight/Frontline Medical News

Maureen Lewis

Restoration of staff morale is another benefit to this kind of practice, according to Maureen Lewis, an accredited psychiatric nurse practitioner who is part of the Hopkins integrated team.

“Med-surge nurses love us. Patients who come in with an overdose or who have any psychiatric conditions but need to have their medical comorbidities dealt with first, they are at their sickest with their psychiatric illnesses when they first arrive,” Ms. Lewis said. “It’s the med-surge nurses who have to care for them, but it’s not their comfort zone or their skill set. They like that we are helping them manage the patient.”

A decline in the number of assaults on the nursing staff also has been recorded since the Hopkins program began, Dr. Lyketsos said.

The psychiatrists themselves tend to be happier, too. “Knowing the cases before you even walk up on the unit is a huge benefit,” Dr. Triplett said. “To have to dive into an emergency all the time is just exhausting. It changes your relationship with the patient. When you’re not in that crisis mode, the patient isn’t a ‘problem’ anymore.”

A formal assessment of the entire medical-surgical staff satisfaction involved in the Hopkins program also is underway, said Ms. Richardson, the director of care coordination.

Having psychiatrists at the fore of this evolution in care provides more opportunities for training, too.

The comanagement model gives medical staff a chance to learn more not just about the direct care of complex behaviorally disordered patients, but also to understand their own emotions and states of mind as they interact with these patients. The teaching happens naturally as the team discusses patients while making rounds, Dr. Muskin said. “That’s really an integral part of what consult-liaison psychiatry is supposed to be about, anyway.”

By helping the medical staff reflect on their experiences, Dr. Muskin said, psychiatrists are helping to change the culture of inpatient medicine. “Once you change the culture, if you keep the things that brought it about in place, it doesn’t change back.”

Creating bridge services

A problem with this kind of inpatient collaborative care model is that hospitals that run them aren’t able to control all the variables associated with the cost of providing them.

The hope is that by spending more up front to identify and treat high-risk behavioral health patients, they won’t need readmission; but if the appropriate follow-up care can’t be found on the outpatient side, they could still end up back in the hospital, driving up readmission rates and possibly lengths of stay.

To address such contingencies, Hopkins has participated in state-sponsored partnerships for improving community care and is using monies from accountable care organization funding to create bridge services. The hospital system also has 14 primary care practices that have embedded psychiatric services, and the plan is to create a team to care for more complicated patients who need care 60-90 days after discharge.

For Dr. Lyketsos, however, fixing what he says is a broken mental health system isn’t up to the hospital alone. “We’re not going to be able to bring about real change without working with our legislators and our payers. It’s a complex problem that needs a complex solution. But there is a commonality of mind that we need to fix things, that patients need better care – and that this is a good place to start.”

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CORRECTION, 6/28/16: A previous version of this article misstated Dr. Hochang B. Lee's name.

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