Published in the June 2012 issue of Today’s Hospitalist
SAY YOU’RE TREATING a 63-year-old patient whose blood pressure has hovered around 170/95 for two days and whose swollen right knee and pronounced limp suggest advanced arthritis. Your first instinct might be to order an ACE inhibitor or hydrochlorothiazide (HCTZ), then start high-dose NSAIDs for some pain relief.
But if the patient happens to be on lithium, that standard plan could be downright dangerous, cautions hospitalist Sarah Rivelli, MD, medical director of the medicine-psychiatry service at Duke University Medical Center in Durham, N.C. “Several hypertension drugs “ACEs, ARBs, HCTZ and furosemide “can raise lithium levels to toxic levels,” says Dr. Rivelli. “Even relatively benign medications like NSAIDs can do the same.”
Hospitalists treating psychiatric patients are also likely to see high rates of previously undiagnosed dyslipidemia, hyperglycemia and even metabolic syndrome, especially in patients prescribed second-generation antipsychotic drugs like olanzapine and risperidone. And while treating conditions like diabetes is essential, Dr. Rivelli points out, hospitalists need to understand patients’ ability to manage a complicated regimen.
“It’s really important for medicine hospitalists to collaborate with psychiatrists in these situations,” she says, “and to weigh the risks and benefits.”
Exactly how hospitalists should structure that collaboration, however, is open to debate. (See “Evolving med-psych models.”) Service lines like Dr. Rivelli’s, with medicine and psychiatry integrated under the leadership of a dually-trained internist-psychiatrist, can reap big benefits in terms of shorter lengths of stay, better disease resolution and fewer readmissions.
But the integrated model of inpatient psychiatric care poses several challenges. For one, not many physicians are dually trained. And only one state “North Carolina “requires the presence of internists or family physicians in state-owned psychiatric facilities.
Also, medicine hospitalists with little psychiatric training find it hard to work with mentally ill patients, despite the fact that such patients are common. And psychiatric patients require a different approach, from taking a broader view of a differential diagnosis to ensuring compliance with medications.
A business case?
While the U.S. has only 430 dedicated psychiatric facilities, more than 1,200 hospitals in the country have psychiatric units, according to the American Hospital Association.
“Between 50% and 70% of psychiatric patients also have concurrent chronic medical conditions or illnesses, but those typically aren’t addressed during the psych admission,” says Roger Kathol, MD, a Minneapolis-based internist-psychiatrist whose company, Cartesian Solutions, helps hospitals set up a variety of units that integrate medicine and psychiatry. “That often contributes to the high readmission rates for some of these patients.”
Hospitalist David Frenz, MD, medical director of addiction medicine for HealthEast Care System in St. Paul, Minn., has firsthand experience with an integrated model. For several years, HealthEast had dedicated medicine hospitalists working in week-long blocks on the psych unit to address patients’ medical issues. Patient care improved, as did length of stay and utilization.
“We saved the hospital nearly $500,000 the first year on labs and imaging,” says Dr. Frenz, who adds that scatter-shot testing is a hallmark of physicians who don’t spend much time treating psychiatric patients. “Most health systems hemorrhage way too much money on unnecessary studies on the psych floor, and having medicine hospitalists can reduce that waste.”
Under that model, psychiatrists acted as attendings while the hospitalists “who were “parked on that floor” “were consultants. At the time, the arrangement paid for itself.
“The hospitalist billed a level 3 or 4 consultation for initial care and then usual follow-up codes if we continued to follow,” Dr. Frenz says. “When consultation codes were eliminated, the whole thing blew up. The best we could bill for initial care was 99233, which is 35 minutes by the clock. But psychiatry patients always take way more time and so each initial encounter occurred at a loss.”
Since 2010, HealthEast no longer has hospitalists rotating through the psych unit, opting instead to have them consult on specific medical issues. While lessons learned about utilization continue to save costs, both the medicine hospitalists and psychiatrists recognize that the integrated approach was superior.
“The psychiatrists are not uniformly happy about the switch,” says Dr. Frenz. “One in particular keeps lobbying to get back dedicated medicine people.”
A different environment
Even where integrated models exist, medicine hospitalists practicing in such settings say the environment is markedly different from what they’re used to.
“Anything basic on a medical unit is not basic on a psych unit,” Dr. Kathol explains. For starters, psych-unit nurses generally don’t put in IVs or do any procedures that might be viewed as invasive. In fact, IVs and monitors of any kind often aren’t available because of the safety risks, from falls to suicide attempts.
Patient interactions can be markedly different as well. “Patients on the medical unit may have to be turned every few hours, but on the psych unit they’re often walking around,” says internist-psychiatrist C. Kendrick Dunham, MD, the medical director of behavioral health at Forsyth Medical Center in Winston-Salem, N.C. Dr. Dunham formerly directed medical services and supervised hospitalists at a state psychiatric facility. “You may not find the patient in the room.”
Dr. Dunham cites a not uncommon example: treating an “ambulatory” psychiatric patient whose pneumonia isn’t improving with oral medications. While guidelines call for switching to IV antibiotics, that may not be practical or even feasible.
“Figuring out how or where to administer the antibiotics can be difficult,” Dr. Dunham says. “If nursing is comfortable handling the IV, you might be able to keep the patient on the psych unit, but the IV lines could be a real concern,” even if one-on-one nursing is available.
Even obtaining a reasonably accurate medical history can be time-consuming, explains Vicki Kijewski, MD, medical director of the 15-bed med-psych unit at the University of Iowa Medical Center in Iowa City.
“Hospitalists may need a bigger time commitment at the outset because sometimes it’s just harder to get a history from the patient,” says Dr. Kijewski.
Hospitalists may also need collateral from other providers or family members to get a sense of what’s going on, Dr. Kijewski maintains. “You have to be more of a detective sometimes,” she says. “You also need to know what serotonin syndrome and neuroleptic malignant syndrome look like, and you’ll have to become an expert on delirium.”
Different order sets are often required for this population. When linezolid is indicated, for example, patients on selective serotonin reuptake inhibitors (SSRIs), serotonin’norepinephrine reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs) ideally require extensive washout periods before starting the drug. In addition, most detox protocols are PO or intramuscular (IM) “and as a rule of thumb, most medications are given PO whenever possible.
“Overall, I try to avoid IV and IM medications on psychiatric units,” Dr. Dunham says. “Many patients view IM medications as punitive, so that can be a real barrier to care.”
He’s also developed detailed order sets and unit-specific interventions to help prevent falls and aspiration, both of which, says Dr. Dunham, are perennial and potentially serious issues for patients taking high-dose psych medications.
In addition, many procedures and rules in behavioral health are markedly different from those on medical units, Dr. Dunham notes. Psychiatrists document diagnoses using the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders), which may be Greek to hospitalists. Patients may be under watch for suicide or elopement, or housed in locked locations.
And rounding hospitalists may need a psych nurse as chaperone when encountering psychiatric patients. For those reasons, Dr. Dunham urges hospitalists to coordinate closely with nursing staff to determine when precautions are in order.
“One of the biggest challenges for hospitalists coming on to behavioral health units is learning to negotiate the culture,” Dr. Dunham says.
Dr. Kijewski adds another key consideration: Hospitalists need to assess their ability to work in multidisciplinary teams. “You won’t be the one to just come in and save the day,” she says. “Some internists want to just get the work done, and they may not be interested in talking about the psych illness or hearing a long social history.”
Likewise, she notes, a psychiatrist won’t want to sit in on an extensive physical exam or have a long discussion on GERD. Instead, both physicians have to structure rounds and case management discussions with an eye to not taking up each other’s time unnecessarily.
Paul Garcia, MD, who is dually trained in internal medicine and psychiatry and directs the inpatient psychiatry unit at Vidant Beaufort Hospital in Washington, N.C., works collaboratively with medicine hospitalists. He notes that hospitalists often have mistaken notions about the dangers that psych-unit patients pose.
“These patients may be difficult to deal with because they’re aggressive, but most of the time, that’s because they’re scared,” says Dr. Garcia, who worked in an academic psychiatric facility before moving to the community hospital. “Most are not violent, and I often have to remind my medicine colleagues that most violence that occurs in the hospital takes place in the ED, not on the psych unit.”
Dr. Garcia also urges hospitalists not to make assumptions about psychiatric patients’ needs or requests for pain medications. He has seen physicians be reluctant to give opioids to patients who have harmed themselves or to those who can recite their medication history, chapter and verse.
“I have been completely wrong on occasions,” he says. “Just because patients can tell you the exact medicine and dose doesn’t mean they’re abusing it. Just focus on respecting the patients and meeting their needs.”
Another challenge with this patient population: Hospitalists should be prepared for the possibility that patients won’t recognize their efforts.
“Don’t expect a lot of ‘thank you, doctor, you’re the best,'” Dr. Dunham cautions. “A history of abuse from authority figures, hallucinations, paranoid thinking or personality disorders may contribute to a patient appearing not to appreciate you or your hard work. Physicians who work in this environment have to find a way to cope with these issues.”
A big professional payoff
Despite what may be very challenging work, caring for patients who are psychiatrically and medically ill can be gratifying. For one, a hospitalist’s presence may be the first time a patient receives anything close to coordinated, comprehensive care.
“You really are helping the underserved,” Dr. Rivelli says. “One way we justified our combined medicine-psych service was showing that if you attack both problems right up front with an integrated team, it not only decreases length of stay, but these patients often get better.”
Dr. Dunham cites similar rewards. “A diabetic with depression usually has worse outcomes in both depression and diabetes than a person with diabetes or depression alone,” he says. “Keeping an eye on the behavioral health unit patient proactively helps prevent those patients from going to medical floors for preventable problems.”
While the need for medical services onsite clearly exists, many hospitalists elect to go into hospital medicine because of the variety it affords, Dr. Frenz cautions. They may not want to devote time to just one patient population.
“But I do think it could be structured as a career for hospitalists who have an interest in mental health and some degree of altruism,” he says.
According to Dr. Kathol, interested hospitalists could begin working with psychiatrists and hospitals in their community.
And to improve care for more complex psychiatric patients, hospitalists and psychiatrists could “set up four or five beds with medical capabilities in the psych unit with medical nursing staff and equipment,” he says, “so there’s no need to transfer patients in and back.”
Bonnie Darves is a freelance health care writer based in Seattle.
Evolving med-psych models
HOW SHOULD YOU COLLABORATE with psychiatrists to care for psychiatric patients with complex medical conditions? In most hospitals, hospitalists and psychiatrists trade off consulting, depending on where the patient is assigned and whether medicine or psychiatry trumps his or her acute conditions.
If mental health or substance abuse problems arise in a patient on a medical ward, “one-on-one nurses are used until the patient is medically stable and can be transferred to a psychiatry unit,” says Roger Kathol, MD, a Minneapolis-based internist-psychiatrist whose company, Cartesian Solutions, helps hospitals set up integrated units. While the majority of hospitals use this model, he notes, it is “far from satisfactory from a quality of care perspective.”
Some hospitals have now moved to hire psychiatric hospitalists who “proactively assess all new medical admissions” rather than wait until a psychiatric crisis arises or the patient is nearing discharge. Data now support this model, Dr. Kathol notes, to improve care and shorten length of stay for general hospital admissions.
Other hospitals are trying that model in reverse: having medicine hospitalists assess medical needs in all inpatient psychiatric admissions. “The assigned medical person is usually a PA or a CNS with hospitalist back-up,” Dr. Kathol explains. “Patients’ medical acuity is usually less than a hospitalist typically feels challenged by.”
Then there’s another model that Dr. Kathol says is gaining popularity: what he calls a complexity intervention unit and others refer to as a med-psych unit.
“A medicine unit is accoutered to handle acute psychiatric and medical illness in one setting, run as a co-attending model,” he says. “Nurses can carry out both medical and psychiatric interventions at the same time because they have been trained in both.” Such units, Dr. Kathol adds, are designed for patients who are outliers because of their complex medical and psychiatric issues.
“Unless they are effectively treated, these patients will lengthen hospital stay, double early readmission rates and require one-on-one nursing,” he points out. While a co-attending model is costly, he says, those expenses are “typically recouped by savings in other areas if units are set up correctly.”
While many hospitalists extol the virtues of maintaining an integrated med-psych service with psychiatrists, that model isn’t widely available. The challenge then becomes, says David Frenz, MD, medical director of addiction medicine for HealthEast Care System in St. Paul, Minn., to either improve the general medical skills of a facility’s psychiatrists or boost the mental health and addiction skills of non-psychiatrists.
To that end, Dr. Frenz suggests any of the following books “and that psychiatrists and hospitalists should consider sharing a library:
“Handbook of Medicine in Psychiatry”
“Psychiatric Care of the Medical Patient”
“Laboratory Medicine in Psychiatry and Behavioral Science”
“Managing Metabolic Abnormalities in the Psychiatrically Ill”
“Handbook of General Hospital Psychiatry”
“Primary Care Psychiatry“