General medical and psychiatric illnesses have long been treated in separate camps. But with an understanding of the inextricable link between mind and body, some hospitalists and psychiatrists are teaming up to coordinate care for patients with concurrent conditions.
Psychiatric illness is common in hospitalized patients but often managed by hospitalists with no direct assistance from a psychiatrist, said James Bourgeois, OD, MD, director of the psychosomatic medicine division and professor of psychiatry at the University of California, San Francisco.
One of his group's studies, published in 2005 in Psychosomatics, showed an estimated 33% risk of psychiatric comorbidity in medical inpatients. In addition, psychiatric illness comorbidity typically increased length of stay by about 10%, regardless of whether the patients saw a psychiatric consultant.
Despite the awareness of this and other deleterious consequences of comorbid psychiatric illness in medical inpatients, many hospitals have not yet perfected the delivery of necessary psychiatric care.
“Psychiatric consultative services in general hospitals, where they exist, typically only see between 1% and 6% of all medical admissions,” Dr. Bourgeois said. “Between the 1% to 6% we do see and the estimated 33% who have the illness...there are obviously questions with what happened with those patients and, if we could help out, maybe that would change how those patients do.”
As hospitals experiment with more direct collaboration between psychiatrists and hospitalists, they are finding that it may improve care and, in some cases, reduce costs.
A comanagement approach
Although consultation psychiatrists at New York Presbyterian Hospital's Columbia campus in Manhattan have always worked with medically ill patients, they haven't always been full members of the clinical team, said Philip Muskin, MD, chief of the consultation-liaison psychiatry service. “The disadvantage was that they could potentially always be strangers [to other team members],” he said, which made it easier for another physician to reject a psychiatrist's recommendations.
Now, the hospital's psychiatrists are involved throughout the entire care process. “Literally, the psychiatrist is a member of the team, rounds with the team, walks around,” Dr. Muskin said. For a patient admitted for pneumonia, for example, the team comes in, listens to her lungs, and discusses antibiotics and expectations. “One person in that group around your bed will be a psychiatrist, and you might or might not know that it's a psychiatrist,” he said. “It's just another face in the room. All patients that the team sees, the psychiatrist sees.”
The comanaging psychiatrist can discuss the patient's recommended treatment with the rest of the clinical team instead of bargaining for a particular treatment as a consultant. “This is now a learning discussion, and I think that that's a great advantage,” Dr. Muskin said.
The hospital refers to these faculty members as psychiatric hospitalists. “We used the term because everyone liked it,” Dr. Muskin said. “I like the term ‘embedded’ better, or ‘dedicated.’ And the term I like the best, obviously, is ‘comanaged.’”
This system of comanagement began when a donation allowed the hospital to hire a full-time psychosomatic medicine psychiatrist. After 1 year, hospital administration noted that patients seen by the comanaging psychiatrist were seen earlier in admission than those seen by the consultation-liaison service and decided to hire a second full-time psychiatrist.
Then the hospital embarked on a quality-improvement program to comanage inpatients with comorbid medical and psychiatric disorders. Dr. Muskin measured the impact of the intervention in “lost days,” or the days by which a patient's length of stay exceeded the expected duration, reporting results in the May/June 2016 Psychosomatics.
After the first year, average length of stay had dropped by slightly more than a day compared to on the same unit a year prior, which prompted the department of medicine to ask the hospital to fund extra staffing for the program, Dr. Muskin said. Based on the data, his team promised to prevent 750 lost days annually—and instead achieved a reduction of 2,889 lost days, saving the hospital an estimated $1.73 million per year, he said. The cost savings was more than triple the program's cost of $700,000 per year to employ 2.5 full-time equivalent psychiatrists and 1 full-time social worker, so the hospital decided to include the program in its budget, Dr. Muskin said.
In addition to building closer relationships with the care team, the comanaging psychiatrist teaches psychiatry to other team members and observes psychopathology without stigmatizing the patient. “By not consulting—that is, by not coming in as a stranger—we really do have an opportunity to change the way patients experience psychiatric services,” Dr. Muskin said.
For example, if the team is caring for a patient with cystic fibrosis who is incredibly anxious about dying, the comanaging psychiatrist, on equal footing with the team attending, could suggest hypnosis as a tool for controlling anxiety, then demonstrate and teach it to the team.
“Very different if I walk in as an outside consultant than if I'm a member of the team and say, ‘You guys should really know how to use hypnosis. It's a really powerful tool in medical care, and it is not quackery,’” Dr. Muskin said. “It becomes part of the training and, at the same time, it offers much broader training to people who are going into medicine.”
An alternative to sending psychiatrists to every patient's bedside is gathering medical patients who most need psychiatric care in a centralized location. At Long Island Jewish Medical Center (LIJMC) in New York, an ethnically diverse patient population with inconsistent access to care often presented with behavioral health issues in addition to their medical problems, said Corey Karlin-Zysman, MD, FACP, chief of the division of hospital medicine.
“We were using an exorbitant amount of continuous observation, or 1-to-1s, where we were paying people to sit and watch these patients 24/7, and we could easily have 20, 30, or 40 patients at once,” she said. “So you have [patient care assistants] each doing 8-hour shifts, 3 of these per patient. Multiply that out, and it's a huge cost, and it's inefficient.”
In 2014, hospital administrators looked to the hospitalist program for potential solutions. “The way we decided to try to solve this problem is to cohort patients who had active medical issues but concomitant behavioral health issues and see if we can reduce the amount of continuous observation we needed throughout the hospital,” Dr. Karlin-Zysman said.
The result was repurposing a 12-bed heart failure unit into one reserved for patients with behavioral health issues who were being cared for by hospitalists or faculty cardiologists. A single hospitalist now takes care of these patients with the support of a nurse practitioner, a psychologist, a nurse manager, and nursing staff.
In addition, and unique to this unit, are patient engagement specialists, workers who have a high school education, relevant experience, and 6 weeks of training on de-escalation protocols. They spend time with the patients and occupy them.
“A lot of times, [these patients] act out or cause problems because they're bored and scared and, if we can help them with that, maybe these things wouldn't snowball” and require continuous observation, Dr. Karlin-Zysman said. “The idea was to have a small, dedicated group of people—a true interdisciplinary team—taking care of these patients.”
A psychiatry consult service also assists the unit in the form of 2 to 3 psych consult liaison teams, which consist of an attending, residents, and fellows. “Their patients are cohorted in 1 spot, so usually, 1 of the consult teams is pretty much living on that unit, rounding with us, doing interdisciplinary rounds with us, and helping us manage these patients,” Dr. Karlin-Zysman said. Psychiatry consultants have been helpful in strategizing care plans for off-hours and discussing potential problematic situations with nurses.
The unit treats a broad scope of medical issues, such as infections, dehydration, hyperglycemia, asthma, chronic obstructive pulmonary disease, abdominal pain, foreign body ingestion, and eating disorders, and it also has telemetry capabilities for conditions such as chest pain and syncope, Dr. Karlin-Zysman said. “These were patients we were taking care of anyway, but they were just spread out all over the hospital. So if anything, it's made my people more efficient because all their patients are on 1 unit,” she said.
The unit achieved its goals: The number of continuous observations was substantially reduced, ultimately into the single digits, and the program gets continued support from hospital administration because of the team's success in caring for these patients, Dr. Karlin-Zysman said. “The feeling is [the cost of] those specially trained [patient engagement specialists] more than made up the cost of all those continuous observations we were doing historically,” she said.
The unit is now one of the calmest in the building, Dr. Karlin-Zysman said. “You'll see one [patient engagement specialist] coloring with one [patient], you'll see another one sitting with a group of people around the TV, and they're occupying them. They're keeping them calm,” she said. “It's a very high-performing unit, and I think positive consequences of creating this team are, for that patient population, much better throughput metrics; it has some of the best patient satisfaction scores of all the medicine units; the reduction in the 1-to-1s.”
One of the secrets to the success of the unit, Dr. Karlin-Zysman said, is that it excludes certain patients. Patients who are not redirectable (that is, who will not respond to distractions or de-escalation or who become aggressive or agitated if occupied) do not land on this unit. Suicidal and homicidal patients and those withdrawing from alcohol may need a 1-to-1 anyway, so they are placed in other units, she explained.
The psychologist on the team serves as a gatekeeper for the unit, making sure that appropriate patients are admitted and that there is balance in terms of their conditions, Dr. Karlin-Zysman said. “Sometimes, if you have too many of 1 type of patient, it's taxing for the unit, so [the psychologist] is able to strike a balance. The beds are always full—that's never the problem. She's there to help create a nice mix to make sure the resources aren't being stretched too thin,” she said.
As some hospitals send psychiatrists to the medical patients, others are placing hospitalists on psychiatry-focused units. An additional component of LIJMC's initiative involves Zucker Hillside Hospital, the inpatient psychiatric facility next door. In the past, 3 internists provided medical consults there, but for patients, there was frequent back-and-forth between facilities, Dr. Karlin-Zysman said. “What was happening is everything was getting sent over to the hospital—high blood pressure, fingerstick [testing],” she said.
In 2015, as part of a new comanagement service, hospitalists formally took over medical services at Zucker. Two hospitalists rotate at the facility at any given time, working on campus all day, and nocturnists at LIJMC are available after hours for any questions, Dr. Karlin-Zysman said. The hospitalists are also working with other Zucker clinicians to create protocols for medical situations such as anticoagulation management, insulin administration, and preoperative clearances, she said.
The setup decreased 30-day readmission rates at both sites by about 31% to 50%. “[By] having hospitalists there who are more comfortable with higher-acuity patients, we're doing a lot more medicine at Zucker and keeping the patients there and interrupting their [psychiatric] care that they need so badly a lot less,” Dr. Karlin-Zysman said.
A ‘geropsych’ approach
A prime target of hospitals' comanagement efforts has been geriatric patients. This year, LIJMC created another comanaged unit, which focuses on older patients with dementia and behavioral health issues such as delirium. A hospitalist trained in geriatrics oversees the new unit, which has 15 beds and the same staff and philosophy as the initial unit that reduced 1-to-1 use.
“What happened is we improved and then we plateaued [with the first unit], and when you looked at our continuous observation use in the hospital, the patients that were still requiring it were the elderly with some dementia. When they came to the hospital due to the medical issues, their delirium would kick in or they'd sundown or things like that due to the fact that they weren't in the comfort of their own home or their nursing home,” Dr. Karlin-Zysman said.
Medical issues on this unit are the clinicians' main concern, but the care of these patients is complicated by their cognitive and behavioral issues, she said. Common medical problems include infections (e.g., sepsis from urinary tract infections, pneumonia, skin infections), electrolyte derangements from poor eating, and gastrointestinal bleeding. “A lot of these medical issues are causing or contributing to their worsening behavioral state,” she said.
With the creation of the geriatric/psych unit, hospital-wide continuous observations plummeted. “It really dropped down to where we had maybe only 4 in the whole hospital—and to think that we would have 20, 30, 40 of these in the hospital, it's phenomenal,” Dr. Karlin-Zysman said. Between the 2 units, the hospital anticipates saving $1.2 million for 2016, she noted.
But this kind of setup doesn't come without challenges. “Triage is an issue when we're a hospital that can easily be at 105% to 110% capacity. Patients in the ED waiting for beds for a long period of time, that can make cohorting a challenge,” Dr. Karlin-Zysman said. That's why it's necessary to have logistical support from bed board staff, who “have become very good at figuring out which patients should go in this unit,” she said. “We've never had to board [other] patients on these units. We usually have too many patients that fit the criteria, not enough beds.”
Another challenge is getting all staff members to want to work on these units. “What we've noticed is once they're on the unit, they actually think it's a pretty cool and innovative, creative thing to be a part of,” Dr. Karlin-Zysman said. “But it was definitely a hard sell.” Plus, this is probably not the right unit for a fresh hospitalist. “This [requires] someone who needs a little experience, has to have a little bit of a backbone [and] be willing to deal with some challenging situations,” she said.
The University of California, Irvine, took a similar approach to psychiatric comanagement several years ago by creating a 12-bed geropsych unit for patients with psychiatric issues and recruiting community geropsychiatrists to comanage them with both internal medicine and geriatric hospitalists, said Alpesh Amin, MD, MBA, MACP, executive director of the hospitalist program. “It was our hospitalists that were there on site, and the geropsychiatrists would come in and round every day to manage the patients from a psychiatric point of view and then go back into their community practices,” he said.
From the start, it was crucial to get all the clinicians on the same page by deliberately outlining the responsibilities of the hospitalists and psychiatrists, Dr. Amin said. The unit decided on joint communication rounds, where each clinician independently rounded on a daily basis in addition to regular administrative rounds in a conference room, he said.
If the geropsych patients needed a transfer to the medical service for a medical management that the unit was not equipped for, the hospitalists knew when to transfer them and how to manage their care, Dr. Amin said. At discharge, summaries, appointments, and medications were split: The hospitalists took care of the medical issues, and the geropsychiatrists handled the psychiatric matters. “That's the way we managed it, and it worked out great for many, many years,” he said. (For regulatory and administrative reasons unrelated to comanagement, UC Irvine has since discontinued the geropsych unit.)
While the unit was in place, it produced positive outcomes in terms of length of stay, readmissions, and quality of care, Dr. Amin said. But not every beneficial outcome is measurable with this kind of intervention. For example, if a patient wasn't doing well and needed antibiotics or evaluation for a change in status, “the hospitalist was there and they managed the patient—otherwise, something would've happened,” he said. “There were many examples like that where you don't necessarily measure it, but you know it's the right thing.”
The comanagement model offers advantages over the typical model of psychiatric hospitalization, which depends on a psychiatrist recognizing that a medical issue requires help from a hospitalist, Dr. Amin said. “In a comanaged role, you don't have to rely on the psychiatrist knowing that, because the hospitalist is already coming in, has accountability, and is looking for all the potential medical issues that they need to resolve,” he said.
As his program found, though, there can be downsides to the model. “It takes additional time, energy, and resources to do comanagement because it's going to save a little bit of time for the psychiatrist in this example and add some extra time and work to the hospitalists,” Dr. Amin said. “So the hospitalists need to have enough support and staffing in order to be able to do something in the comanaged role, whereas the psychiatrist may be able to have enough time to see additional patients and do other things.”
Hospitals considering psychiatric comanagement should base their choices on their priorities regarding outcomes and costs, Dr. Amin advised. “When you start adding in the social worker, case manager, pharmacist, dietician, and other people from the multidisciplinary team, you're doing a lot better for the patient from a chronic disease and continuity perspective,” he said. “But you're putting in a fair amount of resources at the same time.”