June 24, 2022
Three Key Strategies for Improving Acute Med-Psych Patient Status and Management
An estimated 30% of individuals have medical and psychiatric illnesses when entering an emergency department. Co-occurrence of medical and psychiatric illnesses is one of the most common and disabling combinations for patients, and caring for these patients creates significant challenges for providers. Patients with severe psychiatric illness frequently present to acute care hospitals, and many presents with necessary acute medical conditions. Managing status determinations, treatment, and disposition of these patients have become increasingly complex, particularly as the number of acute inpatient psychiatric beds has decreased significantly over the past decades.
Caught at the Center of Perfect Storm
The hospital ED (emergency department) is at the center of this perfect storm. EDs treat acute and psychiatric emergencies and ultimately decide whether a safely stabilized patient can discharge to outpatient medical or psychiatric care. They also decide whether a patient requires further treatment in the acute medical or psychiatric unit.
Many EDs have seen increases in the number of patients with psychiatric comorbidities for which discharge to acute inpatient psych or other disposition (aside from a home or the acute medical unit) cannot occur swiftly. Patients can find themselves stuck in the ED while awaiting safe disposition, occupying a bed used to acutely stabilize a different patient, often with minimal psychiatric coverage support available in the ED. ED departments face understandable pressures to disposition patients. Challenges in caring for patients who are “boarding” may lead to increased requests to move patients who do not require acute medical care to the medical unit while awaiting safe discharge. While this may assist ED throughput, “non-ED” patients are often deprioritized. Moving a patient who ultimately has no acute medical needs from the ED to the medical floor may prolong the patient’s acceptance by an acute psychiatric unit or another facility.
Key Considerations for Helping Med Psych Patients
Every case represents a unique combination of illnesses and environmental situations, but consider these fundamental questions when caring for the patient:
- Is the primary reason for hospitalization medical or psychiatric?
- What is the correct location for the patient (outpatient, acute medical unit, acute psychiatric unit)?
- How do a patient’s co-morbid psychiatric conditions impact your decision for medical hospitalization, level of care, and length of stay?
It is critical for attending physicians to take the difference in reimbursement for psychiatric versus medical treatment into consideration when determining a patient’s status. Vast differences in payment depend on whether the payor is Medicare fee-for-service, Medicaid, Medicare Advantage, or another commercial plan. For example, Medicare Fee-for-service does not explicitly distinguish between medical or psychiatric unit care. Patients may be admitted as inpatients to the medical unit with medical or psychiatric issues so long as they receive transparent services only provided in a hospital setting spanning at least two midnights.
On the other hand, patients without Medicare FFS insurance may have utterly different coverage for medical and psychiatric care. A patient could have the same insurance company covering medical and psychiatric care. However, each form of care gets reviewed by different teams that do not check the case in collaboration. Further complications arise when many commonly used screening criteria for behavioral health issues from an insurer’s perspective only “fully apply” if a patient is on a behavioral health inpatient unit.
The considerations mentioned above complicate the status decision for a patient and the ideal location to best care for them.
There is no universally accepted framework for addressing med-psych patient cases. However, one approach to facilitating the optimal choice of status, location, and management of these cases is to begin by framing each patient as one of 5 different “case types”:
- Acute psych issue with no acute medical issue
- Acute medical issue manifesting as a behavioral change
- Acute medical issue and an acute psychiatric issue
- The initial acute medical issue now stabilized with behavioral issues precluding safe discharge
- The initial acute medical issue is now stabilized, awaiting psych placement
Numbers 1, 4, and 5 represent situations where medical issues have been ruled out or stabilized. If no safe discharge plan is available (either to inpatient psych or alternative placement), the first consideration is whether the patient should stay in the emergency department or be moved to a medical floor while awaiting alternative placement. These cases call for complex care conferences between the ED team caring for the patient, the hospitalist service, psychiatric consultants (if available), care management, and the administrator on call.
A patient-specific care conference can help identify where a patient can be most safely cared for based on unit structure, patient and staff safety needs, and bed availability. Also, non-Medicare FFS medical insurers recognize that patients transferred out of the ED may be deprioritized for alternative placement by other facilities and will frequently not pay for “pure psych” care in the medical unit. Aggressive discharge efforts should be pursued multiple times daily with repeated calls to potential accepting facilities (inpatient psychiatric units, outpatient psychiatric partial hospitalization programs, memory care, etc.).
In the interim, mobilizing all available resources is critical to assist in the active treatment of stabilizing acute psychiatric issues. These resources can include behavioral health consults onsite, telemedicine, medication titration, and addiction medicine consults. A flexible approach to discharge planning with continuous assessment of the appropriate discharge location is ideal. Flexibility is necessary because some patients who initially need inpatient psychiatric care may stabilize for safe discharge to an alternative location such as memory care or other community resources.
Numbers 2 and 3 represent situations when a patient may have behavioral changes secondary to a medical issue or concomitant acute psychiatric and acute medical issues. Initial status determinations should be assigned similarly to other medical patients. For case type 2, it is critical to document the patient’s baseline mental status explicitly. Mental status changes are acute and secondary to the underlying medical condition undergoing treatment. For case type 3, documentation should indicate how a patient’s acute decompensated psychiatric issue complicates the ability to treat the patient’s medical issue, prolongs the length of stay, or complicates discharge. Documenting the clear endpoint of acute stabilization needed to be able to discharge the patient is paramount.
Furthermore, when a patient has been medically stabilized but remains on the medical unit with an inability to be discharged, consideration should be made when petitioning for coverage. If they continue to get treatment for an acute psychiatric condition, should the psychiatric insurer or psychiatric division of the patient’s insurance be petitioned? Denial of coverage for “pure psychiatric” services is common by non-Medicare FFS medical insurers. Still, hospitals may not be taking advantage of the possibility that the psychiatric division could be willing to pay for psychiatric care in the inpatient medical unit if the patient is receiving active treatment for an acute psychiatric condition.
THREE KEY STRATEGIES
1. Consider Creative Solutions
To improve the management of patients with medical and psychiatric comorbidities, consider these questions:
- What may behavioral health resources be available?
- Is psychiatric telemedicine or a behavioral health consultant at another hospital willing to be on call?
- Are we fully expanding our team to include psychiatric nurse practitioners or physician assistants?
- What is the return on investment for obtaining coverage for psychiatric consultation if psychiatric decompensation and unavailability of psychiatric consultation or resources prolong LOS?
- How can we engage and educate hospitalists in documenting how psychiatric issues are complicating the medical treatment of a patient or in being able to initiate treatment for some patients with acute psychiatric issues (for example, treating patients with dementia and agitation with a low dose of Seroquel?)
- Can discharge plans for the patient be dynamic–or is inpatient psych the only option?
- How can we support our discharge planners to be more aggressive in placing high-priority patients?
- How can we better communicate with potential accepting facilities which patients have the highest priority (i.e., discussing all patients during a quick daily phone check-in, etc.?)
- Can we be more assertive in petitioning the psych insurer (or psych division) of a patient’s insurance for coverage for patients receiving “purely psychiatric” care on the medical unit that the medical insurance will not cover
2. Clear Documentation
Documenting the following can help assuage initial denials and arm a physician advisor with a strong command of payer policies to win peer-to-peer conversations with payors for the patient and the hospital:
- The medical and psychiatric acuity of a patient’s condition
- A clear distinction between acute behavioral changes versus chronic behavioral issues
- The anticipated endpoint of care (what symptoms need to be acutely stabilized to achieve safe discharge versus what symptoms are chronic for the patient?)
- How psychiatric comorbidities complicate medical treatment for the patient
- All efforts by the care team to appropriately place a patient who needs inpatient psychiatric care
3. Generate ROI from Innovation and Expanded Resources
Caring for patients with psychiatric issues carries enormous financial costs, exacts a toll on providers, and is growing exponentially. Strategies to create ROI include:
- Engage physician advisors with ED, inpatient and case management teams, and the broader community to invest in resources to help patients, families, and providers.
- Measure return on investment via lowering LOS, ability to stabilize a patient for an alternative level of care, and other key benefits from innovative resources and programs.