Not So Involuntary: Hospitalists and Psych Holds

by Dr. Atashi Mandal MD

He sat on the gurney, with averted eyes and contorted posture, as to avoid my encroaching examination. The usual jargon populated my assessment: psychomotor retardation, flat affect, poor vocalization… I glanced at his intake form and noted that he had been admitted to the emergency treatment unit for suicidal ideation, removed from a family with a history of incarceration, drug use and neglect. At my coaxing to face forward, I glimpsed at the tapestry of well healed linear scars from previous cutting attempts. I now needed to medically clear him so that he could receive his next placement in the “most appropriate setting”.  But I wondered if checking off boxes and signing a form was the most I could do for him.

Sadly, as hospitalists, this scenario is one most, if not all, of us have encountered. We have also grown accustomed to separating medical and behavioral problems into service lines that try not to intersect.  But we all know this is not reflective of the reality of psychiatric illness, and that continuing to function in these silos does a great disservice to this neglected population.  There have been a number of legislative efforts in the past to increase parity between medical and behavioral services, accessibility and payments, including the Mental Health Parity Act in 1996, followed by the Mental Health Parity and Addiction Equity Act in 2008, both of which made strides in requiring parity, but only for some insurers who already provided benefits for mental health and substance abuse.

However, the landscape grew more fruitful with the Affordable Care Act, which provides the long overdue linchpin of mandating coverage of mental health and substance abuse treatment as an essential health benefit. Additionally, spurred on by the opioid addiction crisis, a number of other bills have been introduced to promote enhanced mental health services, including more funding for research, evidence-based practices, telehealth services, and better integration of primary and behavioral healthcare.

One contentious issue that remains is privacy and accessibility of protected health information by trusted caregivers of impaired patients as well as information exchange between providers.  However, a number of recent developments may act as precedents for enhanced information sharing, such as the recent executive action by President Obama to facilitate interagency communication for background checks on gun purchases, as well as a litany of congressional hearings and bills to mandate greater interoperability of electronic health records.

So, meanwhile, what can we do to change this paradigm of fragmented care to one that is patient-centered, multidisciplinary and coordinated? I’m sure that model of care sounds familiar- it is what we hospitalists do best. We have already established our expertise as early adopters and proponents of new models of healthcare delivery. At the organizational level, we can continue to advocate for better accessibility to expert psychiatric care, by the hiring of dedicated psychiatrists or support for telemedicine services.  Additionally, we can take initiative in maintaining communication and coordinating care with our psychiatric colleagues. We can engage in better educational efforts among ourselves and our ancillary staff to judiciously and sparingly utilize sedating medications and restraints. Furthermore, we can advocate at the state and federal levels for passage of legislation that enhances accessibility, parity and information sharing.

Get started here: Ask Congress to support important mental health legislation that will improve patient care via mandating Medicaid coverage for same day mental and primary care services, creating a dedicated office for mental health and substance abuse issues, and providing grants for telehealth services. You can take action with the Society of Hospital Medicine now: https://www.votervoice.net/SHM/campaigns/43146/respond

But we need no special dispensation to provide our most precious therapeutic commodities: our time and compassion, remembering the tremendous suffering that ensues when one is a prisoner of one’s own mind. I told him it didn’t have to be this way for him forever- that he could have a better life, and that I believed in him. The flat affect faded into a faint smile.

 

Dr. Atashi Mandal is a practicing adult and pediatric hospitalist in Los Angeles and Orange County areas. She is also a member of SHM’s Public Policy Committee.

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