Brief
Providing Treatment
Short-Term Intensive in Public Psychiatry
Marjorie
0.
Vincenzo Stephen
R. Sanguineti, L. Schwartz,
Brooks,
Ph.D.
M.D. M.D.
programs that have had varying success in providing rapid intervention in the treatment of acutely mentally ill patients have been dcscribed in the last decade (1-3). Such programs often constitute a muchneeded bridge to ongoing psychiatric treatment and services in the public sector for chronic mentally ill patients. This paper describes a short-term intensive psychiatric treatment unit at a general hospital in Philadelphia and provides data on the number of admissions and their disposition in the first 35 months ofthc program’s operation. The unit was a joint effort of the city’s Office ofMental Health and the department of psychiatry at Jefferson Medical College. Several
Program description The 24-bed locked unit operated between February 1987 and July 1990 at a general hospital located near jefferson Medical College. Operation of the unit was integrated with various programs comprising the city’s public mental health system. The unit also offered opportunities for training and research to faculty and students in the department ofpsychiatry at the medical college.
Dr. Brooks is assistant professor, Dr. Sanguineti is assistant clinical professor, and Dr. Schwartz is associate clinical professor in the department of psychiatry and human behavior at Jefferson Mcdical College, 10th and Walnut
Streets, vania
74
Patients were referred to the unit from the city’s psychiatric crisis centers and medical emergency services, through a system coordinated by the Office ofMental Health. Patients admitted to the unit were involuntarily committed in accordance with rcgulations for emergency involuntary commitment that are part of the Pennsylvania Mental Health Procedures Act of 1976 (6). Pennsylvania commitment laws permit five days ofemergency hospitalization. Within these five days, the treating psychiatrist presented most patients to the mental health court with a petition for commitment for extended treatment. Courtordered dispositions included continued inpatient treatment, commitment for outpatient treatment, or discharge without obligation for furthen treatment. The unit’s social workers arranged transfer to appropniate inpatient facilities or coondinated outpatient services for patients who were judged by the court to require further treatment. The unit’s diical functions were performed by two fully staffed cliicat teams. Treatment was intensive and usually resulted in sufficient reduction of symptoms to allow the patient to be discharged within five days to a less intense level of care, such as outpatient treatment, partial hospitalization, or residential treatment. Patients who were not sufficiently stabilized within the five days of emergency hospitalization were transferred to an inpatient facility for further treatment. Meeting these goals appropriately required rapid and coordinated application ofcliical skills by the multidisciplinary treatment team and open communication among team members. Effective networking was essential, particularly by social work staff, who created linkages with the city’s administrative, clinical, and outreach services and coordinated disposition of patients discharged from the unit. Clinical strategies were directed to factors that affect short-term prognosis and that are most closely related to prompt discharge ofpatients. Specific clinical objectives included assessing the severity of the illness and
Reports
Philadelphia, 19107.
Pennsyl-
The city’s Office ofMental Health had three goals for the unit. First, the city hoped that it would relieve some ofthe burden on the citywide system ofpsychiatnic emergency services and would help ensure that any person in crisis would have access to emergency psychiatric treatment. Second, the unit was expected to stabilize and prepare acutely ill patients for prompt return to the community or for a smooth transition to continued inpatient treatment. Third, it was anticipated that the unit would identify chronic mentally ill persons who were frequent users ofpsychiatnic services and integrate them into the city’s intensive case management program (4). The department of psychiatry at Jefferson Medical College supported the program because it offered opportunities to increase residents’ skills in emergency psychiatry and bniefinterventions and to expand the department’s orientation in public psychiatry. The city and the medical college agreed to a contract that stipulated their respective obligations and responsibilities in operating the unit. The city agreed to provide case management liaison to patients immediately after they were admitted to the unit and to provide follow-up inpatient or outpatient treatment after discharge (5). The department of psychiatry of Jefferson Medical College and ThomasJefferson University Hospital provided professional clinical services and management of the unit, including the services of psychiatnists, psychiatric residents, medical students, social workers, activity therapists, and research and secretarial staff through contract with the host hospital.
January
1992
Vol.
43
No.
1
Hospital
and
Community
Psychiatry
thepresence ofmcdical illness or substance abuse comorbidity, initiating intensive treatment directed toward discharge within five days, and implementing and monitoring pharmacologic treatment. Staffpaid special attention to issues of noncompliance and tried to teach patients and members of their families about mental illness and the ef1cts of mcdication. Staff also assessed patients’ psychosocial supports and initiated interventions to alleviate psychosocial stressons. Research conducted by unit staff focused on identifying and assessing factors associated with admission, recidivism, treatment effects, and substance abuse by chronic mentally ill patients. In addition, research staff maintained a computerized data base and performed quality assurance of unit operations and program evaluations. Admissions and disposition During the first 35 months of the unit’s operation, 3,100 admissions, on 2,278 patients, were referred, treated, and discharged. Of these, 1 ,780 patients represented single admissions. The remaining 498 pensons were admitted 1,320 times, of which 822 were neadmissions. Some patients were readmitted as many as eight times. A total of 26.5 percent ofthe admissions were readmissions. The mean number of admissions per month was 88.6, with a range from 72 to 1 19 admissions. The mean daily census was 19.3, with a mean weekly range from 1 5.8 to 21.3. Patient sociodemographic and diagnostic profiles were consistent with those reported in the literature describing other samples of chronic mentally ill patients (7). The median length of stay was 5.2 days. The mean±SD length ofstay of 6.5±4.63 days exceeded the targeted five-clay length of stay. Of all admissions, 182 (5.9 percent) resulted in discharge and 27 (.9 percent) resulted in transfers initiated by the unit’s psychiatrists before the patient’s case was presented at mental health court. Patients who were discharged were nonpsychotic or had primary substance abuse diagnoses; they were referred to outpatient treatment. Patients
Hospital
and Community
Psychiatry
who were transferred without further mandate by the mental health court required intensive medical treatment
or
had
changed
their
indicated that the unit’s ongoing research and training activities helped to focus attention on local issues in public psychiatry and to enhance the quality ofservicc provided. The readmission rate of 26.5 percent was high but not unusual, given the severe, refractory illnesses of the population treated (8). This rate may reflect the consequences of mappropniate court-ordered discharges of patients whose behavior did not fit legal criteria for commitment but who clearly needed further hospital treatment. The rate may also reflect deficiencies in the system of comprehensive care for chronic mentally ill patients. Evaluation ofreadmitted patients suggested that enhanced mental health services, such as a higher level ofcase management and mobile crisis intervention services, could have ncsulted in a lower neadmission rate. The effect of bniefacute treatment is maximized when it is part ofa comprehensive care system such as those described by the American Psychiatnc Association’s policy statements on public psychiatry (9,10). Without doubt, this intensive treatment service sufl#{232}ned from the vagaries of public funding and the constraints of medicolegal negulations. Nevertheless, data on the unit’s operation showed that a wellplanned and -executed liaison between a public agency and a private institution can meet academic standancis in psychiatry, provide highquality service to chronic patients, and respond to the needs of the local mental health system.
treatment
status to voluntary commitment. The remaining 2,891 admissions (93.2 percent) were presented to the court with the recommendation for continued inpatient treatment. The court ordered continued inpatient treatment in 2,270 cases (73.2 pencent) and discharged patients in 229 cases (7.4 percent) because the petitioner was absent on because the commitment petition was legally weak. The mental health court discharged significantly more patients than were discharged by unit psychiatrists (229 patients, compared with 182 patients; t=17.06, df=409, p
Providing Treatment
Short-Term Intensive in Public Psychiatry
Marjorie
0.
Vincenzo Stephen
R. Sanguineti, L. Schwartz,
Brooks,
Ph.D.
M.D. M.D.
programs that have had varying success in providing rapid intervention in the treatment of acutely mentally ill patients have been dcscribed in the last decade (1-3). Such programs often constitute a muchneeded bridge to ongoing psychiatric treatment and services in the public sector for chronic mentally ill patients. This paper describes a short-term intensive psychiatric treatment unit at a general hospital in Philadelphia and provides data on the number of admissions and their disposition in the first 35 months ofthc program’s operation. The unit was a joint effort of the city’s Office ofMental Health and the department of psychiatry at Jefferson Medical College. Several
Program description The 24-bed locked unit operated between February 1987 and July 1990 at a general hospital located near jefferson Medical College. Operation of the unit was integrated with various programs comprising the city’s public mental health system. The unit also offered opportunities for training and research to faculty and students in the department ofpsychiatry at the medical college.
Dr. Brooks is assistant professor, Dr. Sanguineti is assistant clinical professor, and Dr. Schwartz is associate clinical professor in the department of psychiatry and human behavior at Jefferson Mcdical College, 10th and Walnut
Streets, vania
74
Patients were referred to the unit from the city’s psychiatric crisis centers and medical emergency services, through a system coordinated by the Office ofMental Health. Patients admitted to the unit were involuntarily committed in accordance with rcgulations for emergency involuntary commitment that are part of the Pennsylvania Mental Health Procedures Act of 1976 (6). Pennsylvania commitment laws permit five days ofemergency hospitalization. Within these five days, the treating psychiatrist presented most patients to the mental health court with a petition for commitment for extended treatment. Courtordered dispositions included continued inpatient treatment, commitment for outpatient treatment, or discharge without obligation for furthen treatment. The unit’s social workers arranged transfer to appropniate inpatient facilities or coondinated outpatient services for patients who were judged by the court to require further treatment. The unit’s diical functions were performed by two fully staffed cliicat teams. Treatment was intensive and usually resulted in sufficient reduction of symptoms to allow the patient to be discharged within five days to a less intense level of care, such as outpatient treatment, partial hospitalization, or residential treatment. Patients who were not sufficiently stabilized within the five days of emergency hospitalization were transferred to an inpatient facility for further treatment. Meeting these goals appropriately required rapid and coordinated application ofcliical skills by the multidisciplinary treatment team and open communication among team members. Effective networking was essential, particularly by social work staff, who created linkages with the city’s administrative, clinical, and outreach services and coordinated disposition of patients discharged from the unit. Clinical strategies were directed to factors that affect short-term prognosis and that are most closely related to prompt discharge ofpatients. Specific clinical objectives included assessing the severity of the illness and
Reports
Philadelphia, 19107.
Pennsyl-
The city’s Office ofMental Health had three goals for the unit. First, the city hoped that it would relieve some ofthe burden on the citywide system ofpsychiatnic emergency services and would help ensure that any person in crisis would have access to emergency psychiatric treatment. Second, the unit was expected to stabilize and prepare acutely ill patients for prompt return to the community or for a smooth transition to continued inpatient treatment. Third, it was anticipated that the unit would identify chronic mentally ill persons who were frequent users ofpsychiatnic services and integrate them into the city’s intensive case management program (4). The department of psychiatry at Jefferson Medical College supported the program because it offered opportunities to increase residents’ skills in emergency psychiatry and bniefinterventions and to expand the department’s orientation in public psychiatry. The city and the medical college agreed to a contract that stipulated their respective obligations and responsibilities in operating the unit. The city agreed to provide case management liaison to patients immediately after they were admitted to the unit and to provide follow-up inpatient or outpatient treatment after discharge (5). The department of psychiatry of Jefferson Medical College and ThomasJefferson University Hospital provided professional clinical services and management of the unit, including the services of psychiatnists, psychiatric residents, medical students, social workers, activity therapists, and research and secretarial staff through contract with the host hospital.
January
1992
Vol.
43
No.
1
Hospital
and
Community
Psychiatry
thepresence ofmcdical illness or substance abuse comorbidity, initiating intensive treatment directed toward discharge within five days, and implementing and monitoring pharmacologic treatment. Staffpaid special attention to issues of noncompliance and tried to teach patients and members of their families about mental illness and the ef1cts of mcdication. Staff also assessed patients’ psychosocial supports and initiated interventions to alleviate psychosocial stressons. Research conducted by unit staff focused on identifying and assessing factors associated with admission, recidivism, treatment effects, and substance abuse by chronic mentally ill patients. In addition, research staff maintained a computerized data base and performed quality assurance of unit operations and program evaluations. Admissions and disposition During the first 35 months of the unit’s operation, 3,100 admissions, on 2,278 patients, were referred, treated, and discharged. Of these, 1 ,780 patients represented single admissions. The remaining 498 pensons were admitted 1,320 times, of which 822 were neadmissions. Some patients were readmitted as many as eight times. A total of 26.5 percent ofthe admissions were readmissions. The mean number of admissions per month was 88.6, with a range from 72 to 1 19 admissions. The mean daily census was 19.3, with a mean weekly range from 1 5.8 to 21.3. Patient sociodemographic and diagnostic profiles were consistent with those reported in the literature describing other samples of chronic mentally ill patients (7). The median length of stay was 5.2 days. The mean±SD length ofstay of 6.5±4.63 days exceeded the targeted five-clay length of stay. Of all admissions, 182 (5.9 percent) resulted in discharge and 27 (.9 percent) resulted in transfers initiated by the unit’s psychiatrists before the patient’s case was presented at mental health court. Patients who were discharged were nonpsychotic or had primary substance abuse diagnoses; they were referred to outpatient treatment. Patients
Hospital
and Community
Psychiatry
who were transferred without further mandate by the mental health court required intensive medical treatment
or
had
changed
their
indicated that the unit’s ongoing research and training activities helped to focus attention on local issues in public psychiatry and to enhance the quality ofservicc provided. The readmission rate of 26.5 percent was high but not unusual, given the severe, refractory illnesses of the population treated (8). This rate may reflect the consequences of mappropniate court-ordered discharges of patients whose behavior did not fit legal criteria for commitment but who clearly needed further hospital treatment. The rate may also reflect deficiencies in the system of comprehensive care for chronic mentally ill patients. Evaluation ofreadmitted patients suggested that enhanced mental health services, such as a higher level ofcase management and mobile crisis intervention services, could have ncsulted in a lower neadmission rate. The effect of bniefacute treatment is maximized when it is part ofa comprehensive care system such as those described by the American Psychiatnc Association’s policy statements on public psychiatry (9,10). Without doubt, this intensive treatment service sufl#{232}ned from the vagaries of public funding and the constraints of medicolegal negulations. Nevertheless, data on the unit’s operation showed that a wellplanned and -executed liaison between a public agency and a private institution can meet academic standancis in psychiatry, provide highquality service to chronic patients, and respond to the needs of the local mental health system.
treatment
status to voluntary commitment. The remaining 2,891 admissions (93.2 percent) were presented to the court with the recommendation for continued inpatient treatment. The court ordered continued inpatient treatment in 2,270 cases (73.2 pencent) and discharged patients in 229 cases (7.4 percent) because the petitioner was absent on because the commitment petition was legally weak. The mental health court discharged significantly more patients than were discharged by unit psychiatrists (229 patients, compared with 182 patients; t=17.06, df=409, p
