Complex Care for Behavioral Health Comorbidities Seen to Lower LOS

Nurse Leader Insider, October 5, 2017

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By Jennifer Thew, RN
Originally appeared in Health Leaders Media.

"Oh, East is East, and West is West, and never the twain shall meet." That line from a Rudyard Kipling poem is a good explanation of the way healthcare has typically viewed medical issues and behavioral health issues.

But the reality is the two do not exist in separate realms. They can, and do, occur simultaneously and each can have a profound impact on the other.

To address this reality and improve patient care, Reading Hospital in Pennsylvania opened a medical complexity unit for patients who have primary medical diagnoses and a psychiatric comorbidity.

The 19-bed unit opened on June 26, 2017 and is medically comanaged by psychiatry and the organization's hospitalist program. Ann Blankenhorn, RN, MSN, MBA, NEA-BC, is the facility's senior nursing director.

"We wanted to look at safety and efficiency, and we wanted to look at a holistic approach to care—that we were caring for the whole person not just their pneumonia or their cellulitis. We wanted to make sure we weren't missing any of the psychosocial components or the psychiatric diagnoses that they many have had," she says.

Care Criteria

The organization realized there was a need for the unit when its consult liaison team saw a 38% increase in consultations for this patient population in the main hospital setting.

"These were patients that we were seeing in our hospital," she says. "Previously the [consult liaison team members] were going all over the hospital making sure they didn't miss anybody. Now, we're able to cohort that team a little bit better."

The unit is staffed by registered nurses and patient care assistants who receive training in non-violent crisis intervention and education on being proactive with behavioral aspects of care and psychiatric illnesses as well as traditional medical/surgical knowledge, Blankenhorn says.

To be admitted to the unit, patients must have a primary med/surg diagnosis and a coexisting behavioral health diagnosis. However, they do not have to be in a mental health crisis to receive care.

"If somebody comes in and they're non-compliant with their diabetes [care plan] and their sugars are in the 500s, but they happen to have a long-term mental health diagnosis, that would be somebody that would be ideal because we can manage their medical issue while also making sure they don't backslide with their psychiatric medications or the treatment they were receiving psychiatrically," she explains.

In addition to a variety of medical diagnoses, patients may also present with behavioral health issues such as delirium, toxic ingestion, overdose, or substance withdrawal.

An active mental health crisis is not necessary for admission, however. Additionally, patients from the hospital's inpatient mental health unit who require medical intervention may also be cared for on the unit.

"We're also looking at our relationship with other facilities that send us patients with mental health diagnoses that have a medical problem so we can develop relationships and really enhance that care for the patient," Blankenhorn says.

Promising Outcomes

In addition to providing consistent, patient-centered care, Blankenhorn says the unit's goals are to decrease the need for one-to-one care and length of stay.

"Oftentimes, this patient population could have a longer length of stay if they get mixed in with the crowd," she says.

"On this unit, we have a dedicated social worker and case manager. We do daily interdisciplinary walking rounds at 8 a.m. so we're able to really focus on what the needs of the patient are and what we need to do to get them to the next step in their care."

In the unit's first three months, Blankenhorn estimates that around 15 to 20% of the patient population need to go on for inpatient psychiatric care once their medical issue is resolved.

"Our length of stay in our first two months was below six days," she says. "And on average we were seeing 11 days for this patient population. So, we've seen some optimistic results there."

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