Med-psych interface/units

[393656]

Hi guys, wondering if anyone has an interest in the medical-psych interface in the form of either med-psych units or liason with outpatient IM doctors? This is a big interest of me and as a 4th year resident had a great experience consulting in the outpatient IM resident clinic at a large university and the interface was absolutely great. It built up so much respect and great relationship with the entire department.

I am starting a new job out in Arizona (anyone from AZ here?) at a large hospital that is not a university hospital and not a teaching hospital although have some residents rotate (just to give a perspective on what kind of place) It is a very large hospital with all sub-specialities, inpatient/outpatient psych etc.

I have the great opportunity to start a med-psych unit that will be fully integrated into the medical floors (not in psych building) as a floor on the medicine units. There will be an IM attending and psych attending (myself) who will be co-attendings. This is brand new at this hospital and it will get started later this summer so lots of kinks to work. The cool thing is there is a lot of room to design it from the ground up. I have done a lot of reading on the various types that exist and a big variation seems to be out there. This will be severe medical and severe psych-reason for being in the medicine part of hospital to be able to handle anything v. some med-psych units on psych floors cannot handle really complex medical.

Anyway wondering if anyone has experience with these units and things that work, do not work or from experience would like to see in a med-psych unit that maybe your unit didnt have but would have benefited from?

Thanks guys

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[nitemagi]

Sadly, I'd be content with a unit that would do blood draws in less than 6 hours.

 

[billypilgrim37]

Sadly, I'd be content with a unit that would do blood draws in less than 6 hours.

SDN needs a Like button.

 

[393656]

SDN needs a Like button.

HAHAHA totally!

That is the story of my residency-OMFG NO NO NO someone needs a liter of fluid, someone needs a blood draw that is NOT at 7AM, I NEED nicotrol ihalers STAT-

that is the story of my inpatient unit now as a resident!!!

 

[whopper]

I was told that U. of Cincinnati is possibly working on a specific med-psych unit.

It's uncommon, but on the order of at least once every 2-3 months, I saw a case in general psychiatry where the medical/psychiatric interplay was vitally important to the point where the patient was actually not getting adequate treatment, but because of the separation of the two fields, and of course a narcissistic doctor not willing to talk to the other doctor, the patient's case did not advance.

E.g. As a resident, I saw a patient with tooth pain that was suicidal as a result of it. In the hospital I was at, she could not see a dentist there, nor could a dentist enter the psychiatric unit to treat her. She told us she would not be suicidal if her tooth pain went away and it was not being treated with PRN acetaminophen or ibuprofen.

After two weeks of her suffering in pain, she was transferred to the long term facility because she was still suicidal, and her tooth was never treated.

I had another patient that was "medically cleared" but was suicidal. She told me she was that because of pain in her abdomen. The GI doctor medically cleared her without doing any labs, IMHO because he just didn't like dealing with psychaitric patients. She was transferred to our unit, but the attending psychiatrist argued that her suicidality was due to her medical problem not being treated. The hospital rule was that a consult had to be referred to her original GI doctor, who without seeing her merely wrote that she was fine.

Finally, after about 12 days of the patient suffering, the hospital got another doctor to see the patient, and it turned out the patient did indeed have some GI problems needing treatment.

Again, a case where the right thing was obvious, but due to hospital politics and bureacracy nothing was done in an appropriate amount of time.

 

[393656]

Its probably pretty hospital specific as far as the need goes. Atleast where I trained a lot of a need for med-psych is logistics of how long people awaiting psych placement sit on the medical floor (days or weeks) due to lack of psychiatric beds. They do not recieve any (or minimal) treatment sitting up there and it ties up a lot of resources. The idea is to be able to treat their psych needs in a quality fashion (maybe not quite as good as a dedicated psych unit) while they are recovering medically from a suicide attempt or other medical issues that end up causing a patient to be suicidal.

The biggest part of it would be better management of delirious patients so they do not have to sit there untreated and would have a place to be put and treated quickly.

But its the logistics and real life workings of a unit that I lack and am trying to learn about.

 

[Manicsleep]

Sadly, I'd be content with a unit that would do blood draws in less than 6 hours.

Dual units are great. I proposed a level based system once and was summarily shot down but in my opinion there should be a level based system. I think it had to do with something trivial like finances.

Med psych. with primary team assigned based on chief complaint.
Geropsych, addiction, neuropsych.
Regular psych.
Axis II psych.

It would allow for better teaching and treatment. It would also allow for more appropriate and faster discharge.

 

[michaelrack]

Med-psych units don't work too well outside of academia- especially if they are not run by a doctor who is dually-trained.

"There will be an IM attending and psych attending (myself) who will be co-attendings"

Who will have ultimate responsibilty for the patient? One of you will be the attending of record, and the other will be a consultant (though who plays which role can vary from patient to patient).

 

[393656]

Yes to clarify on paper the IM doctor will do the billing as the primary doctor as obviously the medical stuff will be the majority of cost in a med-psych unit. I would be billed as the consultant. However practically the unit does not exist yet so the way we have been talkin about it would be two attendings working together. Obviously its nice if you work well with someone but yes surely kinks will need to be worked out.

And actually disagree that it works better in academia. Private hospitals are more geared to profits and med-psych units have huge possibility of profits as insurance pays much more for medical stays than psych stays, therefore if someone avoids going to a pure psych floor and is in the med-psych unit, they will get a ton of reimbursement without having to take a loss or barely get paid in the psych unit. There is a lot of literature out there on cost savings so that is not something really up for debate-the evidence already exists. Also patient care is much more efficient and better compared to the model of consultants not even talking to each other.

 

[Manicsleep]

I had suggested psych primary with medicine consulting daily so that billing from both ends would be possible but it didn't work out.

I had something like this at the VA where I worked a while back although they got the chief residents to act as attending with a PGY2 actually running the service (good enough for govt work).

 

[393656]

The only way it works financially is to have IM as the primary and treat it like any other medical unit because the people (atleast on the unit I am talking about) have severe enough medical problems that they otherwise would be on a normal medical floor with a psych consultant. So medical coverage is not an issue. The psych is also needed and would otherwise be a consultant on the patient. Its not that you get paid anymore having this unit but you save bed days and time in the hospital which is the benefit, not to mention patient outcomes and care is better and more efficient. Just having 2 doctors that are in constant communication is a huge benefit as this does rarely happen in a simple consulstant relationship (in my experience anyway)

 

[Manicsleep]

It really depends.
After a while you (psychiatrists) get so used to treating certain things that you can do it with certain basic guidelines. Also, the nursing is different on these floors.

So having psychiatry being the primary is more appropriate if the person is, for example, a demented schizophrenic who has CHF with an EF of 35%, afib, brittle DM and COPD being admitted for a psychotic episode. Here, I need someone to tune him up medically and monitor him from a nsg standpoint too but I can be the primary. Contrast that with someone who is all those things but comes in with chest pain. They need a psychiatrist, but the problem is cardiac.

The chief complaint should really be your guide. Unfortunately turf wars break out and that is even before the finances come into play.

 

[393656]

It really depends.
After a while you (psychiatrists) get so used to treating certain things that you can do it with certain basic guidelines. Also, the nursing is different on these floors.

So having psychiatry being the primary is more appropriate if the person is, for example, a demented schizophrenic who has CHF with an EF of 35%, afib, brittle DM and COPD being admitted for a psychotic episode. Here, I need someone to tune him up medically and monitor him from a nsg standpoint too but I can be the primary. Contrast that with someone who is all those things but comes in with chest pain. They need a psychiatrist, but the problem is cardiac.

The chief complaint should really be your guide. Unfortunately turf wars break out and that is even before the finances come into play.

Someone needing a tune up however shouldnt be considered for a med-psych unit. That can be easily accomplished with an IM consult on a regular psych floor. The entire point is a unit for medically unstable people who could not go to the psych floor and would be treated medically first then transferred to psych when stable. This unit can treat them or begin treating while they are having to be on the medical floor whether it be for monitoring after OD< delirium or another serious medical problem that presents with a psych symptom after they already got to the hospital.

Mild medical problems or moderate ones where the patient is stable would simply go to psych with IM consults.

 

[michaelrack]

. There is a lot of literature out there on cost savings so that is not something really up for debate-the evidence already exists. Also patient care is much more efficient and better compared to the model of consultants not even talking to each other.

I agree that there is cost savings for the health care system, but this is a lot different from profit for the hospital.

My experiences in med-psych (including attending on a med-psych ward) are limited to academia.

Look forward to hearing about your experiences in about a year. I hope you are successful.

One tip for you- finding the MD staffing for a med/psych ward is the easy part- finding the nursing staffing is the hard part.

 

[393656]

Yes I obviously can't speak directly to the cost savings. From my reading and investigating that is what seems to be the concencus. What spurred the movement on at my new job was too many patients sitting on medical floors getting no treatment while waiting for psych beds-largely due to lack of psych beds. This makes IM very unhappy and the hospital as they are often not being reimbursed for these people to sit here and recieve no real treatment.

Financial is peripheral for me however and I am more interested in the clinical side. I feel the hospital patient populuation is severely undertreated and I have a special interest in delirium being either undiagnosed, late diagnosis or mis-treated. The morbidity rate is so high in delirium that this is one thing faster accurate treatment would really make a difference.

The other big thing that is often missed is working as a team with IM to use medications that work for both of us and not having a bunch of meds that cause psych problems or vice versa. Utilizing consults just doesnt provide much of this.

The most important is I just enjoy the medical aspect of these patients. I like the psychotic or delirious patients who have a mysterior underlying medical condition.

The coolest one I have had was a 50 year old lady with leukemia and paraneoplastic induced lupus cerebritis. Presented with psychosis and mania. Blasted with steroids and was fine. 9.9/10 this would have been blasted with anti-psychotics and probably missed if simply treated by the primary team. So having a system where sick medical pts with psych symptoms go to the med psych unit guarentees a thorough workup from 2 different approaches (im and psych)

Now this is all my hope. I may hate it, or it may not work logistically--who knows. I would be happy if anyone else with expereince continues to keep in touch and discuss some of this. In the end I think its better for patietns.

 

[Midwest Doc]

Sorry for the delay in responding to this thread but it was only recently brought to my attention.

I am boarded in internal medicine and psychiatry and ran a med-psych unit, now called complexity intervention units (CIUs), for 13 years at a university hospital. The unit I started and worked on is still in operation, even after an 11 year absence.

Since leaving full time academic practice, I have been helping others develop integrated programs, not just CIUs. In fact, with the heatlh reform changes going on, there is an increased interest by many hospitals in pursuing this approach to improved patient care. There are several specific questions that are answerable in the thread that you started in April.

1. There is no advantage of an academic center over a private/county hospital or hospital system. Comorbid patients are found in both these settings. While improved care is the rule, cost savings and patient safety are the primary motivations for starting units.

2. It is easy to find nurses to work on CIUs if it is properly set up and they are trained in cross disciplinary care. Nurses like "holistic" patient care. Having helped set up a number of units, this has never been a problem.

3. Setting CIUs up as full service medicine units is preferable to setting them up as psych for economic (billing) reasons. It is best to have full psych safety capabilities and consolidated med and psych policies and procedures, however, since the greatest health improvement and cost savings occurs in those with more complicated and acute illness. This can only be done if the unit is set up to take care of really sick psych patients.

4. The best model is a co-attending model for professional billing. The med attending is primarily responsible (and bills) for med conditions and the psych for the psych illness(es). In the consultant model, the consultant always loses. I never had trouble with collections for either my med or psych staff, nor legal issues (same day billing) during 13 years of operation. Jointly trained docs, e.g. FP/psych, IM/psych, are helpful but not necessary for an effective CIU.

5. About 2 to 5% of general hospital admissions are appropriate for admission to CIUs, though CIUs should take only the worst of these. In general hospitals without CIUs, most psych issues are never addressed. It is impressive to see the number of actively delirious patients discharged from general hospitals since their medical conditions no longer meet medical continued stay criteria. A quick look at delirium outcome stats gives one an idea about how great a disservice this is to these patients.

There are many other points that I could make but this is a start. CIUs are going to be increasingly important in the future so PC or psych residents interested in this area of practice will have many opportunities in the future. Having taken care of these patients for years, I can also say that they are some of the most interesting and challenging in medicine.

 

[houseforrent]

Hi guys, wondering if anyone has an interest in the medical-psych interface in the form of either med-psych units or liason with outpatient IM doctors? This is a big interest of me and as a 4th year resident had a great experience consulting in the outpatient IM resident clinic at a large university and the interface was absolutely great. It built up so much respect and great relationship with the entire department.

I am starting a new job out in Arizona (anyone from AZ here?) at a large hospital that is not a university hospital and not a teaching hospital although have some residents rotate (just to give a perspective on what kind of place) It is a very large hospital with all sub-specialities, inpatient/outpatient psych etc.

I have the great opportunity to start a med-psych unit that will be fully integrated into the medical floors (not in psych building) as a floor on the medicine units. There will be an IM attending and psych attending (myself) who will be co-attendings. This is brand new at this hospital and it will get started later this summer so lots of kinks to work. The cool thing is there is a lot of room to design it from the ground up. I have done a lot of reading on the various types that exist and a big variation seems to be out there. This will be severe medical and severe psych-reason for being in the medicine part of hospital to be able to handle anything v. some med-psych units on psych floors cannot handle really complex medical.

Anyway wondering if anyone has experience with these units and things that work, do not work or from experience would like to see in a med-psych unit that maybe your unit didnt have but would have benefited from?

Thanks guys

It's several years since you posted this - wondering what your success was with starting the med/psych unit in Arizona. I work for the University and am interested in what you found out.