Inpatient Psych: when to admit and discharge

[throw-away-go-away]

Our inpatient is mostly at a Private Community Hospital in a big city.

For admission, I don't think we have criteria. We take admissions that the other hospitals refuse (for not meeting admission criteria) all the time.

For discharging, criteria seems non existant.

It's easy to study Maudsley, Stah;s, KS, DSM5 to learn more, but what would you recommend for really getting a good handle on who should really be admitted and when they should be discharged. I feel like when I work some place else I am going to run into a lot of issues.

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[splik]

Each institution will have widely different criteria. Private for profit hospitals will take anyone, sometimes with very dubious diagnoses, hospitalize them for as long as insurance pays, and then discharge them. On the other end, many public facilities will only admit patients who are a danger to others or totally incapable of caring for themselves due to gross disorganization. Veterans Hospitals often have very soft criteria for admission. Some states have plenty of beds meaning patients can more easily be admitted, whereas there is a scarcity in other states.

I suppose you could read the McKesson Interqual criteria if you wanted to get a sense of what insurance usually pays for. Otherwise, this is something that is really dependent on the particular setting, the patient population, the available resources (there may be a lower bar for admission if there is no PHP/IOP available or crisis diversion services), the number of beds, and what insurance pays for. This is why it is good to train in a program where you rotate at multiple sites. If not, moonlighting at different facilities will also give you a sense of things. In short, you have to adapt to the setting you are working in. Of course, you should avoid harm and ethically dubious practices (for example UHS one of the big for profit chains illegally held patients and fraudulently billed for unnecessary or imagined services on an epic scale) regardless of where you work.

 

[PikminOC]

Each institution will have widely different criteria. Private for profit hospitals will take anyone, sometimes with very dubious diagnoses, hospitalize them for as long as insurance pays, and then discharge them. On the other end, many public facilities will only admit patients who are a danger to others or totally incapable of caring for themselves due to gross disorganization. Veterans Hospitals often have very soft criteria for admission. Some states have plenty of beds meaning patients can more easily be admitted, whereas there is a scarcity in other states.

I suppose you could read the McKesson Interqual criteria if you wanted to get a sense of what insurance usually pays for. Otherwise, this is something that is really dependent on the particular setting, the patient population, the available resources (there may be a lower bar for admission if there is no PHP/IOP available or crisis diversion services), the number of beds, and what insurance pays for. This is why it is good to train in a program where you rotate at multiple sites. If not, moonlighting at different facilities will also give you a sense of things. In short, you have to adapt to the setting you are working in. Of course, you should avoid harm and ethically dubious practices (for example UHS one of the big for profit chains illegally held patients and fraudulently billed for unnecessary or imagined services on an epic scale) regardless of where you work.

What's uhs?

 

[brycew85]

As far as discharges go a wise attending once told me:

"If the patient wants to leave, they should probably stay. If the patient wants to stay, they should probably leave"

 

[clozareal]

What's uhs?

huge healthcare system all over the US with lots of facilities in the east and south.

 

[PikminOC]

United hospital systems?

 

[hallowmann]

Here, IF we have a bed, it goes to the most acute person. If there's high suicidality, self-harm, homicidality, or severe self-neglect 2/2 to their condition, they can usually be admitted, assuming there is not a way for them to be effectively managed outpatient even with close follow-up and they will actually "benefit" from hospitalization.

This criteria obviously leaves plenty of room for interpretation.

 

[comp1]

Admission and discharge are clinical decisions, but both are based almost entirely on what the available resources are in a particular area at a given time, inpatient and outpatient. Thus, you probably won't find a very satisfying answer here. You got a great DBT PHP? You might not admit that suicidal patient with borderline PD. No one knows what DBT is in the state you're practicing in? You probably will admit them and then keep them longer than you would in a place with a robust step down program. The patient doesn't change.

 

[UTsksk]

Admission and discharge are clinical decisions, but both are based almost entirely on what the available resources are in a particular area at a given time, inpatient and outpatient. Thus, you probably won't find a very satisfying answer here. You got a great DBT PHP? You might not admit that suicidal patient with borderline PD. No one knows what DBT is in the state you're practicing in? You probably will admit them and then keep them longer than you would in a place with a robust step down program. The patient doesn't change.

I wish my hospital (public hospital that takes all the people who don’t have good insurance) had a PHP or IOP. There are plenty of patients admitted that don’t necessarily need an admission.

 

[robellis]

United hospital systems?

Universal Heath services

 

[NickNaylor]

For most insurers, admission criteria are:

- Imminently dangerous to self, OR
- Imminently dangers to others, OR
- Marked decline in functioning such that the patient is unable to function outside of the hospital setting

AND

- Unable to be managed appropriately in the outpatient setting

Discharge criteria generally mirror these points. I would note that the goal is not to completely eliminate any safety risks, and patients will often remain symptomatic at discharge. This is a critical teaching point for many residents, who often have very unrealistic expectations of what will be accomplished during an inpatient admission. As long as a patient has improved sufficiently such that they are able to continue to engage in treatment after discharge - e.g., a patient who presents acutely psychotic has at least some degree of insight into the potential benefits of continuing to engage in treatment - and you are convinced that the patient is unlikely to kill themselves or others imminently after discharge, you will likely start to receive pressure from payers to discharge. In short, you need to be able to provide a justified answer to the question, "why can't this patient receive the treatment that you're offering in a less restrictive setting (e.g., PHP/IOP, general outpatient follow-up, etc.)?" Some payers are just idiotic - e.g., one payer that we are contracted with will refuse to authorize severely depressed patients with marked neurovegetative symptoms because they argue that the patient doesn't have the ability to actually kill themselves - but if you can make a case in your documentation that inpatient management is necessary and that the patient is receiving benefit, you likely won't have too much trouble.

Whether or not those criteria are appropriate and/or whether patients that do not meet those criteria could benefit from inpatient treatment is another question altogether. I would argue that 1) they are too restrictive and 2) patients can benefit from inpatient admission even if they are not imminently dangerous or profoundly functionally declined, but most payers will disagree. Whether or not that is relevant to your practice will depend on the setting that you're working in and the financial pressures your unit is under. As an example, our unit's contribution to our health system is not providing revenue, thus the fact that we lose 7 figures annually is less of a concern to the broader institution and institutional leadership. Our value is provided elsewhere (teaching, making disposition from the ED easier, a sense that a leading academic institution should provide all available services regardless of other factors, etc.). A free-standing, private psychiatric facility or a psychiatric unit as part of a larger, private healthcare system is unlikely to take the same approach.

I say this as someone who works on an academic inpatient unit.

 

[robellis]

For most insurers, admission criteria are:

- Imminently dangerous to self, OR
- Imminently dangers to others, OR
- Marked decline in functioning such that the patient is unable to function outside of the hospital setting

AND

- Unable to be managed appropriately in the outpatient setting

Discharge criteria generally mirror these points. I would note that the goal is not to completely eliminate any safety risks, and patients will often remain symptomatic at discharge. This is a critical teaching point for many residents, who often have very unrealistic expectations of what will be accomplished during an inpatient admission. As long as a patient has improved sufficiently such that they are able to continue to engage in treatment after discharge - e.g., a patient who presents acutely psychotic has at least some degree of insight into the potential benefits of continuing to engage in treatment - and you are convinced that the patient is unlikely to kill themselves or others imminently after discharge, you will likely start to receive pressure from payers to discharge. In short, you need to be able to provide a justified answer to the question, "why can't this patient receive the treatment that you're offering in a less restrictive setting (e.g., PHP/IOP, general outpatient follow-up, etc.)?" Some payers are just idiotic - e.g., one payer that we are contracted with will refuse to authorize severely depressed patients with marked neurovegetative symptoms because they argue that the patient doesn't have the ability to actually kill themselves - but if you can make a case in your documentation that inpatient management is necessary and that the patient is receiving benefit, you likely won't have too much trouble.

Whether or not those criteria are appropriate and/or whether patients that do not meet those criteria could benefit from inpatient treatment is another question altogether. I would argue that 1) they are too restrictive and 2) patients can benefit from inpatient admission even if they are not imminently dangerous or profoundly functionally declined, but most payers will disagree. Whether or not that is relevant to your practice will depend on the setting that you're working in and the financial pressures your unit is under. As an example, our unit's contribution to our health system is not providing revenue, thus the fact that we lose 7 figures annually is less of a concern to the broader institution and institutional leadership. Our value is provided elsewhere (teaching, making disposition from the ED easier, a sense that a leading academic institution should provide all available services regardless of other factors, etc.). A free-standing, private psychiatric facility or a psychiatric unit as part of a larger, private healthcare system is unlikely to take the same approach.

I say this as someone who works on an academic inpatient unit.

You could also do what many do and make up /bend the truth a bit to justify your admission

 

[NickNaylor]

You could also do what many do and make up /bend the truth a bit to justify your admission

I do not advocate defrauding payers and presenting things inaccurately. Most payers will authorize a set number of days simply based on the complaint provided; e.g., a patient who is suicidal may be authorized for 2-3 days out of the gate with additional reviews after that if needed. That should provide enough time to get a sense of what is going on and make an argument for continuing inpatient hospitalization or, if they don't require hospitalization, then getting a discharge plan in place. The key is actually documenting this... if notes are short with no exposition or explanation as to what's going on, then you are almost certainly going to be asked to complete peer reviews. If all that you write in your note is "denies SI" but don't add any explanation as to why there are still imminent safety concerns, then you're probably going to get shot down by the payer. That's their job, and frankly I don't think that's an unreasonable demand.

In general, physicians are given a lot of leeway - even by payers - with respect to clinical judgment if you can simply make a cogent argument for why the patient needs to be in the inpatient setting. If you can't justify that decision to yourself or to others, then I think it's perfectly appropriate to question why the patient is still hospitalized.

 

[hallowmann]

In general, physicians are given a lot of leeway - even by payers - with respect to clinical judgment if you can simply make a cogent argument for why the patient needs to be in the inpatient setting. If you can't justify that decision to yourself or to others, then I think it's perfectly appropriate to question why the patient is still hospitalized.

I interpreted robellis's comment as the bolded. It is certainly not worth risking your license over a lie, especially not to keep someone in the hospital when they don't need it likely at the cost of someone who does, but sometimes artfully arguing why a patient needs to be inpatient is necessary. Especially on those damn "peer-to-peers". This assumes you truly believe they need to be inpatient.

 

[NickNaylor]

I interpreted robellis's comment as the bolded. It is certainly not worth risking your license over a lie, especially not to keep someone in the hospital when they don't need it likely at the cost of someone who does, but sometimes artfully arguing why a patient needs to be inpatient is necessary. Especially on those damn "peer-to-peers". This assumes you truly believe they need to be inpatient.

Yes, I agree. I don't think "bending the truth" is necessary to further that goal, though. I do think that in cases where the argument for ongoing admission is not facially obvious (e.g., "Mr. Smith continues to endorse significant hopelessness and SI with a plan to hang himself"), you do have to be a bit more thoughtful in making that argument. We all know that "denies SI" does not necessarily mean that the patient is good for management outside of the inpatient setting. The challenge is being able to identify why that is and presenting that case in your documentation so that payers are satisfied with your reasoning.