Who sees these patients?

[SoulinNeed]

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[nexus73]

Community mental health centers. These patients probably have disability benefits.

 

[OldPsychDoc]

I've been rotating through the ER recently, and we routinely get Psych patients on different Psych meds. They're usually homeless with little means to maintain their care. However, I constantly hear about how so few Psychiatrists there are, about how so many only see cash only patients, and how out of reach psych care is for them, and how so many mental health clinics have closed. So, how are they getting psych med prescriptions? Primary care clinics? Psych clinics staffed by residents? I'm genuinely curious about how these incredibly poor people with no insurance. Obviously, I'm at a major teaching hospital. Is that where they go? Cook County Jail is the biggest mental health provider in the country, and they have a major shortage of Psychiatrists. Are the primary care docs there just treating these illnesses?

Why don't you just ASK them? (The patients, I mean. You might learn a few things.)

 

[Promethean]

When you are mentally ill in public, sometimes you find yourself being hauled in to the local psych hospital's emergency department for care, whether you'd like it or not. If you are homeless, you are always in public. Folks I've known who are in that position got treatment in that way. Once you get plugged into the system, recognized as someone who is seriously mentally ill, sometimes you are lucky enough to be routed into a track where you can keep accessing services, even if you can't pay for them.

It doesn't always work out so well. You aren't seeing all of the folks who weren't able to access even that safety net of help and so did not survive, or who were routed into prison instead of treatment, or who are so actively paranoid that they don't seek medical care and so don't present at your ER. So that skews the numbers so that you mostly see people who are relatively fortunate to be able to get some care, by whatever means.

You also aren't seeing longitudinal care. Some of the people you meet may have only fairly recently become homeless, and may still have resources from an earlier period in their life prior to a decompensation of chronic issues.

As for community resources, my little sister the social worker once had a job where she delivered psych meds to homeless people who had been diagnosed and had prescriptions written during hospitalizations. Like, for instance, if you admitted one of your patients, and psych saw them and wrote for them to start one drug or another. When the hospital discharged them back to the street, some county agency or another paid my sister to go out and fill their prescription for them once a month, until the next time they washed up in a hospital bed. There wasn't a follow up med check with the psychiatrist, or anything like that. Just sis.

 

[Shikima]

Bring back the state funded institutions of yesteryear.

 

[thoffen]

It depends. In many major metropolitan areas with grant funded institutions, especially with an academic affiliation, there are those who are better off without insurance than with. If you are homeless and without income, how does medicaid help you when you can't afford the copay for your visits or medications? And formularies for insurances may restrict some important treatment options.

 

[dpmd]

It depends. In many major metropolitan areas with grant funded institutions, especially with an academic affiliation, there are those who are better off without insurance than with. If you are homeless and without income, how does medicaid help you when you can't afford the copay for your visits or medications? And formularies for insurances may restrict some important treatment options.

where I live there usually isn't a copay for medicaid. It does however take some jumping through hoops to get to a psych with it for someone who didn't have a psych hospitalization but the pcp will write for meds for stuff they feel comfortable treating.

 

[SoulinNeed]

Why don't you just ASK them? (The patients, I mean. You might learn a few things.)

I do. The vast majority get on the meds through the hospital's inpatient unit. Some, however, are not. Some have to get outpatient treatment, or they need refills. I've been seeing it the last few days. The reason why I don't ask those who come in like that is because they're usually intoxicated, overdosed, or in the ER and are in no position to talk when I see them briefly in the ER. So, I'm just wondering how it works in other parts of the country or other major urban locations. Is it Psychiatrists? PCP? Just inpatient units at teaching hospitals (like here), prisons, community centers staffed by residents?

 

[OldPsychDoc]

I do. The vast majority get on the meds through the hospital's inpatient unit. Some, however, are not. Some have to get outpatient treatment, or they need refills. I've been seeing it the last few days. The reason why I don't ask those who come in like that is because they're usually intoxicated, overdosed, or in EP and are in no position to talk when I see them briefly in the ER. So, I'm just wondering how it works in other parts of the country or other major urban locations. Is it Psychiatrists? PCP? Just inpatient units at teaching hospitals (like here), prisons, community centers staffed by residents?

Yes to all.

 

[thoffen]

where I live there usually isn't a copay for medicaid. It does however take some jumping through hoops to get to a psych with it for someone who didn't have a psych hospitalization but the pcp will write for meds for stuff they feel comfortable treating.

That would be awesome, but not the case here.

It is another issue, though. Finding a provider who takes a significant load of medicaid patients is tough due to differential in reimbursement. Also, availability of psychotherapy and other supportive type interventions is low and/or of lower quality coupled with challenges in transportation and patient cost. Repeated ER visits and hospitalizations foster dependence on the system, often without a first-line treatment even suggested (e.g. DBT for borderline patients).

 

[smalltownpsych]

I do. The vast majority get on the meds through the hospital's inpatient unit. Some, however, are not. Some have to get outpatient treatment, or they need refills. I've been seeing it the last few days. The reason why I don't ask those who come in like that is because they're usually intoxicated, overdosed, or in EP and are in no position to talk when I see them briefly in the ER. So, I'm just wondering how it works in other parts of the country or other major urban locations. Is it Psychiatrists? PCP? Just inpatient units at teaching hospitals (like here), prisons, community centers staffed by residents?

EP? Extreme psychosis? Never heard of that one and when i googled came up with emergency physician who are usually fairly verbal and endogenous pyrogens who aren't frequent flyers in the ER.

 

[erg923]

Bring back the state funded institutions of yesteryear.

I think was actually during "yore."

 

[SoulinNeed]

EP? Extreme psychosis? Never heard of that one and when i googled came up with emergency physician who are usually fairly verbal and endogenous pyrogens who aren't frequent flyers in the ER.

Sorry, typo. Meant to say ER. As in, they're in need of emergency care, and are in no means to communicate.

 

[Shikima]

Sorry, typo. Meant to say ER. As in, they're in need of emergency care, and are in no means to communicate.

Saw this during residency. Came in screaming for no cause. Gave her injectables and put her to sleep... she awoke on the Inpt unit, not knowing how she got there and ate her breakfast.