Mohammed T. Abou-Saleh

THE MEDICAL PSYCHIATRY INPATIENT UNIT 711psychiatric treatment or require close observation in order toachieve diagnostic or therapeutic results.Patients with general medical problems associated withpsychiatric disturbances are challenging with respect to clinicalmanagement. However, several studies have implied that patientstreated on such a unit benefit with respect to improved quality ofcare and shorter length of stay 4 . Medical psychiatry units are alsomore likely, compared to traditional units, to benefit patients withfunctional or cognitive impairment. For example, patients withcoexisting dementia and depression are much more effectivelyaddressed in a shorter time frame, with resultant decrease inlength of stays, compared to those patients treated on a generalmedical unit 5,6 . Moreover, treatment in the medical psychiatryunit with aggressive outpatient follow-up may obviate the needfor nursing home placement 6 . Primary interventions on a medicalpsychiatry unit may include pharmacologic or somatic therapies,as well as ongoing efforts to optimize the patients’ generalmedical/physiologic status. Coping with illness, issues relating toloss and self-esteem, feelings toward a caregiver and socialchanges are other important psychotherapeutic themes commonlyaddressed in a geriatric medical psychiatry unit. Medicalemergencies, e.g. cardiac arrest or status epilepticus, must beconsidered and anticipated. Emergent symptoms of delirium mayalso need attention and in these cases, the legal doctrine of impliedconsent applies.PROBLEMS, ADVANTAGES AND CAVEATS WITHGERIATRIC MEDICAL PSYCHIATRY INPATIENTUNITSThe quintessential factor that determines the success of a medicalpsychiatry inpatient unit is nursing care. Ideally, nurses recruitedfrom medical/surgical units or critical care areas who are keenlyinterested in psychological dimensions of patient care, areconsidered best-suited to the medical psychiatry inpatient unit.Professional attire and more traditional uniforms often help tominimize confusion about the medical role of the unit. Nonpsychiatricnurses may be useful in order to update and maintainmedical skills of the staff, and serve to maintain familiarity withnewer techniques of intravenous therapy, oxygen therapy, suctionand skills in cardiac monitoring, respiratory care and postsurgicalcare. Because nursing is the critical element in the successfuloperation of these units, appropriate head nurses are invaluableand a difficult resource to obtain.Reimbursement and financial integrity are long-standing issueswith the medical psychiatry unit 7 . For example, in the USA, theTax Equity and Fiscal Responsibility Act (TEFRA) of 1982 hasdetermined payment for services in psychiatric units. TheBalanced Budget Act (BBA) was passed by Congress in 1997and has replaced the TEFRA of 1982. This has resulted in areduction of approximately 7–8% in revenues for care provided ina psychiatric unit. However, patients with concurrent medical andpsychiatric illness may add an average of 40% to the annual costof health care when compared to patients without concurrentmedical and psychiatric illness 8–10 . Thus, psychiatric programs ingeneral hospitals catering to the medically ill psychiatricallydisordered patient are progressively less able to meet financialgoals, because of the costs of ancillary medical service utilization,and free-standing psychiatric hospitals are also unable to includethese patients in their patient mix. On average, psychiatricfacilities are already losing money when they treat patients withcombined medical–psychiatric illness 11 . Further, under theBalanced Budget Act, facilities in the USA stand to lose anadditional 12% or more on such cases. 12Medical psychiatry units in the USA that pride themselves onthe ability to treat complicated geriatric patients with comorbidillness must consider the need to take immediate stepsthat will allow them to remain fiscally solvent. Further limits onadmissions with no medical co-morbidity, or preference topatients with low psychiatric acuity, are the easiest solutions.However, these solutions do not allow the medical psychiatryinpatient unit to respond to the clinical needs of thecomplicated, high-cost co-morbid patient. A more satisfactorysolution to this problem has been suggested by Goldberg andKathol 11 . Specifically, a partnership among medical/surgicalprofessionals, hospital administration and psychiatric departmentsis suggested. A model of providing full psychiatric care,yet billing to general medical reimbursers, is recommended,allowing higher reimbursement of per diems through medicalservice billings that are adequate to cover the costs of medicaltests and procedures typically not included in psychiatric orbehavioural health payments. Such service integration can bedone in such a way that units can actually cover direct costsand make significant contributions to the indirect costs inhealthcare systems, while improving care 13 . This is particularlytrue if general medical patients at high risk for, or demonstrating,psychiatric co-morbidity with high healthcare utilization aretargeted for admission. When this is done, costs savings forsuch patients accomplished through shortened length of staycan be as much as $4000 per admission 11,13 . Thus, it is possibleto capitalize on the relatively higher reimbursement availablewith general medical admissions—even under the DRG system,which is also affected by the BBA, while continuing to addresspsychiatric difficulties.The interaction of medical and psychiatric illness requires a unitorganized in the fashion previously outlined. As forementioned,this approach allows treatment that assists the patient in movingtoward recovery, with the development of policies and standardsthat document quality, improved outcomes and better attentionfor patients treated with medical psychiatry morbidity 14 . Underthis format, the psychiatric unit director or consultant becomesinvolved in creating and finding ways to enforce these standardsand adequate reimbursement to cover costs is achievable. Clearly,general hospital units will not be able to afford to providepsychiatric care for the medically ill, and medical psychiatric unitsunder pressure from the Balanced Budget Act in the USA willrequire reorganization in order to contend with the facets of theprospective payment system introduced in 1999. Without amedical psychiatry approach, medical psychiatry patients will bescattered about the hospital, with practices that will necessarilylead to poorer quality and higher costs in the average medicalsetting. Hospital administrations in the USA will find that theimpact on medical length of stay will create worse financialliabilities for the DRG reimbursement. Administrators thereforemust continuously monitor length of stay, admission diagnoses,and dispositional plans, while maintaining a favorable prospectivepayment format. Direct care costs, indirect operating costs,recovery of costs, costs offset with reduced utilization, as well asother indicators of cost effectiveness, should be considered in theoverall economic equation. 2 Mumford et al. 15 have reported thattreatment in a medical psychiatry inpatient unit may resolveproblems that might otherwise become chronic and moreexpensive. Generally, however, units must deny admission tocertain patient types whose care would exceed the permissiblestay, and units must not become a way-station for problempatients. Without strict and clear guidelines, the medicalpsychiatry unit may become clogged and ultimately result indenial of care to a more appropriate patient. Cost-effectivenessstudies are clearly needed to clarify many of these fiscal issues.Kathol 13 is of the opinion that many advantages of a medicalpsychiatry unit depend heavily upon the medical director. Perhapsthe most convenient model employs collaboration between themedical director and a liaison internist or psychiatrist who