Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0132Care in Private Psychiatric HospitalsK. G. Meador 1 , M. M. Harkleroad 2 and W. M. Petrie 21 Duke University, Durham, NC, and 2 Memory Disorders Center, Nashville, TN, USAPsychiatric care and treatment for mental disorders in the elderlyin a private psychiatric setting is fundamentally a public healthissue. The location of treatment and the clinical services availableare shaped by public policy, financial incentives and theemergence of managed care. With the implementation of theMedicare Part A Hospital Insurance Trust Fund, most acuteinpatient psychiatric care and treatment for the elderly in the1970s and 1980s occurred in special geropsychiatric units ingeneral medical units and private psychiatric hospitals. Datareflect the trend of the shift from public sector inpatient care toprivate and general medical hospital inpatient units. State andcounty organizations providing mental health care decreased7.6%, while private hospitals increased 95.5% and generalmedical hospitals with inpatient mental health services increased21.6%. The relative percentage of mental health expenditures forstate and county hospitals decreased from 48.5% in 1975 to23.6% in 1994 for total mental health expenditures; while thepercentage of expenditures for private psychiatric hospitalsincreased from 7.1% to 19.5% during that same time period.Outpatient and community-based programs, including partialhospital programs, increased as a relative percentage of totalmental health expenditures from 1.8% in 1975 to 26.8% in 1994 1 .In addition to addressing concerns inherent to providing qualitymedical care, any discussion focused on the care of older personsmust include content regarding the logistical and ethical dimensionsof financial and familial responsibilities. In the context of anincreasingly aged population, Henderson 2 challenges us with apublic health agenda of: (a) developing ‘‘bold and innovativemeans for assisting families to care for a relative with dementia’’;(b) improving the ‘‘contributions of general practice to the care ofmental disorders in the elderly’’; and (c) investigating the socialenvironment of the mentally ill elderly and promoting moreadaptive alternatives when feasible. These challenges are particularlypertinent in the private psychiatric facility, where the‘‘financial disincentives and shortages of trained personnel’’ 3common to the discipline of geropsychiatry are frequentlyamplified.There are several factors that necessitate the private psychiatriccommunity becoming more aggressive and innovative in the careof older persons, despite the substantial constraints and disincentives.The first is the void left by the inadequacies in thecommunity mental health center and the shift from treatment instate and county hospital programs for this population 4 . Second,the overall demand for inpatient psychiatric treatment for theelderly has continued to grow as the number of elderly, especiallythose over 80, has grown dramatically 5 . A third factor leading toan increased demand for private psychiatric care is that internistsand primary care physicians are frequently not trained in thebehavioral management of geriatric patients, and there is agrowing subspecialty of geriatric psychiatry which is generatingparadigms for diagnosis and treatment of older persons withneuropsychiatric and behavioral disorders.The World Health Organization has identified acute inpatientpsychiatric care as an important component in the continuum ofcare for the elderly 6 . Although the USA and the AmericanPsychiatric Association have not published specific practiceguidelines for geriatric inpatient treatment, there are generallyaccepted principles of quality care and treatment of elderlyindividuals in inpatient settings. These principles of care include:preadmission screening and linkages with community providers ofcare; comprehensive assessment and care planning; multidisciplinarystaff with specialized experience and interest in theelderly; ongoing staff training and education; therapeutic programmingand care approaches sensitive to the needs of an agingpopulation; environmental and physical design of program;individual, group and family therapy; discharge and aftercareplanning. With the emergence of managed care and financialincentives for community care, there has been a lack ofcoordination and integration of mental health services, especiallyfor the elderly with severe mood disorders, psychosis, anddementing illnesses with complicating psychiatric and behavioraldisorders. These forces combine to magnify significant gaps intreatment for the most frail and psychiatrically needy elderly whoneed comprehensive psychiatric and medical treatment, mostappropriately provided in an acute inpatient geropsychiatrictreatment program. Keill 7 proposes that it is ‘‘still possible withinthe system and with proper incentives to provide an accessible,comprehensive network’’. He emphasizes that within this networkthere must be a continuity of care, which is defined by Bachrach 8as ‘‘a process involving the orderly, uninterrupted movement ofpatients among the diverse elements of the service deliverysystem’’. In the context of these challenges and stipulations, wepresent an example of a geropsychiatry service in a privatehospital through which such issues can be discussed.DESCRIPTION OF PROGRAMThe Parthenon Pavilion at Centennial Medical Center inNashville, Tennessee, is a 162 bed private proprietary psychiatrichospital that has developed a cost-effective model programfor the delivery of acute inpatient geropsychiatric services. Thehospital currently operates two 12 bed Alzheimer’s disease andrelated disorders–memory disorders units and a 16 bed generalPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd