Saturday, September 30, 2017

Treatment Setting Mismatches - The Implications

Most physicians first experience with treatment setting mismatches occur when they are medical students and residents.  The ethos of medical training fosters an attitude of being put upon by the trainees - partly because they are or at least they were.  There was a history in American medicine as using the trainees in particular as inexpensive labor - doing all of the admissions to training hospitals and staffing them all night long.  In many if not most cases that meant long hours and minimal staff supervision.  The staff typically would hear about late night admissions only if they gave their resident team specific parameters to call them.

That work flow created tension in the system of care.  Depending on the institution teams could negotiate for admissions but typical the emergency department (ED) physicians had veto power in getting people in the hospital.  They were in the highest risk situation because they were responsible for what happened with discharges from the ED and they were responsible for getting patients out of the ED in a timely manner.  This led medical and surgical teams to view some of the admissions pejoratively as weak or dumps.  Many of these admissions were discharged as soon as possible - partly due to circumstances and partly self-fulfilling prophecy.  The treatment setting mismatches in these case could occur in both the ED and the hospital if the patient did not need to be there.  These problems has bee addressed over the part 15 years with the advent of hospitalists.  Hospitalists have a more enduring relationship with their colleagues in the ED.  There is more consensus on admissions and hospitals are staffed 24/7 by hospitalists rather than trainees.  That does not mean that the treatment setting mismatch has been solved.  You start to notice the issues involved with treatment setting mismatches after you are practicing medicine and you are no longer a trainee.  A few examples will illustrate this point.    

Hospital to Home

A 75 year old woman with diabetes mellitus Type 2, hypertension, and new onset atrial fibrillation is discharged home after two days in the hospital. She came in taking 5 medications but is leaving with 8.  She lives alone and during the nursing review at the time of discharge she knows how to set up the medications out of the bottles every day and the basics of what she needs to avoid in her diet.  There are some red flags with her medications in terms of potential interactions and symptoms that she needs to quickly report to her physician.  She currently has no primary care physician.  Her physician quit the practice and moved to a different clinic.  She tried making appointments with the other physicians in the clinic and had the feeling that "none of them like old people".  She is discharged with a bundle of medication side effect sheets highlighted by the nursing staff.  She is advised to review the highlights and report those symptoms to the clinic. 

Hospital to Facility

An 82 year old man with dementia and agitation is admitted to an acute care psychiatric unit.  He comes in with the message that his current facility will not take him back because he is too aggressive.  The initial assessment shows that he is barely mobile due to osteoarthritis but that he requires intensive nursing care for diabetes mellitus Type 2, wound care for foot ulcers, nebulizer treatments for asthma/COPD, and careful attention to his input and output each day because of moderate renal failure and a tendency to take inadequate amounts of fluids.  After two weeks of working with medical consultants, the attending psychiatrist realizes that there is no Skilled Nursing Facilities where the patient will get the level of care he is currently getting.  Without that level of care the patient will be dead in a few months. 

ED to Home

Patient X is a 50 year old man with alcoholism, alcoholic liver disease, and mild emphysema.  For the past three months he has been drinking 750 ml of vodka per day.  After an intervention with his friends and family he was referred to a substance use treatment facility.  The family was told at that time that he should be admitted to a detox facility because detox was not available at the treatment facility.  The patient decided to go to the ED.  He was given IV fluids and discharged 3 hours later with a prescription for lorazepam and told to go home and detoxify himself of go directly to the treatment setting.  He took all of the lorazepam on the first day and resumed drinking vodka.  He tried to get in to the original treatment facility and was turned down again because he still needed detox.

ED to Treatment Facility

The patient is at a local drug and alcohol treatment facility when he experiences a sudden acute mental status change.  He is confused and starts to experience auditory hallucinations part way through a detoxification protocol.  He asks to leave the treatment facility.  The facility and the patient's family convince him to go to the ED.  While there the staff treat him with benzodiazepines and IV fluids and tell him to return to treatment.  He tries that but the treatment facility disagrees with the ED and see his mental status and being too compromised to participate in treat.  He goes home and resumes drinking instead.

Hospital/ED to Jail

Patient Y a 29 year old man is detained by the police in a local shopping mall for creating a public disturbance.  He was panhandling. When none of the shoppers responded favorably he got very close to them and made loud threatening noises until the police were called.  When the police asked him to leave the mall, he shouted at them and threatened to kill them.  He was arrested but because the police suspected a mental illness he was taken to the emergency department for evaluation.  The arresting officers were hoping he would be admitted for further observation and treatment.  After the ED evaluation was completed as social worker came out and asked about what would happened if the patient was discharged to the street.  The officers responded that he would be arrested and taken to the local county jail.  At that point the patient was released on the basis that he was not dangerous and transported to county jail.   

These scenarios are all hypotheticals based on my experience.  Any physician with similar experience can cite hundreds of these examples and many, many catastrophic endings.  The common biases are that alcohol is not that much of a problem and that most people with chronic mental health and medical problems can continue to plug along with minimal assistance.  The error is to ignore the real dangers and not be focused on quality care that by definition solves and addresses clear health problems.

These scenarios all have some common dimensions.  First, the receiving setting is easily exceeded by the patient's medical needs.  In some cases the receiving setting is not medical oriented at all and is ill equipped to address medical problems.  Obvious examples are people who are discharged to jail or care facilities that are funded on the basis that they provide little to no medical care.  The scenario where the man with chronic (or in some cases acute) mental illness being sent to jail rather than hospitalized for effective treatment is one of the reasons why county jails have become the largest psychiatric hospitals in the USA.  It is one thing to recognize that fact but it is another to think about how that is happening.  In most cases hospitals have little to no bed capacity for psychiatric patients.  If they do - they are inadequately funded to provide complex care with inadequate staffing, length of stay, and in some cases inadequate medical and psychiatric coverage. At some point the politicians and bureaucrats decided to align the incentives so that level of care would be best provided in jail. 

Second, the discharge to inadequate facilities are driven by rationing of acute care facilities as "expensive and possibly unnecessary facilities".   That determination is complicated by the fact that receiving facilities have also been depleted by the same rationing mechanisms.  The reality of American healthcare at this point is that it is almost all rationed by a middleman who are incentivized to make as much profit as possible by rationing.  A great example is detoxification from drugs and alcohol.  Despite the fact that this process is potentially life threatening, at the minimum is associated with a high degree of distress, has significant psychiatric morbidity including suicide risk, and needs to be properly done in order to facilitate sobriety very few people in the USA are admitted for appropriate detoxification.  Like people with severe mental illnesses they are mostly sent home or to a facility with minimal to no medical coverage and then sent home.  In cases where a person is incarcerated they often go through acute detoxification with no medical assistance.  In many cases they suddenly stop opioids, benzodiazepines, or opioid agonist treatment (methadone or buprenorphine) and go through severe withdrawal in jail. 

Third, leaving a medical facility where there is intensive nursing care is like falling off a cliff for a lot of people.  There is no transition or assurance that many people can manage their own care in their own homes.  There used to be more options.  Public health nursing comes to mind.  Twenty years ago the attending physician could write an order and a public health nurse would see the patient in their own home and make sure that the transition was occurring properly and if not stay in contact with the patient and provide ongoing assistance.  That service was eliminated along time ago in order to reduce costs.

Fourth, an entire system of shadow care has evolved to make it seem like care is being provided when it is not.  Typical examples include health club discounts or a life style coach that calls you up on the phone and encourages you to be more physically active or eat less.  The ultimate advertising these days is a plan where you get a very modest health insurance discount through your employer if you sign up for one of these options and demonstrate compliance.  It makes it seem like both your employer and your health plan care about your health.  In the larger scope of things, it is nothing compared to the lack of care that happens in the above scenarios.

The final point to be made here is the irony of spending more money on health care than any other country in the world and having a large portion of it go up in smoke.  The source of that smoke is the huge administrative costs and profits of rationing health care under the guise that it is more "cost effective" or "efficient".

There is nothing cost effective or efficient about rationing poor quality care to patients.  The best evidence is during care transitions and the resulting treatment setting mismatches.

George Dawson, MD, DFAPA

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