Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
Hospital exclusion of people with co-morbid challenges has worsened over the 30 years Dr. Carol Olson has been practicing psychiatry in Phoenix. She’s a physician at District Medical Group and chair of the Department of Psychiatry at Valleywise Health System in Phoenix.
Arizona’s crisis system is well known for implementing core components of the Crisis Now model and the National Guidelines for Behavioral Health Crisis Care, released by the Substance Abuse and Mental Health Services Administration in 2020, including diverting from law enforcement, 24/7 mobile crisis response, 23-hour crisis receiving and stabilization programs and the “no-wrong door” approach, where crisis care facilities accept everyone who comes. “In Maricopa County, we have four 24-hour urgent psychiatric centers that take voluntary and involuntary patients — police have drop-off wait times of less than five minutes,” says Olson. These facilities can help people stabilize over a short period of time but are not medium or long-term stay settings.
While most people in mental health distress don’t require inpatient hospitalization, some do. Olson shares that where there’s a gap in Arizona and nationwide is when a person’s mental health emergency is too acute to be stabilized at a short-term receiving and stabilization program and they also have medical comorbidities. “There aren’t many psychiatric hospitals that accept people with a neurologic or other medical comorbidity — such as a major neurocognitive disorder like Alzheimer’s disease — that requires ongoing treatment.” She points out that as people with psychiatric challenges age, they might also develop dementia. “There are a lot of barriers to getting psychiatric hospitals to take these patients,” she says, “especially if they’re involuntary, have difficult-to-manage behaviors or aren’t incredibly straightforward.”
Valleywise Health is one of the few hospitals that accept involuntary cases at the beginning of the process — even before the case goes to court. “Nearly all of our beds are taken up by people at the beginning of the involuntary treatment process.”
Many psychiatric hospitals exclude patients with co-morbid conditions because they’re costly and perceived as beyond the scope of their skill set, including patients who might need ongoing physical, occupational or respiratory therapy. “These patients need to be somewhere where they can get psychiatric and medical treatments simultaneously, and most psychiatric hospitals can’t provide those medical services.”
They also often exclude people whose care requires close collaboration with medical specialists, such as people with unstable diabetes, those who need long-term care enrollment or aren’t yet eligible for long-term care but have functional limitations, requiring at least some hands-on care. A hospital might refuse a person who needs wound care or has an enlarged prostate and needs a urine catheter. Also on the list of exclusions are people with intellectual or developmental disabilities. “Psychiatric hospitals are perfectly willing to take people whose cases are uncomplicated and who don’t need any special extra nursing care or staff supervision.”
Olson notes that people with medical conditions may be at extreme risk for falls or have medical devices — like an ace bandage for a sprained ankle or a urine catheter, which are considered ligature risks on a psychiatric unit. “That would require one-on-one supervision at all times, which is costly and can be very difficult to provide in a time of extreme staff shortages for hospitals.”
Barriers to inpatient care affect not only people who require medical care but also those with psychiatric symptoms and behaviors that are difficult to treat. For example, people with self-starving behavior — due to an eating disorder or behavior secondary to another type of psychiatric diagnosis — face great difficulty getting admitted to psychiatric hospitals because they might require tube feeding. There’s a similar reluctance of hospitals to admit people with chronic self-injuring behaviors, repeated aggression toward care staff or peers, or people with treatment-resistant psychotic conditions who may require a long length of stay to improve. “Even though there is only one acute care behavioral health hospital license, most hospitals are allowed to determine who they’re going to take, and from a financial perspective, it benefits them not to take people who will be more costly to care for.”
Like elsewhere in the health care system, improved access often turns on funding. Thanks to 988 and corresponding legislation and the American Rescue Plan Act, commonly called the Covid-19 stimulus package, there’s increased focus on mental health and substance use disorder crises and insurance parity. The bulk, though, notes Olson, focuses on diverting people from avoidable psychiatric inpatient hospitalization, and there’s less emphasis on what happens to the small portion of people who need a higher level of care. “While most people don’t need inpatient care, of those who do, a significant number also have medical comorbidities.”
Olson says that psychiatric hospitals should be funded similarly to medical surgical hospitals, where reimbursement rates are higher for patients with higher needs than can be met in less acute settings. This would appropriately compensate psychiatric hospitals willing to accept the broad spectrum of acute psychiatric patients. For example, just as medical surgical hospitals have a higher intensive care rate, states and insurers must recognize that a proportion of psychiatric hospital patients need high-level staffing and are costly to treat. “The payment system needs to reflect the increased needs and costs.”
Regulatory changes also could help ensure a similar no-wrong-door approach to psychiatric hospitals, so they can’t only accept the most straightforward, least complicated patients. “An acute care psychiatric hospital needs to be able to address the broad spectrum of commonly occurring psychiatric disorders.”
She also believes stratifying psychiatric hospitals could be a potential solution, similar to the different trauma care levels at acute care hospitals and funding levels that follow from that designation. “Trauma centers are stratified according to the level of expertise the hospital offers,” she says. “If they are a level one trauma center, funding comes with that to maintain the range of staff needed to manage more difficult and complex problems.” She highlights that the trauma center funding arrangement — tiering levels of care — doesn’t exist for psychiatric hospitals, and correspondingly, neither does reimbursement. If it did, those hospitals accepting more complicated patients would receive more reimbursement than those that don’t, which would compensate for the increased staff levels, expertise and broader range of services required to treat complex psychiatric patients. “If hospitals don’t have to take the broad spectrum of patients, then those willing to do so should be recognized in a certain category and compensated appropriately; payers should be willing to pay a different rate for people with complex needs.”
Another important consideration for states as they develop legislation and funding for higher-need psychiatric patients is what happens next. In acute care medical hospitals, subacute settings can take these patients upon discharge. For example, a patient who will be on a ventilator for the rest of their life can go to a subacute nursing home setting and the facility will get a differential rate for managing such patients. However, Olson points out there’s no similar layer of care in the psychiatric treatment setting. There are 24-hour behavioral health residential facilities that can take more complicated cases but there’s no setting for patients who need a hospital level of care for a long period of time. “There currently isn’t a good solution for those patients in our system, which leads hospitals to exclude them,” she says. “They’re worried about getting patients they won’t be able to discharge.”
Traditionally state hospitals existed to serve this role but state hospitals beds have decreased dramatically over the years, and many of them now are taken up by forensic cases (patients ordered there by a criminal court), so the wait time for a non-forensic patient can be over a year. Also, state hospitals have similar concerns about getting patients who are likely to have high needs for the foreseeable future and being unable to discharge them back to the community. As a result, they, too, have tightened admission criteria not to accept patients they don’t anticipate will improve enough to be discharged.
“That leads to a system in which hospitals can cherry-pick which patients they will take and, more often than not, they will take the ones who are less expensive and less complicated for them to treat,” says Olson.
