"In a fee-for-service system, it's very hard to justify expanding psychiatric services," says one expert. "But reducing length of stay is a compelling statistic when you're talking to a hospital administrator."
By the end of July, Johns Hopkins Hospital in Baltimore hopes to have six behavioral health teams working side-by-side with physicians and nurses to help manage the mental health of patients.
The ambitious plan aims to prove that investing in behavioral health specialists is good for patients and the bottom line.
Patrick "Pat" Triplett, MD, clinical director and physician advisor at Johns Hopkins Hospital, says that two months ago, getting a psychiatric consult request during a patient's discharge was common. "We were really only responding to emergencies," he says.
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Now, in a pilot program on three general medicine floors, Triplett is part of a three-member behavioral intervention team (BIT) that screens patients for mental and behavioral health shortly after they're admitted.
A leading nonprofit health system is aggressively pursuing a proactive strategy toward mental health care for patients to reduce length of stay and readmissions.
"The goal is to be able to intervene early," Triplett says. "We're in on day one instead of day five."
Triplett is also overseeing the expansion of an additional five BITs at the hospital by the end of July. Currently, the BIT is made up of Triplett, who serves as a half-time psychiatrist for the team, a full-time nurse practitioner and a full-time social worker.
When the BIT program is fully rolled out later this summer, Triplett says the team structures will be similar, but will include two behavioral specialists, either a licensed clinical professional counselor (LCPC) or a social worker with psychiatric expertise.
"Having that psychiatric background is important," Triplett says. "They are able to walk into room and do a psychiatric assessment—to some degree."
The real influence, though, comes from the nurse practitioner.
That was a tip Triplett says he received from Hochang "Ben" Lee, MD, founding director of Yale-New Haven Hospital's Psychological Medicine Research Center psychological.
Lee is a former faculty member at Johns Hopkins Hospital, and co-authored a study showing that a proactive psychiatric consult approach reduced patients' length of stay.
"We're finding that the nurse practitioners having conversations with floor nurses and nurse managers is where the power of the program seems to lie," says Triplett.
"Nurses see the value of it because they really do manage the setting."
BIT in Action
When a patient is admitted, the BIT members swing into action. Patients are screened for active and dormant psychiatric issues, classified into three tiers, and triaged accordingly:
- Tier 1: Patients who have debilitating psychiatric symptoms.
- Tier 2: Patients with a wide-ranging spectrum of acuity.
- Tier 3: Patients with the lowest risk of psychiatric illness interfering with the primary medical diagnosis.
A tiered triage system helps the BIT members know when and how often to confer with the medical team taking care of the patient.
BIT members help with medication management, communication and coordinating care with the hospital's substance abuse services, if needed.
Regardless of how patients are triaged, Triplett says the BIT members consult with the medical team before seeing the patient.
"Context matters," Triplett says. "After we talk to the medical team, we may walk in and say, 'We're from psychiatry, how do you feel your bipolar disorder is being handled?' Sometimes patients do not want someone from psychiatry in their room, and sometimes you pick up things that might not appear in the chart."
It's this psychiatric expertise that helps the most. BIT members notice patient nuances that medical teams may overlook. Triplett says the hallway conversations that ensue are opportunities to educate physicians, nurses and other health care professionals about what a patient is experiencing.
"They're focused on acute medical issues," he says. "They may have heard a snippet of it on floor, but we can explain to them what is happening to the patient from a psychiatric perspective."
Integrating with medical teams has been good so far, says Triplett. The nurses and physicians like the help, especially because BIT members are intervening early and often to prevent sometimes explosive episodes that can delay a patient's discharge or affect their outcome.
"We weren't sure how it would work out," says Triplett. "But they're happy we're here. The only complaints I've received are from the medical floors that we didn't pick."
Measuring the Value of Mental Health
Johns Hopkins Medicine is one of several health systems directing more resources to the mental healthcare of patients.
Commercial retailers also recognize the need for additional resources. Walgreens launched a mental health screening program in May that also offers connections to therapists via video for $60.
Numerous studies show the link between poor health outcomes and common mental illness diagnoses, such as depression, bipolar disorder and schizophrenia.
With hospitals preparing to be on the hook for the total care of patients, not just an episode, leaders are looking for ways to achieve cost reductions through LOS and readmission improvements.
Triplett says that in addition to LOS and readmission reductions, other benchmarks could also be added to determine the effectiveness of early mental healthcare intervention. He says measuring patient and staff safety would be a good indicator of the BIT's impact and suggests looking at nursing and physician satisfaction rates over time.
"If you're providing a service that allows nurses to do the job they're meant to be doing, it may affect nursing turnover," Triplett says.
One of the most difficult benchmarks for mental health initiatives, such as the BIT, is financial.
"In a fee-for-service system, it's very hard to justify expanding psychiatric services," Triplett says. "But reducing length of stay is a compelling statistic when you're talking to a hospital administrator."
Jacqueline Fellows is a contributing writer at HealthLeaders Media.