Friday, September 24, 2021

The Hospital: A Very Expensive Pathway of Least Resistance for Broken Systems

Recently, we discharged an, intellectually disabled patient after a stay of 257 days in the hospital. 

The patient, who was over 50, originally presented to the Emergency Department with her group home caregiver. In the several months prior she had been in and out of the hospital and psychiatric facilities with behavior related issues such as throwing herself on the floor. The reason for her admission to the hospital was that she was acutely unable to walk. She was sent to our Integrative Care Unit with a diagnosis of an infection. 

Her infection was treated, and she returned to her previous state of health after a few days of care- the work of our Integrative Care Unit was done. 

And then the waste began since she no longer needed to be in the expensive setting of the acute care hospital. GBMC has no inpatient psychiatric unit to provide treatment to a patient like this. For the next step in discharge, the question then became whether she would go to subacute rehab, long term care, or back to her group home. She is financially supported by the State, through the Maryland Developmental Disabilities Administration, since she is not capable of supporting herself.  

During her hospitalization the patient would frequently act out, screaming, cursing, and exhibiting other attention seeking behaviors. Due to her high acuity behavioral needs, she was initially recommended to go to a neuropsychiatric disorder unit, but a bed was not available. Then the care team learned that she had exhausted her lifetime Medicare days but that her Medicaid benefit had not yet kicked in. By the time she became Medicaid eligible roughly two months later, the team learned that she could not go to the neuropsychiatric unit and she would have to be admitted to a state operated facility. 

We know that the longer someone remains in the acute care hospital, the more at risk they are for hospital acquired conditions. This patient developed a hospital acquired condition and was transferred to another unit where she stayed for 36 days. She was then transferred back to the Integrative Care Unit.

During this time, planning for her discharge continued. Her family was hoping for a group home placement closer to where they lived. Over the next few months, the patient was declined by several facilities as they were not able to accommodate her needs. 

During her sixth month of hospitalization a facility reviewed her case and subsequently approved her for admission. However, the facility had not yet been approved by the Developmental Disabilities Administration, so the team continued to wait. It was only recently that the team learned that the facility had been approved and they were finally able to plan for her discharge. 

The Integrative Care Unit Team was incredibly resilient in caring for her. They took turns reading books to her. The patient loved our volunteer guitarist Chris Maggitti and would sing along when he played for her. Nurse Manager Carolyn Keller took her to our beauty salon in the West Pavilion twice for a haircut during her stay, which was challenging due to her behavior. Lisa Palmer, our hairstylist, was patient and compassionate. Dr. Rebecca Moore from psychiatry managed the patient’s medications which at times needed to be adjusted daily to control her behavior. Dr. Moore had a wonderful relationship with this patient. Dr. Rachna Raisinghani, the unit’s Medical Director, spent much time assisting to find a placement for the patient.  Sarah Sackett from social work worked tirelessly, day in and day out to advocate for her and to coordinate the safest and most appropriate placement. Our Hospitalist Team also deserves recognition for being there to support the patient through her entire stay and for attending to any issues that arose. The entire Integrative Care Team went above and beyond to provide kind and compassionate care to a patient who was incredibly trying to care for, as GBMC does not have the resources to provide inpatient psychiatric treatment or residential psychiatric care. 

The case underlines the need for redesign of the behavioral health system and for the simplification of our health insurance system. The acute care hospital is often used as the pathway of least resistance to care for behavioral patients and the public should demand that leaders step up to find a better way. 

Please join me in thanking everyone that cared for this patient. They were determined to make things as good as they could even though the patient was not in the right setting. We are indebted to all of them. 

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