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Preparing to treat addictions and co-occurring psychiatric disorders

November 1, 2009
by Patrice M. Muchowski, SCD, Paul R. Lemieux, PhD, and Susan B. Hillis, LICSW
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AdCare Hospital takes on analytical, financial, developmental, and organizational challenges of new program

The existence of co-occurring psychiatric disorders within the addicted population has been well documented. Current estimates suggest that 50-75 percent of persons presenting to substance abuse treatment facilities suffer from co-occurring mental health disorders (SAMHSA, 2005). As AdCare Hospital evaluated and expanded its capacity to treat persons with co-occurring psychiatric disorders, several administrative issues were identified.

AdCare Hospital is a 114-bed acute care hospital dedicated to the treatment of persons with addictions. Because AdCare is a hospital, patients with co-occurring medical conditions have long been admitted. More recently patients with co-occurring psychiatric illnesses have been admitted and successfully treated within the structure of our existing treatment program.

The specific administrative issues that AdCare has addressed include data analysis, workforce development, fiscal concerns, and collaboration with psychiatric treatment providers.

Analyze and Understand Your Data

Annually, AdCare conducts a demographic review of patient discharges and patient outcomes such as AMAs, administrative discharges, and transfers. These data are analyzed for trends that may suggest programmatic needs, identify cost issues, and reflect length of stay concerns. AdCare's data have indicated an increased number of patients with co-occurring disorders over the past several years. Further analysis measured patient outcomes for this population. In our analysis, AdCare focused on psychiatric transfers. It was determined that patients were being transferred when suicidal ideation was expressed, but were often cleared psychiatrically and returned. AdCare developed a standardized suicide risk assessment, which is conducted when suicidal ideation is expressed, and several procedures which allow for better management of suicidal ideation. These reduced the need for transfers. Programs could analyze other outcomes such as administrative discharges. Patients may be discharged for rule infractions or behaviors symptomatic of an unmanaged psychiatric illness, which could be more aggressively managed within the treatment program.

Workforce Developement

Thorough data analyses often lead to programmatic changes that require new or additional resources in the workforce. Staff training is a necessary but insufficient component for addiction treatment facilities treating co-occurring disorders. AdCare has found that training must be coupled with ongoing supervision and small group tutorials that review current clinical issues. Training and supervision are more effective if extended beyond direct clinical staff to secondary caregivers (aides, patient care assistants, crisis intervention counselors). Training and data may suggest the need to attract staff with more experience in mental health treatment to bolster effective treatment services.

Fiscal Issues

Treatment of co-occurring disorders does have fiscal implications. Ongoing training and supervision is a cost issue that needs to be factored into budgets. At a minimum, psychiatric services need to be available in the form of consultation or on-site staff, again adding costs to the program.

Not to be overlooked is the cost associated with increased pharmacy utilization. This will increase as capacity for treating persons with co-occurring disorders increases and length of stay increases (often another by-product). Expanding formularies to include psychotropic medications necessary for the types of co-occurring conditions that a program is treating must be undertaken with a view to efficacy and cost. Contracts need to be evaluated to determine if effective care can be rendered within the current reimbursement arrangement and contractual changes made when necessary. AdCare has developed different rates for treatment of co-occurring disorders within certain contracts.

Make Friends, Not Enemies

Despite the best treatment plans, situations arise when patients with co-occurring disorders need to be transferred to acute psychiatric facilities. Transfer agreements are useful and development of a simple referral process is critical. AdCare is very fortunate to have developed linkages with two psychiatric facilities for transfer. Trust has been built between the organizations and patients are easily transferred. This reduces stress on staff and patients and eliminates the use of emergency rooms for triage of such patients.

Discharge planning activities are more complex for persons with co-occurring illness. Ongoing medication monitoring is a key component of the discharge plan. Some persons may benefit from Visiting Nurse Association (VNA) psychiatric care to administer and monitor medications.

Addiction psychiatrists are an extremely valuable and necessary resource, but may be difficult to find. AdCare has worked with our local medical school, the University of Massachusetts, and hosts an addiction rotation for psychiatric residents. An addiction psychiatric fellowship also has been developed with AdCare as the site for these fellows. The goal of this collaboration is to develop more capacity within our community to provide specialized services for this population.

In conclusion, addiction treatment facilities have unique opportunities to enhance and expand their service delivery to patients with co-occurring psychiatric disorders. Attending to the associated administrative issues may be useful for programs to consider.

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