Insurers Delay Hospitalization of Severely Ill Psychiatric Patients

Hospitalization of severely ill psychiatric patients can be delayed because of authorization required by insurance companies, a study reported in the Annals of Emergency Medicine has found. The study was headed by Amy Funkenstein, M.D., a child psychiatry fellow at Brown University, and J. Wesley Boyd, M.D., an assistant clinical professor of psychiatry at Harvard Medical School. (Funkenstein and her colleagues conducted the study while she was a psychiatry resident at Harvard Medical School.) The study included 53 severely ill psychiatric patients in the Cambridge Health Alliance Psychiatric Emergency Department. Psychiatry residents tending to the patients averaged 38 minutes from the time of first contact with an insurance company until authorization to hospitalize the patients was either granted or denied. Although half the authorization requests took less than 20 minutes to be approved, for about 10 percent of patients authorization requests took an hour or more, with the longest request taking five hours.

"Private insurers are obstructing care by requiring authorizations before a qualified psychiatrist can hospitalize a dangerously ill patient," Boyd said in a press statement. "With doctors, nurses, and emergency departments already overburdened, adding a time-consuming bureaucratic task that doesn't help patients is unconscionable."

To read more about the challenges that emergency psychiatrists face in their work, see Psychiatric News here and here. Also see Clinical Manual of Emergency Psychiatry, from American Psychiatric Publishing.

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Four Simple Questions Identify Youth at Risk of Suicide

Researchers at the National Institute of Mental Health (NIMH) are reporting that a set of four questions that emergency department (ED) physicians or nurses can ask successfully identifies youth who are at risk for attempting suicide. Lead researcher Lisa Horowitz, Ph.D., M.P.H., an NIMH clinician and researcher, explained why a rapid screening tool is so important. "Many families use the emergency department as their sole contact in the health care system," she said, but most of them don't show up in the ED and say they want to kill themselves. "Rather, they show up with physical complaints and do not discuss their suicidal thoughts. But studies have shown that if you ask directly, the majority will tell you." However, there have been no validated screening instruments to assess suicide risk in youth who come to the ED complaining of physical symptoms.

In their study of 17 candidate questions in patients aged 10 to 21 who came to academically affiliated pediatric EDs with psychiatric or medical/surgical issues, Horowitz and colleagues found that 4 of the questions used as a set accurately predicted suicide attempts. The questions asked about "current thoughts of being being better off dead, current wish to die, current suicidal ideation, and history of suicide attempt." Positive responses to 1 or more questions identified 97% of the youth at suicide risk, regardless of whether they came in for psychiatric or general medical problems, they reported in the Archives of Pediatric and Adolescent Medicine. They note that the instrument derived from these questions, the Ask Suicide-Screening Questions (ASQ) "is the first time such a screen has been validated for pediatric and young adult patients evaluated in EDs for medical/surgical reasons."

For more information on assessing suicide risk, see The American Psychiatric Publishing Textbook of Suicide Assessment and Magement, Second Edition.

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Emergency Psychiatry Not What It Used to Be

The recovery model--isn’t that something that takes lots of time to bring to reality for a patient? Not when it happens in the emergency department, Anthony Ng, M.D., told the audience at APA’s Institute on Psychiatric Services in New York.
“The emergency department is the gateway to care,” said Ng, medical director of Arcadia Health System in Bangor, Maine. “This is where they’ll get their first impression of psychiatry, so even if they’re not ready to accept treatment, we can prepare them for that moment.”

Traditionally, emergency department psychiatry worked on a “triage-and-refer” model. Now an alternative approach (at least for some patients) can see the first stages of treatment there, although not without some major adjustments. For instance, the practical concerns of operating an emergency department creates a sense of urgency that is at odds with the usual paradigm of psychiatric care, said Ng.

“You have to do recovery work in minutes or hours versus days or months,” he said. But there can be a payoff if that effort reduces use of restraints or leads to fewer readmissions and trips back to the emergency department.

Engaging patients long enough to figure out what they really want when they approach the hospital may reveal that alternatives like day hospitals, crisis teams, or even phone calls may meet their real needs and cut unnecessary usage.

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