In this article we will address the discharge planning process. Affecting a proper discharge plan is an important continuation of the care rendered during the inpatient psychiatric hospitalization. This observation is especially true as the length of inpatient stays has become briefer. What an individual can expect upon leaving the hospital is a direct consequence of the insurance coverage they have. Persons having commercial insurance, in general, have a more limited range of post discharge options than those insured by Medicaid and/ or Medicare. It is also largely the case that persons suffering with the most serious and complex mental illnesses are most often covered by Medicaid and/ or Medicare. Persons lacking insurance represent a third group when considering aftercare options. These latter 2 groups are often treated by the public mental health system. This article will address the aftercare possibilities for those whose care is received through the public sector.
The services indicated for a soon to be discharged consumer insured under Medicaid and/ or Medicare are a clinical matter, while which services they can actually access on a timely basis are matters of geography and availability. New York State has made great strides in creating an array of post-discharge levels of care to which individuals can be referred. Ours is a state of vastly differing environments from the densely urban regions such as New York City, to suburban regions exemplified by such counties as Westchester or Nassau to the rural regions in its Western and Northern reaches. We in Westchester County are fortunate that our county has among the broadest array of programs at each care level recognized by the NYS Office of Mental Health. Other counties may not have all levels of care and may not have enough capacity of any given type of program. Appropriate housing remains an obstacle across all parts of our state.
Clinically relevant issues to be discussed by patients and/ or their families with the staff of the units on which they are being treated include whether the consumer would fare best being treated at a clinic, continuing day treatment program or partial hospital program after discharge, and whether case management services of any of several levels of intensity are indicated. The possibility of seeking court-ordered treatment through Assisted Outpatient Treatment (AOT) under Kendra’s Law may also be considered. It is also useful to ask about whether the consumer would benefit from longer acting injectible antipsychotic medications. In brief, aftercare planning is a process of cobbling together a plan most suitable for the individual from the several relevant categories of care available.
The psychiatrist, social worker, and/ or discharge planner should have a clear perspective of what the clinical precipitants were leading to the need for admission. For example, many who work in the field of inpatient psychiatry are aware that when patients stop taking their psychoactive medications, they become vulnerable to symptomatic relapse and readmission. Other stressors may have to do with lack of adherence to treatment regimens, family conflict, economic and entitlement stressors, legal entanglements, etc. Each of these should be evaluated in the context of the discharge planning process. Once an optimal plan has been thought through, it then remains to be determined the availability of the preferred services. Ultimately, discharge plans represent a compromise between what might be best and what is currently accessible in the area.
Perhaps a composite clinical vignette will help to illuminate the discharge planning process. Mr. M was admitted to the hospital under an involuntary status. He had been brought to the emergency department by the local police. He came to their attention when he was reported to have been wandering into traffic. When questioned he evidenced disorganization, belligerence and paranoia. A drug screen was positive for cocaine and he had an elevated blood alcohol level. Once settled on the inpatient unit, additional history was obtained from Mr. M and his family. He had a history of several prior admissions along with problematic adherence to his aftercare plans over the past several years. Recently he had stopped taking his medications and attending his clinic appointments. He had let his Medicaid lapse. In order to design an appropriate discharge plan for Mr. M, the treatment team will need to integrate the information presented. Reactivating his Medicaid will be a necessary first step. Once that is done the team can consider which level of treatment and case management will best provide the needed support and structure for their client. For example, the clinical team may decide that, given the history of multiple admissions as well as non-compliance with treatment, intensive case management (ICM) would help Mr. M access and stay with a partial hospital program which includes a “double trouble” track for persons suffering with a mental illness and substance use disorder. ICM services would also help him maintain his “room,” keep appointments, and remain current with his entitlements. They may also suggest the use of a long acting injectible antipsychotic medication. Given his history, however, the clinical team has decided to refer him to the highest level of treatment – an Assertive Community Treatment (ACT) team. An ACT Team is a mobile treatment team that goes to the consumer instead of the consumer coming to an agency for treatment appointments. As an ACT Team had not yet been tried with this individual, and since ACT is considered to be the least restrictive treatment to keep this individual safely in the community, AOT will not be pursued. AOT would be considered in the future if the present plan was unsuccessful in helping Mr. M remain in the community and begin to move forward with his recovery plan.
Persons without insurance may have a more difficult road to travel despite the extensive access provided for them in programs licensed by the state. It is important for the treatment team to be aware of their uninsured status early in the course of treatment. With that information in hand, affordable medications can be prescribed during the admission. For example, atypical antipsychotic medications may cost hundreds of dollars per month and be unaffordable. However, efficacious alternatives exist. Typical antipsychotics, several classes of antidepressants and mood stabilizers can be purchased at minimal cost at pharmacies at such stores as Walmart, Target, Stop and Shop, and others. There the medications on their formularies can be purchased for $4 per month or $10 for a 3-month supply.
Barry B. Perlman, MD, is the Director of the Department of Psychiatry at Saint Joseph’s Medical Center in Yonkers, New York. He is the Immediate Past President of the New York State Psychiatric Association. John Turtz, PhD, is Program Coordinator – Mental Health at the Westchester County Department of Community Mental Health, located in White Plains, New York.