Saturday, December 20, 2008

I now pronounce you ... medically cleared.

Emergency room (ER) staff hold a special fondness for psychiatric patients. Overt psychosis, statements to kill self or others, inability to care for one basic needs or imminent risk do not classify as serious enough to be treated before minor physical maladies. And, even though mentally ill patients do not appear to be in distress, they require the same basic diagnostic procedures as all other patients.What does it mean to be "medically cleared?"

  • I screened a "medically cleared" 10 year old on stimulant medications in an ER and recommended transfer to a freestanding psychiatric hospital. When the receiving hospital asked for the patient's results from the lab screens, they were informed that no lab tests were done.
  • A few days ago, a crisis worker met with a "medically cleared" young adult who ingested 25 to 30 ibuprofen tablets a few hours before presenting to the ER. Fifteen minutes into the screening, the patient began vomiting uncontrollably and asked that the interview end because she was in too much discomfort.
  • An adolescent patient "medically cleared" from an ER vomited eight times in route to a freestanding psychiatric facility. He arrived dehydrated and was sent to another emergency room and medically admitted to a telemetry unit for two days.
  • I have been asked to assess "medically cleared" patients from pediatric intensive care units (PICU) prior to transfer and admission to other psychiatric hospitals. The most recent lab results were from tests taken 2 days prior to the request for assessment.

Medically clearing a patient is largely based on where the patient will be in the next few days and what supports will be immediately available during that time. Most hospitals require basic lab  screens including blood alcohol level (BAL) and drug for adolescents and adults, pregnancy screens for females and others tests to address a patient's history of diabetes, hypertension or other chronic illnesses. In cases of drug ingestion, a period of 48 hours observation on a medical unit is required prior to transfer. Intoxicated patients cannot be interviewed until their BAL is below 100 as they are medically compromised and may be hallucinating, delusional, aggressive, suicidal or homicidal because of an alcohol-induced acute episode. Patients with acute eating disorders frequently present not only as underweight but as dehydrated and fluid imbalances which may require monitoring on a telemetry or intensive care unit. Self-injury patients may present with wounds at risk for infection, inflammation or damage to major arteries, tendons or organs. 

The purpose of medical clearance is not for CYA; it is to increase the patient's chances in being able to successfully engage in the next level of prescribed care.

Wednesday, December 17, 2008

taking care of our youth

Here in the great state of Illinois (governor not included), we have a community crisis stabilization program for Medicaid and unfunded families of children and adolescents. The SASS (Screening, Assessment and Support Services) program originated in the early 90's as a grant-based program primarily for wards of the state and lower income families seeking treatment.

As most behavioral health providers can agree, our work improves consumers functioning in at home, school, and in the community as well as job retention, overall general health, crime reduction and a host of benefits to society at large. We can also agree that we have done a poor job of showing how that grant money is spent. As a result, the feds decided to go after the non-profit providers and established a fee-for-service model for reimbursement. Early on, we heard rumblings about it as well as the institution of mandatory hospital prescreenings for all Medicaid and unfunded families. What we did not know was that Governor Blagojevich, in his infinite wisdom, would roll out the model with the crisis program.

Try to imagine providing a face-to-face emergency screening within 90 minutes, determining a need for psychiatric hospitalization or community-based crisis stabilization services and writing up an invoice.

The state of mental wellness

There are a lot of good things happening in mental health service delivery. Consumers taking responsibility for their recovery, motivational interviewing, practice guidelines and the use of technology permit us to work smarter. But some of us rely on the old ways of treating patients with illness and maintaining dependencies on the programs that have withered away or disappeared for lack of funding. How our government justifies taking money from non-profit community programs and giving it to for-profit corporations who have squandered enough resources from greed and ecomonic strip-mining.

We need to support families and communities by holding us all to the highest standards. Let us not settle for less from each other. Set examples that our politicians would envy. Insist on enriching opportunties for our children and places where they can be safe from gunfire and predators. Treat others as we would be treated.

And so it begins ...

As a seasoned frontline clinician who has seen a lot of things, I realize that I have worked with many who are well -intentioned but logically clueless. I am using this as an opportunity to address issues that, in the greater scheme, seem inconsequential to those who do not deliver or receive behavioral health services. Believe me, there are much larger ills that face us. But for some of us, who paint our little mental health corner and want our neighbors and consumers to benefit from our efforts. For 23 years, I have consistently told families that my goal as a mental health worker is to put myself out of a job. In order to do this, we need to do a lot of things differently. Details to follow.