Address the Inpatient Dilemma in Behavioral Healthcare

Hospital care can be lifesaving for many people with mental health and substance use disorders. It is a safe place in a time of crisis and the setting where many people start a long path to recovery. The hospital is often the only place where stabilization can occur, in-depth evaluations can begin, and people finally accept treatment as being essential. This level of care is intense for all involved.

The dilemma of inpatient care is less what goes on inside the hospital and more how people get there. It is quite often unplanned. Crises reach life-threatening levels and family members search haphazardly for a safe place. Few behavioral professionals work at this level of care. They are distant islands ignored by most clinicians. Outpatient therapists generally do not know the clinical criteria for admission.

While it is possible to make general comments about higher levels of care, it must be acknowledged that there are differences for commercially insured and Medicaid populations. The focus here is commercially insured groups where socio-economic circumstances are less likely to complicate severe clinical problems. Yet the impact of non-clinical life circumstances is important for all.

What does the inpatient dilemma mean in people’s lives? Some people enter facilities in a confused crisis and neither need nor benefit from this level of care, and conversely, some people who desperately need higher levels of care never get there. We should redirect some of our focus on inpatient stays to the challenge of ensuring everyone gets placed at the right level of care.

Struggles between managed care companies and inpatient providers tend to focus largely on length of stay. Why? It is more difficult to question the need for an inpatient admission than to debate its ongoing length of stay. Care management processes shifted long ago to discharge planning and aftercare. This avoids an unsolved dilemma: how to ensure people get the right care at the right time.

We do not have good structures in place to solve this dilemma. The problem is not the hospitals. We realized long ago that people clinically need intermediate levels of care like partial hospital and intensive outpatient programs. We lack good ways to get people there, and so they are typically used as a step-down from hospitals. The dilemma is facilitating admissions, and that is an outpatient problem.

We lack a feeder system for higher levels of care that is clinically based and efficient. Outpatient behavioral clinicians are actively treating too few of the patients who end up in hospitals. PCPs have vastly more patient contact, providing nearly 500 million outpatient visits each year, but they do not have the skills to assess and refer for higher levels of care in behavioral health.

The gap between outpatient and inpatient care must get closed at the outpatient level. The solution starts by repositioning a significant percentage of outpatient psychotherapists to the primary care setting. This setting is where most potential crises will be found, and it needs internal behavioral expertise. This setting is optimal because long-term monitoring of clinical risk is a core function.

Primary care needs a core behavioral health competency. This must include expertise in applying patient placement guidelines for higher levels of care. It then requires connectivity with higher levels of care to streamline admissions. The goal is to facilitate inpatient admissions, as well as to direct many urgent cases to intermediate care. Such a system can ensure people get the right care at the right time.

Our current system has many people entering inpatient care because it is the only place to stabilize a crisis. A more rational system grounded in primary care would direct patients to higher levels of care as clinically indicated. This will require that we right-size each level of care. Appropriate referrals start with appropriate resources being available. We will need to build and strengthen intermediate care.

We must start by acknowledging that too many people fall through the cracks in our current system. For those negotiating a path to admission, there is too much confusion and pain for patients and families. Intensive outpatient, partial hospital and other variants of intermediate care are an excellent match for many people. They will not exist in sufficient number until primary care is transformed.

When the primary care setting serves as “central command” for allocating behavioral resources, then we can ensure people get timely interventions at the least restrictive level of care. The consequences of this change should be clear. Many more people will be treated overall when access begins in primary care (less stigma), and more people will be treated at each of the higher levels of care (easier access).

The reforms contemplated here are complex but not quixotic. Funding exists. The parity law was extended in the Affordable Care Act (ACA), which is now primed to evolve. Investors see the potential for growth in our field based on equitable insurance funding. Investments will grow due to the enormous need for behavioral care. Investors will follow our lead. They can help solve our dilemmas.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.