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This paper represents a position statement of the American Association of Community Psychiatrists (AACP) regarding treatment plans. We regard treatment plans, a documentation requirement, in this position statement, as distinct from the process of treatment planning. The AACP is concerned that treatment plan documentation in its current state, creates unnecessary administrative burden for physicians, without evidence of benefit for patients, reducing direct patient contact time, thereby negatively impacting quality of care. In this position, we echo the statements made by the American College of Physicians in their position paper entitled "Putting Patients First by Reducing Administrative Tasks in Health Care". We recommend a review of the treatment plan documentation requirement across the nation, engaging consumers, providers, regulatory agencies in all states, as well as national reimbursement and regulatory agencies, in order to promote the process of quality driven care and documentation.
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Documentação , Transtornos Mentais/terapia , Planejamento de Assistência ao Paciente , Serviços Comunitários de Saúde Mental/métodos , Psiquiatria Comunitária , Documentação/métodos , Documentação/normas , Humanos , Relações Interinstitucionais , Relações Interprofissionais , Transtornos Mentais/economia , Planejamento de Assistência ao Paciente/normas , Comportamento Problema , Psiquiatria , Sociedades Médicas , Estados UnidosRESUMO
This study examined the feasibility, acceptability, and initial impact of bridges to better health and wellness (B2BHW), a culturally-adapted health care manager intervention for Hispanics with serious mental illness (SMI). Thirty-four Hispanics with SMI and at risk for cardiovascular disease were enrolled. Mixed-linear models were used to examine changes over 12-months on patient activation, self-efficacy, patient-rated quality of care, receipt of preventive primary care services, and quality of life. The majority of participants completed the intervention (85%) with high satisfaction. Significant improvements were found for patient activation, self-efficacy, patients' ratings of quality of care, and receipt of preventive primary care.
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Doenças Cardiovasculares/prevenção & controle , Hispânico ou Latino , Transtornos Mentais , Aceitação pelo Paciente de Cuidados de Saúde , Serviços Preventivos de Saúde , Atenção Primária à Saúde , Qualidade da Assistência à Saúde , Autoeficácia , Adulto , Idoso , Administração de Caso , Assistência à Saúde Culturalmente Competente , Estudos de Viabilidade , Feminino , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Participação do Paciente , Satisfação do Paciente , Assistência Centrada no Paciente , Qualidade de VidaRESUMO
The purpose of this study is to assess the educational impact of incorporating a psychiatry consult service into a medical student-run clinic. In November 2014, a psychiatry consult service was introduced at the Columbia-Harlem Homeless Medical Partnership (CHHMP), a student-run clinic located in Harlem, New York. From September 2015 to January 2016, surveys (Qualtrics) were then distributed to student members of the clinic. Surveys assessed how the psychiatric consult service impacted students' knowledge, skills and attitudes about psychiatry. According to survey results (83.8% response rate, n = 31), 100% of students at CHHMP agreed that the psychiatry consult service is a useful addition to the clinic, and 94% agreed that the service helped increase their perceived knowledge of psychiatry. Survey results suggest that having a psychiatry consult service at a student-run clinic is a beneficial educational model in increasing medical students' perceived knowledge and comfort with psychiatry.
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Serviços Comunitários de Saúde Mental , Prestação Integrada de Cuidados de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Seleção de Pessoal , Clínica Dirigida por Estudantes , Estudantes de Medicina/psicologia , Pessoas Mal Alojadas , Humanos , New York , Inquéritos e QuestionáriosRESUMO
This mixed-methods study examines the primary health care experiences of Hispanic patients with serious mental illness. Forty patients were recruited from an outpatient mental health clinic. Participants reported a combination of perceived discrimination and stigmatization when receiving medical care. They rated the quality of chronic illness care as poor and reported low levels of self-efficacy and patient activation. These indicators were positively associated with how patients viewed their relationships with primary care providers. A grounded model was developed to describe the structural, social, and interpersonal processes that shaped participants' primary care experiences.
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Hispânico ou Latino/psicologia , Transtornos Mentais/etnologia , Atenção Primária à Saúde , Feminino , Grupos Focais , Humanos , Entrevistas como Assunto , Masculino , Transtornos Mentais/terapia , Pessoa de Meia-Idade , Cidade de Nova Iorque , Participação do Paciente , Qualidade da Assistência à Saúde , Racismo , Autoeficácia , EstereotipagemRESUMO
Previous studies of physical assaults in hospitals focused primarily on inpatient psychiatric units, leaving unanswered questions about the extent to which findings generalize to psychiatric emergency rooms. Assault incident reports and electronic medical records from one psychiatric emergency room and two inpatient psychiatric units were reviewed. Qualitative methods were used to identify precipitants. Quantitative methods were used to describe characteristics of each event, as well as demographic and symptom profiles associated with incidents. During the five-year study period, there were 60 incidents in the psychiatric emergency room and 124 incidents on the inpatient units. Precipitating factors, incident severity, means of assault, and interventions were similar in both settings. Among patients in the psychiatric emergency room, a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder with manic symptoms (Adjusted Odds Ratio (AOR) 27.86) and presenting with thoughts to harm others (AOR 10.94) were associated with an increased likelihood of having an assault incident report. Similarities between assaults in the psychiatric emergency room and inpatient psychiatric units suggest that the broader literature from inpatient psychiatry can be generalized to the psychiatric emergency room setting, although some differences exist. Reprinted from J Am Acad Psychiatry Law 2020; 48:484-495, with permission from The American Academy of Psychiatry and the Law. Copyright © 2020.
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OBJECTIVE: The psychological sequelae of the COVID-19 crisis will increase demands for psychiatric care in already strained emergency and mental health systems. To address the shortage of psychiatrists (and nurse practitioners and physician assistants) in emergency settings (ESs), the American Association for Emergency Psychiatry (AAEP) has established recommendations for utilizing nonprescribing mental health professionals in the evaluation and management of psychiatric patients in these contexts. METHODS: Faced with limited research on the roles and competencies of nonprescribing psychiatric emergency clinicians (PECs), a multidisciplinary committee of members of AAEP was tasked with developing recommendations for use of PECs. RESULTS: The committee developed eight recommendations regarding the role of PECs in evaluation and management of patients who present to ESs with behavioral emergencies. PECs should have the following competencies: conducting independent psychiatric and substance abuse evaluations; managing behavioral emergencies; aiding in the recognition of confounding medical illnesses, intoxication and withdrawal states, and adverse drug reactions; developing appropriate treatment plans; recognizing when consultation from a psychiatrist or emergency physician is indicated; possessing self-awareness and recognizing clinician-patient dynamics; understanding medicolegal issues, such as involuntary holds and decision-making capacity; and collaborating with clinical teams in ESs. PECs are not meant to replace psychiatrists but to extend the psychiatrist's reach. Use of PECs has already been implemented in some areas of the country. CONCLUSIONS: On the basis of the AAEP recommendations, ESs can address staffing shortages while ensuring safe management of patients with behavioral emergencies. With appropriate orientation and training, the PEC can serve effectively and competently in an ES.
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Serviço Hospitalar de Emergência , Serviços de Emergência Psiquiátrica , Transtornos Mentais/diagnóstico , Transtornos Mentais/terapia , Médicos/provisão & distribuição , Psiquiatria , Centros Médicos Acadêmicos , Ambulâncias , Conselheiros , Humanos , Enfermeiras e Enfermeiros , Admissão e Escalonamento de Pessoal , Psicologia , Assistentes SociaisRESUMO
Previous studies of physical assaults in hospitals focused primarily on inpatient psychiatric units, leaving unanswered questions about the extent to which findings generalize to psychiatric emergency rooms. Assault incident reports and electronic medical records from one psychiatric emergency room and two inpatient psychiatric units were reviewed. Qualitative methods were used to identify precipitants. Quantitative methods were used to describe characteristics of each event, as well as demographic and symptom profiles associated with incidents. During the five-year study period, there were 60 incidents in the psychiatric emergency room and 124 incidents on the inpatient units. Precipitating factors, incident severity, means of assault, and interventions were similar in both settings. Among patients in the psychiatric emergency room, a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder with manic symptoms (Adjusted Odds Ratio (AOR) 27.86) and presenting with thoughts to harm others (AOR 10.94) were associated with an increased likelihood of having an assault incident report. Similarities between assaults in the psychiatric emergency room and inpatient psychiatric units suggest that the broader literature from inpatient psychiatry can be generalized to the psychiatric emergency room setting, although some differences exist.
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Serviço Hospitalar de Emergência , Hospitais Psiquiátricos , Pessoas Mentalmente Doentes/estatística & dados numéricos , Violência/estatística & dados numéricos , Adulto , Feminino , Humanos , Incidência , Pacientes Internados/estatística & dados numéricos , Masculino , Transtornos Mentais/diagnóstico , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
Latinos with serious mental illness (SMI) experience health and health care disparities and may benefit from interventions that improve access to, coordination of, and receipt of primary care services. The aim of this qualitative study was to examine the experiences of Latinos with SMI and at risk for cardiovascular disease participating in Bridges to Better Health and Wellness (B2BHW), a culturally-adapted health care manager intervention delivered in a public outpatient mental health clinic. A total of 29 Latino participants completed a post-intervention survey that included an open-ended question about the three things they liked most about B2BHW; a subset of 16 participants participated in one of three post-intervention focus groups. Results indicate that what mattered most to participants was the health education they received, the positive relationships they formed with their health care managers, the care coordination assistance they obtained, and the motivation and activation they gained from this intervention. Study findings suggest that key elements of the health care manager intervention (e.g., care coordination, and patient activation) shaped participants' experiences with B2BHW and were perceived as beneficial.
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Doenças Cardiovasculares/prevenção & controle , Hispânico ou Latino , Transtornos Mentais/terapia , Serviços Preventivos de Saúde , Atenção Primária à Saúde , Adulto , Idoso , Administração de Caso , Assistência à Saúde Culturalmente Competente , Feminino , Grupos Focais , Humanos , Masculino , Transtornos Mentais/psicologia , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Participação do Paciente , Satisfação do Paciente , Assistência Centrada no Paciente , Pesquisa Qualitativa , Qualidade de VidaAssuntos
Atitude , Centros Comunitários de Saúde Mental , Grupo Associado , Diretores Médicos/psicologia , Transtornos Psicóticos/reabilitação , Reabilitação Vocacional/psicologia , Adaptação Psicológica , Adulto , Feminino , Objetivos , Humanos , Descrição de Cargo , Satisfação no Emprego , Mentores , New York , Transtornos Psicóticos/psicologia , Autorrevelação , Apoio SocialRESUMO
Medicare and the Affordable Care Act (ACA) base reimbursement partly on hospital readmission rates, but there is little guidance for providers to reduce these rates. This column describes a model of care used by Washington Heights Community Service (WHCS) in New York City. Without benefit of external funding, WHCS has implemented practices, such as family involvement at all treatment levels, community outreach, effective medication prescribing, shared electronic medical records, and proactive provider communication, that have led to lower rates of readmission in addition to low rates of admission and emergency room use and a high rate of outpatient follow-up--all particularly relevant in this era of ACA mandates.
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Serviços Comunitários de Saúde Mental/normas , Reembolso de Seguro de Saúde/normas , Transtornos Mentais/terapia , Patient Protection and Affordable Care Act/normas , Readmissão do Paciente/normas , Adulto , Serviços Comunitários de Saúde Mental/economia , Hospitais Psiquiátricos/economia , Hospitais Psiquiátricos/normas , Hospitais Psiquiátricos/estatística & dados numéricos , Humanos , Reembolso de Seguro de Saúde/economia , Transtornos Mentais/economia , Transtornos Mentais/epidemiologia , Cidade de Nova Iorque/epidemiologia , Patient Protection and Affordable Care Act/economia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto/normas , Estados UnidosRESUMO
BACKGROUND: Health-care manager interventions improve the physical health of people with serious mental illness (SMI) and could be widely implemented in public mental health clinics. Local adaptations and customization may be needed to increase the reach of these interventions in the public mental health system and across different racial and ethnic communities. In this study, we describe how we used the collaborative intervention planning framework to customize an existing health-care manager intervention to a new patient population (Hispanics with SMI) and provider group (social workers) to increase its fit with our local community. METHODS: The study was conducted in partnership with a public mental health clinic that serves predominantly Hispanic clients. A community advisory board (CAB) composed of researchers and potential implementers (e.g., social workers, primary care physicians) used the collaborative intervention planning framework, an approach that combines community-based participatory research principles and intervention mapping (IM) procedures, to inform intervention adaptations. RESULTS: The adaptation process included four steps: fostering collaborations between CAB members; understanding the needs of the local population through a mixed-methods needs assessment, literature reviews, and group discussions; reviewing intervention objectives to identify targets for adaptation; and developing the adapted intervention. The application of this approach enabled the CAB to identify a series of cultural and provider level-adaptations without compromising the core elements of the original health-care manager intervention. CONCLUSIONS: Reducing health disparities in people with SMI requires community engagement, particularly when preparing existing interventions to be used with new communities, provider groups, and practice settings. Our study illustrates one approach that can be used to involve community stakeholders in the intervention adaptation process from the very beginning to enhance the transportability of a health-care manager intervention in order to improve the health of people with SMI.
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Pessoal Administrativo/estatística & dados numéricos , Transtornos Mentais/terapia , Serviços de Saúde Mental/normas , Planejamento de Assistência ao Paciente/normas , Centros Comunitários de Saúde Mental , Pesquisa Participativa Baseada na Comunidade , Comportamento Cooperativo , Atenção à Saúde/normas , Hispânico ou Latino/estatística & dados numéricos , Humanos , Relações Interprofissionais , Transtornos Mentais/etnologia , Cidade de Nova Iorque , Melhoria de QualidadeAssuntos
Serviços de Emergência Psiquiátrica/métodos , Trabalhadores Voluntários de Hospital , Transtornos Mentais/terapia , Satisfação do Paciente , Centros Médicos Acadêmicos , Adulto , Diagnóstico Duplo (Psiquiatria) , Humanos , Cidade de Nova Iorque , Transtornos Psicóticos/terapia , Transtornos Relacionados ao Uso de Substâncias/terapiaRESUMO
We describe the case of a young pregnant woman with refractory schizoaffective disorder and how we reached a decision to apply for court-mandated outpatient psychiatric treatment (Assisted Outpatient Treatment or AOT). The patient was stable when we made this application as a preventive measure, given her serious prior episodes of illness. While there has been court-mandated outpatient obstetrical treatment, as far as we know this is the first report of mandated outpatient psychiatric treatment in connection with pregnancy. The ultimate benefit of this AOT application was the development of a therapeutic alliance and improved voluntary adherence to treatment, and a safe outcome to the pregnancy.
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Assistência Ambulatorial/legislação & jurisprudência , Internação Compulsória de Doente Mental/legislação & jurisprudência , Complicações na Gravidez/psicologia , Complicações na Gravidez/terapia , Transtornos Psicóticos/psicologia , Transtornos Psicóticos/terapia , Administração de Caso , Custódia da Criança/legislação & jurisprudência , Proteção da Criança/legislação & jurisprudência , Pré-Escolar , Comportamento Cooperativo , Feminino , Humanos , Lactente , Recém-Nascido , Comunicação Interdisciplinar , New York , Cooperação do Paciente/psicologia , Relações Médico-Paciente , Gravidez , Complicações na Gravidez/diagnóstico , Resultado da Gravidez , Transtornos Psicóticos/diagnóstico , Transtornos Puerperais/diagnóstico , Transtornos Puerperais/psicologia , Transtornos Puerperais/terapia , Prevenção Secundária , Adulto JovemRESUMO
OBJECTIVE: This paper describes the role of an agency Clinical Director in developing a project to assess and begin to address obesity-related health problems of patients treated in a community-based mental health clinic in New York City. After a five year review of outpatient deaths revealed a high rate of deaths from cardiovascular and diabetes-related issues, the Clinical Director assembled a group of clinicians, researchers, and administrative staff to design a pilot project to assess health and nutrition status of primarily Hispanic day treatment patients with severe and persistent mental illness. METHOD: About 69 of the 105 patients at the clinic were assessed by chart review, interview about nutritional habits and medical care, and somatic measurements for blood pressure, weight, girth, body mass index (BMI), glucose and lipid levels. RESULTS: Patients were predominantly between the ages of 25 and 64 years, 51% were female, and 78% were Hispanic. Around 57% were diagnosed with schizophrenia-spectrum disorders, 86% were receiving antipsychotic medications, and 25% were on two or more antipsychotics. Only 11% of the women and 41% of the men had normal weight. A total of 29% of the women and 18% of the men were overweight (BMI = 25-29.9); and an additional 60% of the women and 41% of the men were obese (BMI > or = 30). Atypical antipsychotic treatment was significantly associated with obesity (BMI > or = 30) (chi sq = 5.5, df = 1, P < 0.025). Using American Heart Association criteria, waist measurements showed significant abdominal obesity among female patients. Blood pressure was elevated in 77% of the patients: 45% were pre-hypertensive with BP 120-139/80-89 and 32% were hypertensive with BP > or = 140/90. About 53% had elevated random blood glucoses (>110 mg/dl). On the positive side, patients generally had had recent medical follow-up, and most had adequate cooking facilities. CONCLUSIONS: This project revealed that these predominantly Hispanic, severely mentally ill individuals were at high risk for cardiac illness, highlighting the need for developing culturally-sensitive interventions in urban outpatient psychiatric settings. Findings were disseminated in educational presentations and clinical discussions, and have mobilized an institutional effort to significantly improve medical monitoring for these patients.
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Instituições de Assistência Ambulatorial , Hispânico ou Latino/estatística & dados numéricos , Transtornos Mentais/diagnóstico , Transtornos Mentais/etnologia , Obesidade/diagnóstico , Obesidade/etnologia , População Urbana/estatística & dados numéricos , Adulto , Índice de Massa Corporal , Nível de Saúde , Humanos , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Inquéritos e QuestionáriosRESUMO
Latinos appear to be relatively protected against suicidal behavior, but the factors that mediate this effect are not known. Some protective factors may be related to cultural constructs that provide a buffer against suicidal behavior in the face of psychiatric illness. We sought to determine whether the Reasons for Living Inventory (RFLI) might capture protective factors against suicidal behavior in Latinos and non-Latinos. Patients with major depression, bipolar disorder, or schizophrenia were interviewed regarding their depressive symptomatology and lifetime history of suicidal behavior. The RFLI, which measures protective factors against suicidal acts, was also administered. Multivariate analyses were used to assess the relationship between suicide measures, ethnicity, and selected clinical and demographic variables. Although Latinos and non-Latinos did not differ significantly in attempter status (attempter/nonattempter), number of attempts, or suicide intent, Latinos reported significantly less suicidal ideation and made less lethal attempts. On the RFLI, Latinos scored significantly higher on subscales regarding survival and coping beliefs, responsibility to family, and moral objections to suicide, possibly reflective of cultural norms endorsed by Latino groups. Multivariate analyses suggested that although being Latino was independently associated with less suicidal ideation, other suicidal behaviors held a stronger relationship to moral objections to suicide and survival and coping skills than to ethnicity. Self-identification as Latino may be associated with espousing cultural constructs that mediate protective effects against suicidal behavior. Constructs identified in the RFLI may protect Latinos from acting on suicidal thoughts, affecting moral objections to suicide and survival and coping beliefs. Further studies to elucidate the impact of these factors on suicidal behavior and their relationship to specific cultural constructs would be of interest.