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Level of Care

Before the 1960s in the United States, most psychiatric care for serious mental illnesses took place in hospitals. The rest was individual therapy with a psychiatrist or psychologist or other highly trained professionals; this treatment was reserved mainly for patients considered “neurotic” and having the means to pay for hourly sessions that would often occur several days a week.

Several forces changed this. The community mental health movement was motivated by social justice, occurring at a time defined by the civil rights movement. Experts argued that the housing of seriously mentally ill patients in a public hospital was unjust. The treatment there emphasized long-term custodial care rather than rehabilitation, and few patients improved. Visionaries such as Walter Barton, then medical director for the American Psychiatric Association, argued that the federal government must lead the way to develop alternatives to the current system of institutionalization. The result was The Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963, championed by President Kennedy, who proposed a “wholly new emphasis and approach to care for the mentally ill.”

The act and the amendments that followed it under President Johnson initiated the federal government’s role in mental health care, something previously left to the states. It established a grant program for states to establish local mental health centers, under the overview of the National Institutes of Health. The purpose was to build a robust network of mental health centers for community-based care as an alternative to long-term institutionalization.

Only about half of the proposed centers were built, and funding for these sites has been chronically inadequate. Thus, the movement was more successful at deinstitutionalizing mental health care than it has been at offering quality alternatives. Part of the reason for this is another crucial force in the US health care system, the rise of managed care. Managed care emphasizes seeking the lowest level of care possible and the use of lower-cost professionals as a way of saving money.

The result is that we now have a myriad of treatment settings, services, and options. Most rely on grants and third-party payers, although some require considerable patient expenditures. The details and terminology differ by institution and region. However, they roughly fall into several categories. In this chapter, we briefly describe these options as well as the requirements and goals for each treatment. Our purpose is to help the reader navigate these options with an emphasis on choosing the treatment that is best for the patient. Although analogous services exist for children and adolescents, this chapter focuses on adult levels of care.

Table 26-1 summarizes the main levels of care that we should consider for most psychiatric patients.

INPATIENT ADMISSION

Inpatient admission units are usually specializing in intensive psychiatric care. The patients may voluntarily agree to hospitalization, or clinicians may hospitalize them against their will in a manner consistent with state law. The units are usually locked and equipped to restrain or seclude patients when required. Nurses and other staff are present around the clock. Physicians are present on the unit at least 5 days a week, and a covering physician is always available.

The hospitalization allows an intense treatment, with regular observation throughout a day and robust treatments, including medical adjustments, group, and individual psychotherapies, case management, and milieu treatments. Previously the most common form of psychiatric care, inpatient hospitalization is now reserved for patients who are unsafe in or unlikely to benefit from other treatments.

The patient’s risk of illness or severity is usually high. Many patients are hospitalized because they are at high risk of imminently harming themselves or others. Alternatively, their disorder may be so impairing that they cannot function adequately outside the hospital or attend to even basic activities of daily living (ADLs).

Usually, the treatments required are ones that clinicians cannot safely or practically give in other settings. These include treatments that require daily observation for serious side effects. They may be given with such frequency, such as some intense psychotherapies, that other settings are not practical. In the latter case, the clinicians have often already tried other settings and have decided that the patient is likely to deteriorate should they continue the attempts to treat the patient in another setting.

In some cases, the practicality of alternative treatments arises from a patient’s poor insight or inability to cooperate with treatment. Such patients may require involuntary hospitalization, and an inpatient unit is the only setting that would be appropriate to hold them against their will until the treatment allows them an ability to make their ordinary appropriate judgments. In the most severe cases, staff may have to restrain a violent or self-harming patient physically.

Except for some specialized care facilities, the goals of treatment are short term. Treatments aim to manage the crisis and stabilize the patient to the point that treatment can continue in a less restrictive setting for the patient. Crisis interventions, intense and frequent therapy, and medications are usual treatments. Longer-term treatments may begin in this setting, but usually to continue the treatments following the hospitalization.

The length of stay varies widely. A 2010 Centers for Disease Control and Prevention (CDC) survey reported the average length of stay for patients with schizophrenia as about 7.2 days, and for major depressive disorder, about 10.6 days. This number varies significantly by regional practice. Internationally, it varies by health care system, economic resources, and many other factors. Figure 26-1 gives some example comparisons of the average lengths of stay in 2010 for various countries.

The goal of treatment is to return the patient to a safe and functional state so that the team can then transition the patient to a lower level of care. This goal includes reducing the patient’s threat to themselves or others, decreasing the symptoms of the disorder, and improving the patient’s functional level.

Discharge planning usually begins on day one of the hospitalization. It helps to identify early on the likely next step in treatment, should it be back home, to a transitional setting or, less often, to long-term custodial care.

PARTIAL HOSPITAL TREATMENT

Partial hospitals are facilities that provide a near hospital level of care, the exception being that the care takes place for about 6 to 8 hours a day, after which the patients can go home. The service is fully staffed in a manner typical to a psychiatric hospital unit, however only during the day. The units usually offer a full range of treatment from various psychotherapies and psychosocial options to medication management. The patient usually attends daily, for 5 days a week.

Appropriate patients for a partial hospital program include patients who may be at significant risk for harm to themselves or others. However, the treatment team assesses that the patient is sufficiently stable such that the reinforcement of the intensive treatment is sufficient to prevent such harm. Thus, the patient is not an imminent risk or is not too impulsive to be trusted to be independent during the evening.

The patients are usually of moderate severity in symptoms. Similarly, they often have moderate dysfunction such that their self-care may be substandard. They often have ongoing trouble maintaining normal relationships.

The program usually offers a variety of psychotherapy treatments, often in a group setting. They have the benefit of milieu therapy in the unit environment. Case management is also available. Psychiatrists are present and help manage the patient’s medication and overall treatment plan.

The average length of treatment is from 1 to a few weeks, although in some cases it may be longer. The treatment should continue until the patient is sufficiently stable for a less intensive mode of treatment.

INTENSIVE OUTPATIENT TREATMENT

Intensive outpatient treatment (IOP) is a treatment in the outpatient setting that involves 3 to 4 hours of psychosocial treatment for between 1 and 4 days of treatment, with an average of 6 to 12 hours of treatment per week.

This care is usually appropriate when the level of danger is sufficiently stable so as not to be at imminent risk of harming themselves or others.

Patients usually have moderate symptoms and mild to moderate functioning. For example, their self-care may be mildly below what we would expect for them. However, they should be sufficiently functional to be able to live independently or with assistance from a caregiver.

Although sufficiently stable to live independently, the psychiatrist should be sure that the patient’s home environment is sufficiently safe and without illness triggers to allow for improvement with treatment.

The treatments emphasize a group format but often include some individual psychotherapy treatments or medication management. Psychotherapies may include cognitive behavioral therapy, interpersonal therapy, or other therapies in a group format.

The length of treatment varies widely and depends on the illness, but usually lasts 1 to several weeks. The goal is to address the patient’s symptoms sufficiently that a less intensive model of care is feasible.

OUTPATIENT CARE

Outpatient care is pharmacologic or psychosocial management, provided by a health care professional, usually in an office setting.

This care is usually appropriate when the danger to the patient is considered reasonably low risk. Patients need not be free of all thoughts of harm to themselves or others; however, this risk should be low, and the clinician should have a reasonable belief that the patient can warn them should their situation worsen.

Also, the patient’s disorder should be likely to improve with outpatient care. This situation, fortunately, includes most psychiatric disorders. The modes of treatment may include psychotherapy or medication or a combination of both.

Patients are voluntary and require some level of motivation for their treatment, sufficient so that they can show up regularly for their appointments. At times of symptomatic worsening, family members or other caretakers may assist with providing some external motivation until the patient can resume on their own.

The length of treatment varies widely depending on the disorder. The frequency of treatment also varies. In the case of an acute illness, such as an episode of major depressive disorder, a manic episode, or a worsening of anxiety, the treatment may occur weekly or more frequently. Generally, the frequency of treatment will decrease as the patient improves, but as many disorders are chronic, patients often require ongoing medication or therapy to maintain remission. For patients who have been stable for an extended time, twice a year follow-ups may be reasonable. However, the clinician should work out with the patient a plan for increasing the follow-ups when necessary, as it less likely the clinician will catch a pending recurrence of the illness early.

RESIDENTIAL CARE

Residential care is a 24-hour facility that offers a level of treatment less intensive than traditional inpatient treatment. It generally does not have the level of security typical of an inpatient unit. Although medical and nursing staff are available, the units do not have the same level of staffing, and the treatments are not as frequent as an inpatient unit.

Patients may be at some risk of harming themselves or others, but not at imminent risk and thus not requiring the level of observation or restraint available in an inpatient unit. Their symptoms are moderately severe, as they can have severe functional limitations such that they cannot safely live independently. The patients are usually voluntary, although they may be court-ordered for treatment; however, in those cases, they are willfully participating. The units are usually not locked.

The facilities offer a variety of treatments, often in a group setting. The units differ from long-term rehabilitation units, such as nursing homes, in that the goals are improvement in symptoms and functioning and return to a lower level of care.

References

American Association of Community Psychiatrists. Level of care utilization




Level of Care Level of Care Reviewed by Web of Psychiatry on December 07, 2021 Rating: 5

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