Academic Psychiatry 26:4-8, March 2002
© 2002 Academic Psychiatry
Enhancing Continuity of Care
Residency Training in an Integrated Inpatient–Partial Hospital Program
Edward Kim, M.D.,
Irina Efremova, M.D. and
Pradeep Arora, M.D.
Dr. Kim and Dr. Efremova are Assistant Professors of Psychiatry at Robert Wood Johnson Medical School; Dr. Kim is Medical Director and Dr. Efremova is an Attending Psychiatrist at the Acute Adult Psychiatric Services, UMDNJ-University Behavioral HealthCare, Piscataway, NJ. Dr. Arora is a Staff Psychiatrist for an adult inpatient unit at Health Resource Center, Jacksonville, FL. Address correspondence to Dr. Kim, Department of Psychiatry, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey-University Behavioral HealthCare, 671 Hoes Lane, P.0. Box 1392, Piscataway, NJ 08855-1392.
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ABSTRACT
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This paper describes a teaching/service model that integrates inpatient, partial hospital, and intensive outpatient treatment. In this model, individual multidisciplinary treatment teams retain responsibility for a patient's care for any or all of three levels of intensity of services accessed during an episode of illness. This teaching/service model allows residents to follow patients for an average of 2.5 weeks across an entire acute episode of care compared with the 7.3 days of the average inpatient stay at the inpatient facility. The opportunity to continue treatment in step-down settings over longer periods of time allows residents and medical students to develop a fuller understanding of their patients. The authors believe that this continuum-care service model more efficiently trains residents in multiple aspects of psychiatric practice and provides patients with better care than the traditional inpatient-care service model.
Key Words: Inpatient Programs • Partial Hospital Programs • Continuity of Care
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INTRODUCTION
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Between 1988 and 1994, the average length of stay in general hospital psychiatric units decreased by more than 25%, from 12.6 to 9.4 days (1). The increased turnover of patients and shortened episodes of inpatient care raise concerns regarding the quality of the educational experience offered to residents on acute inpatient units. This trend has changed the experience of acute inpatient psychiatry to emphasize brief stabilization goals. As a result, residents may become demoralized by the "assembly line" nature of rapid treatment units and may learn little about the continuum of care available in contemporary behavioral health delivery systems. The shortening of treatment episodes may reduce opportunities for residents to perform more than a cursory assessment of patients and to observe the results of their interventions.
The influence of managed care pressures on academic psychiatry in general, and on psychiatric residency training in particular, has raised concerns regarding the future of psychiatric education (2,3). The demand for greater efficiency in service delivery, with associated reductions in staffing and increased case loads, presents challenges to the professional development and skill acquisition of residents rotating through inpatient services. Core educational objectives on inpatient psychiatric rotations include acquisition of clinical skills, development of a requisite knowledge base, and professional growth (4). Psychiatry residents must familiarize themselves with a modified set of treatment models and clinical skills different from those taught on inpatient units prior to the 1990s (5). Their professional identity must evolve beyond the individual therapist-physician model to one that promotes team leadership and multidisciplinary interdependence.
Houghtalen and colleagues (5,6) have described a short-term treatment unit in Rochester, NY, integrating inpatient and partial hospital programs at a university hospital as a means of providing continuity of residents' treatment experience with patients. This service uses screening criteria to select patients at intake for "factors predicting effective brief admissions." Benefits of this integrated experience include the opportunity to monitor patients as they improve clinically and to observe their responses to changes in levels of care. However, these efforts to provide residents with the experience of treating patients in a variety of settings, from an inpatient facility to ambulatory care, are challenged by the requirement of the Accreditation Council for Graduate Medical Education (ACGME) for training experiences in particular modalities that are traditionally offered in discrete blocks of time (3). The ACGME requires that residents spend 9 to 18 months rotating through general adult inpatient units. Partial hospital programs are not credited toward this requirement "unless the rotation ... is comparable in breadth, depth and experience to training on general inpatients units" (7).
The clinical teaching/service model at the University of Medicine and Dentistry of New Jersey–University Behavioral HealthCare (UMDNJ-UBHC) integrates an acute inpatient unit with a 5-day-a-week partial hospital (comparable in breadth, depth, and experience to training on general inpatients units) and an intensive outpatient program. In this teaching/service model, each multidisciplinary treatment team treats patients on all three levels of care. Unlike the service described by Houghtalen et al., our service does not select patients on the basis of any screening criteria.
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DESCRIPTION OFTEACHING/SERVICE MODEL
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UMDNJ-UBHC is an academically affiliated community mental health center with multiple sites throughout central and northern New Jersey. UBHC provides a broad range of services including inpatient, case management, and traditional outpatient treatment for mentally ill and dually diagnosed patients (mentally ill with substance abuse). In addition to serving a public patient population, UMDNJ-UBHC services a commercial capitated behavioral health contract covering approximately 300,000 lives in central and northern New Jersey. The organization also services noncapitated contracts with other commercial third-party payers. Approximately 40% of registered patients are Medicare or Medicaid beneficiaries, 40% have commercial insurance, and the remaining 20% are medically indigent.
Located adjacent to the Robert Wood Johnson Medical School campus, the Acute Adult Service of UMDNJ-UBHC is the primary teaching service for the UMDNJ-Robert Wood Johnson Medical School psychiatric residency and a major teaching affiliate for the third-year psychiatry clerkship for medical students. It consists of a 24-bed locked voluntary inpatient unit physically contiguous to a 30-patient partial hospital unit that operates 6 hours a day 5 days a week. The partial hospital unit includes an intensive outpatient program, which is a 3-hour component of the partial hospital. Patients are admitted to any level of care in the Acute Adult Service by direct admission from outpatient providers or through a 24-hour on-site psychiatric emergency service. Residents and medical students are exposed to a broad spectrum of psychiatric disorders, as indicated in Table 1. More than half of the patients treated have comorbid substance abuse disorders. Inpatients and partial hospital patients attend separate programming in their respective units, although program staff is shared between the units. This segregated programming permits staff to focus on the goals and needs of each patient population. Inpatient programming emphasizes discharge planning and preparation for return to the ambulatory setting and its attendant stressors. To this end, groups and activities focus on improving reality testing, impulse control, and self-care. The partial hospital emphasizes more longitudinal goals and patients' ability to cope with environmental and relationship stressors in their home environment. A substance abuse recovery group is operating as part of the partial hospital. Inpatients who are sufficiently motivated and clinically stable to be allowed off the inpatient unit can also attend this group. This linkage enables patients to begin working on recovery as soon as clinically appropriate. This treatment model emphasizes a functional stabilization approach intended to progressively increase patient self-regulation and reduce risk of harm. The goal is to enable patients to return to outpatient treatment and an acceptable level of functioning.
The service is staffed by four treatment teams, each consisting of an attending psychiatrist, a psychiatry resident, a medical student, a nurse, and a social worker. The chief resident acts as a supervisor for junior residents but does not carry his or her own team. This is a required experience for 4th-year residents. The treatment teams meet 5 days per week to discuss patient progress, changes in clinical management, and discharge planning needs. One team is based primarily at the partial hospital and admits all patients referred by the emergency service, outpatient offices, or other hospitals. The other three teams accept admissions to the inpatient unit. The same treatment team follows patients throughout the full episode of acute care, regardless of the program to which the patient is initially admitted.
Abbreviated transfer summaries have replaced comprehensive discharge summaries when patients are transferred between units within the service. An abbreviated assessment form is also substituted for a comprehensive assessment when patients are transferred between units. This system is possible because the same treatment team follows the patient. A comprehensive assessment and discharge summary are performed only once.
Educational Programming
The assigned faculty has developed an educational program to help residents and students achieve an optimal learning experience in this unique delivery system. The curriculum includes a weekly case conference in which residents or students present a patient who is subsequently interviewed. A discussion follows the interview. Attending psychiatrists and outside faculty participate as discussants. The focus is on differential diagnosis and management of complex patients. Medical students are expected to review the records of patients in order to provide detailed collateral information on patients' prior treatments. The case conference also provides an opportunity to collaborate with outpatient providers. A weekly interviewing conference provides residents with an opportunity to observe one another conducting brief therapeutic sessions with their patients while receiving instructive feedback from the observing faculty. Instruction is provided in managing the therapeutic alliance and in effective short-term interventions. A two-way mirror is used for both the case conference and the interviewing conference. Each of these conferences is 1 hour in duration.
The didactic curriculum consists of 2- to 4-hour modules covering principles of acute psychiatric assessment, psychopharmacological management in the acute care setting, formulation development, and medical aspects of psychiatry. An additional 2 didactic hours provide an overview of cognitive testing and the use of structured rating scales. Attending psychiatrists teach this didactic curriculum, emphasizing case-based learning as a means of orienting residents to the goals, opportunities, and limitations of acute treatment within each level of care.
Service Statistics
In fiscal year 1999, the inpatient unit received 686 admissions (an average of 57.2 patients per month) with an average length of stay of 7.3 days (Table 2). The average daily census was 14.6 patients. The partial hospital admitted 395 patients in fiscal year 1999 (an average of 32.9 patients monthly), with an average length of stay of 7.4 days and an average daily census of 13.2 patients. Of the total admissions to the partial hospital, 294 (74.4%) were transfers from the inpatient unit and 101 (25.6%) were direct admissions from outpatient offices or other facilities. Thus, 42.9% of inpatient admissions were transferred to the partial hospital.
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EVALUATION OF TEACHING/SERVICE MODEL
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Informal interviews with residents at the conclusion of their rotation elicited positive views regarding the integrated model of care. Specifically, residents felt that they were able to "know the patients better" through different phases of treatment. As a result, they were able to observe changes in the patients' functioning as they make the transition from inpatient to ambulatory treatment. Residents also felt that they were able to "learn how to manage patients in different treatment settings."
Some residents complained about the burden of paperwork associated with the high patient turnover. In response to this, a multidisciplinary assessment process was developed to enable different disciplines to build on one another's assessments. Additional modifications are planned to reduce redundancy of paperwork across levels of care while meeting regulatory and payer requirements.
The current faculty, all of whom were trained under the traditional model that included an inpatient care rotation completely separated from outpatient care, consider this innovative approach to be preferable for teaching residents optimal clinical skills and disease management approaches across the spectrum of symptom severity and functional impairment that they are likely to encounter in practice.
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DISCUSSION
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Psychiatric educators have long identified the need for residents to learn about the role of inpatient treatment in organized behavioral health delivery systems (8). Inpatient rotations remain a valuable vehicle for residents and medical students to develop an in-depth understanding of psychiatric patients within a brief time period. This process is facilitated through frequent patient contact, multidisciplinary team assessment, and consultation with collateral sources of information such as family, outpatient providers, and clinical records. The controlled environment of the inpatient milieu, combined with the severity of psychopathology encountered in such settings, provides residents with a rich, multidimensional learning experience. The supervised experience of functioning in an interdependent, integrated treatment team also fosters development of the resident's identity as a clinical and administrative team leader in addition to the development of traditional clinical skills. In less financially austere years, service fragmentation and lack of coordination were critiqued as deleterious to patient care. More recently, fiscal concerns have reinforced the need to coordinate care as a means of reducing utilization of costly inpatient services without sacrificing outcomes. In 1989, Johns Hopkins Hospital reorganized an inpatient teaching service, replacing junior residents with more experienced residents in the emergency room and adopting specific criteria for admissions (9). This reorganization, combined with improved coordination with outpatient services, led to a 20% reduction in average length of stay between 1990 and 1994. In another innovative approach, Houghtalen and colleagues (6) developed an integrated inpatient/partial hospital teaching service that provided coordination of care through a continuous treatment team model. This unit adopted screening criteria for admission to the integrated service as a means of selecting patients likely to benefit from a short-stay, integrated program.
In contrast to Houghtalen's integrated teaching service and Johns Hopkins Hospital inpatient teaching service, the Acute Adult Service of UMDNJ-UBHC uses no structured selection criteria, yet it provides a range of acute inpatient and ambulatory services within a larger integrated behavioral health delivery system. This teaching/service model allows residents to follow patients for an average of 2.5 weeks during an acute episode of care. Additional contact with patients in different settings and over a longer period of time, compared with a model that involves only inpatient services, allows residents and medical students to develop a richer understanding of their patients' longitudinal needs. By incorporating ambulatory care into their rotation, residents are able to manage patients as they return to their homes, families, work, and other potentially stressful settings. This continuity of care enables residents to develop competencies in interdisciplinary team leadership, case management, psychopharmacological management, and brief psychotherapies—all requisite skills in preparing residents for postresidency clinical practice (2). The focus on functional stabilization within a framework of social supports and community-based case management, rather than individual psychotherapy, represents a fundamental paradigm shift in residency training (5).
The increased acuity of patients' complaints, in addition to reductions in length of stay, require attending psychiatrists to exercise greater direct involvement in patient care than in longer-stay settings. This may reduce residents' opportunities to make more autonomous decisions, unless the attending–resident relationship is carefully managed to provide appropriate supervision while encouraging the resident to exercise clinical decision making (5). Special attention must be paid to the role of the teaching attending in facilitating resident development while providing high-quality care in an acute service.
Our model satisfies the ACGME requirements for an inpatient-equivalent rotation despite the inclusion of ambulatory care. The standards of accreditation, however, do not specify a requirement for acute partial hospital rotations. In light of changes in both the economic environment and delivery systems in which residents are trained, a review and clarification of the ACGME requirements may be warranted. We suggest that acute partial hospital rotations should be recognized as an important element in psychiatric residency training. Development of this level of care should be encouraged in other training programs because this modality is increasingly used as an alternative to hospitalization.
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CONCLUSION
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We have described one attempt to modify a clinical teaching/service model to balance the different demands of resident education and patient service. The authors recognize the realistic limitations that fiscal and utilization pressures have placed on psychiatric education. We conclude that this model more efficiently trains residents in multiple aspects of psychiatric practice.
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This article has been cited by other articles:
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R. M. Steinbook
Continuity Clinics in Psychiatric Residency Training
Acad Psychiatry,
February 1, 2007;
31(1):
15 - 18.
[Abstract]
[Full Text]
[PDF]
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ABSTRACT
INTRODUCTION
