Data are presented that describe the clinical characteristics of 96 patients treated at the C.F. Menninger Memorial Hospital, Topeka, Kansas, from November 1983 to June 1989. Their Axis I eating disorder diagnoses were as follows: 53 had diagnoses of bulimia; 21 had anorexia nervosa; 2 had both diagnoses; 17 had atypical disorders or eating disorders not otherwise specified; and 2 had a diagnosis of psychological factors affecting physical conditions. Seventy-three percent of the cohort were found to have either Axis I or Axis II disorders or both, comorbidity. Borderline personality disorder was found in 46% of the sample, although 20% of the patients with borderline disorders were diagnosed retrospectively. Depression was the largest comorbid Axis I diagnosis. Patient variables for sexual abuse, drug and alcohol addiction, purgative behaviors, and interpersonal relationships are also described. The authors conclude that a substantial subpopulation of eating disordered patients are significantly comorbid for other psychiatric illnesses. This high incidence of comorbidity may help explain the frequency of refractoriness of many eating disordered patients who do not respond to outpatient or short-term inpatient hospitalization. The authors recommend that additional research studies address the problems of the comorbid eating disordered patient and suggest that the findings be taken into account by clinicians and payers.
Recent and dramatic changes in this country's mental healthcare service are widely documented. To assess the extent and timing of those changes at one private psychiatric hospital, the authors examined length of stay, number of admissions, and patient age for general trends between 1980 and 1990 and more closely examined trends between July 1990 and December 1991. We related our findings to data for other private psychiatric hospitals and compared them with data from psychiatric units in general hospitals. The results are discussed in terms of changes in insurance coverage, changing utilization by different age groups, and a national shift from inpatient to outpatient care.
Increasingly, various stakeholders from insurance companies to patients are demanding verification of treatment effectiveness. With this pressure for accountability, program evaluation is essential to the continued existence of psychiatric hospitals because it permits understanding the effects specific interventions or procedures have on the quality and effectiveness of care. Two inpatient aspects of program evaluation are treatment outcome and continuous quality improvement. This article describes the conceptual bases of both treatment outcome and continuous quality improvement, depicts their complementary characteristics, and suggests how these two aspects of program evaluation can be integrated.
While most of the recent national attention on healthcare reform has focused on physicians, acute-care hospitals, and the insurance industry, what about mental healthcare providers? Where do psychiatric hospitals, psychiatrists, psychologists, and other mental healthcare professionals fit into the healthcare payment system of the future? For example, if the United States ends up with what is called universal access--a payment source for all Americans--will it include mental health benefits? The stakes are high; one quarter of the American population either has no health insurance or is covered by Medicaid. Many current reform proposals include tort reform; but how would it affect mental healthcare providers? Will managed care--primarily health maintenance organizations (HMOs) and preferred provider organizations (PPOs)--be a part of the reshaping of the United States healthcare system? This article has three objectives: To summarize the various healthcare reform proposals and provide a description of the key elements anticipated in the most likely reform package. To consider the strategic implications of payment reform for the mental healthcare industry. To identify strategies for mental healthcare providers that are likely to be useful regardless of the shape of healthcare reform.
Child siblings of children admitted to psychiatric hospitals often find themselves in a unique and potentially isolating situation. Because of the crisis affecting all family members and the focus of both parents' and professionals' energies on the identified patient, this sibling group is often overlooked. This paper describes an educational and supportive group designed by the authors to begin to address the needs of this population and offered as part of the family-services component of a child and adolescent psychiatric unit. The group serves multiple functions by diminishing the non-hospitalized children's sense of isolation, offering them education and support, and providing the treatment providers an opportunity to assess the needs of the inpatient's sibling. The authors describe a highly structured format that facilitated group members' participation.
Private psychiatric hospitals are acquiring information systems to provide timely and accurate data for improved patient care and financial operations. Serious commitment of staff time, effort, and financial resources is required during the selection and management of the system to achieve full benefits from this technology. Active participation by senior management and the end-user community in the planning and acquisition process will lay the foundation for a successful system implementation.
The importance of outcome research in the field of children's mental health treatment has increased in recent years because of enhanced consumer awareness, a decrease in available resources, and payers' demand for accountability. The present study evaluated the treatment program of a child psychiatric unit in a public university hospital in the southeastern United States. The research used a single-group, pre- and post-test design and the Child Behavior Checklist (CBCL) as the outcome measure. Children receiving inpatient psychiatric treatment demonstrated statistically significant improvements in CBCL scores. The strengths and limitations of this study are discussed.
The author applied a twelve-item checklist of criteria for hospitalization to determine the impact of each on length of stay for a group of depressed adolescents admitted to two units of a private child and adolescent psychiatric hospital. Attempts were made to control for the influence of insurance status on time spent in the hospital. Active suicidal preoccupation without active preparation or attempt was the only item found to have significant impact on length of stay.
With the increasing pressure from managed care companies and in cooperation with its medical staff's independent practice association, the Vista Hill Foundation formed its own specialty health maintenance organization. This is a report on an outpatient study of treatment satisfaction among 124 mental healthcare providers (50% of whom were psychiatrists) and their 218 patient experiences. Treatment outcome was rated as "very satisfactory" or "satisfactory" in 82% of the studied cases. Managed care was found to cause "mild" to "moderate" treatment interference in 26% of the cases and "significant" to "major" interference in 6%. There was no interference reported in 60% of the cases studied. Our study demonstrates that a hospital provider and its managed care system can provide satisfactory care, but it also reveals the need to constantly review treatment programs to reduce interference. The study and report are part of Vista Hill Foundation's ongoing quality review efforts.
Because of the trend in inpatient psychiatry toward a marked decrease in length of hospitalization, clinicians must reconceptualize the manner in which psychosocial treatments are organized in the inpatient milieu. Considerable data suggest that problem-solving therapies may be a productive way to integrate the groups and activities in the therapeutic milieu. This paper describes the application of a problem-solving approach to the therapeutic milieu and indicates that the therapeutic gains from this approach may be enhanced by combining inpatient treatment with a transitional day hospital program. We identify the empirical underpinnings of this model and describe how it has been used to treat a schizophrenic patient. We suggest that problem-solving therapies are effective for promoting behavioral change on the general psychiatric inpatient unit.
Informed price setting in private psychiatric hospitals is based on many factors, including accounting cost, economic cost, mission, long-term plans, and competition. Because no single cost accounting method yields the "right" price without the input of judgment and the consideration of other factors, several appropriate and useful methods of cost accounting should be considered. And because various approaches to price setting carry varying degrees of risk, informed price setting must evaluate them all.
The science and marketing of psychiatric treatment are rapidly changing, and the changes are reflected, in part, in the recent evolution of the use of laboratory services. Nevertheless, there are few, if any, articles in the literature addressing how a laboratory service can best assist a psychiatric hospital. This article presents a scaffolding of current issues to be considered when determining how a laboratory can assist the psychiatric facility. It cites the special laboratory needs of the psychiatric hospital and issues to be considered when evaluating laboratory service.
The past decade has brought extraordinarily rapid changes to the treatment of patients with severe mental illnesses. Changes evolved from advances in technologic and pharmacologic understanding as well as from complex fiscal and political pressures. Increasingly, regimented standardization in approach narrows the range of treatment options. Both within and outside of psychiatry, some disparage psychodynamic approaches. Psychiatrists are required to accept as plausible standardized and constricted time frames for evaluation and treatment. Thus we are asked to view the mind's storms as strictly neuronally based and to view our patients as passively compliant. By implication, treatment alliance is to be cemented by a prescription and authority. This paper presents clinical material drawn from hospital-based experience at The Chestnut Lodge Hospital, Rockville, Maryland, meant to place current trends in an historic context. The author offers possible alternatives to resignation in the face of current pressures.
This study examines staffing patterns, lengths of stay, and utilization rates in medical school-based psychiatric hospital treatment of children and adolescents. Results of surveys taken in 1984 and 1988 show that lengths of stay decreased during these four years, but utilization rates and number of beds tended to remain the same or increase. As economic pressures force hospitals to consider reducing staff, it is important to establish baseline data to evaluate and plan staffing patterns for child and adolescent inpatient units.
Changes in clinical management and reimbursement approaches have placed new pressures on psychiatric hospitals to have immediate access to critical information. Information systems management is in the difficult position of responding--while under this pressure--to a host of requests for computer applications that may be at cross purposes with each other. Pine Rest Christian Hospital, a full-continuum, 146-bed, not-for-profit psychiatric facility in Grand Rapids, Michigan, has been preparing tactics to deal with information systems management under pressure. This paper describes the consequent information systems management approaches and some of the critical computer applications Pine Rest has installed.
Charter Medical Corporation's computerized Clinical Information System is described. The computerized system helps clinicians formulate and document individualized patient treatment plans along the continuum of care and to improve internal medical record keeping. The system can also help improve the efficient collecting, storing, retrieving, and reporting of clinical information, both for internal use and for external utilization review and case management. In the future, the system will be linked to Charter's continuous quality improvement efforts and to its new Clinical Outcome Monitoring System.
National developments suggest that the Mental Health Statistics Improvement Program (MHSIP) offers a suitable philosophical framework as well as standards for a minimum core of mental health data for the total field. With an emphasis on agency-level development and use of data systems, MHSIP could further management objectives in both the public and private sectors. Performance indicators derived from the MHSIP content could be the vehicle for the transformation of automated reams of data into a meaningful and useful consolidated management tool, a tool that would also further quality of care. This article briefly describes the background and content of the MHSIP and the type of performance indicators that can be derived from it and used by management.
Violence perpetrated on the staff in our psychiatric hospitals is increasing. We believe an in-hospital support group for employee victims of violence is an effective and economical means of helping our staff, our patients, and the hospital in general. We believe that it is crucial to provide education about and to foster sensitization to issues of violence and that our staff must work together within the facility and with outside agencies, such as those in the legal system. We are just starting our support group at the Carter Center, and this paper discusses various practical points encountered thus far and some of the theoretical issues surrounding our beginning. We believe ours is an important prototype of staff support groups, which are vitally needed. I hope to publish a follow-up report on our group and the progress it has made.
The National Association of Private Psychiatric Hospitals (NAPPH) initiated the Critical Indicator Project in 1986 to develop measures of quality and other important clinical aspects of inpatient psychiatric treatment. The tools used to collect data have undergone extensive refinements, and the data collected have been analyzed by researchers and clinicians. After careful review, in January 1990 the NAPPH Board of Trustees endorsed full implementation of the Critical Indicator Project in all member hospitals. This paper describes the project and its current major implications.
The field of geriatric mental health is confronted with the dilemma of a sharp rise in the elderly segment of the population and a concomitant shortage of age-appropriate psychiatric intervention services. There is tremendous need for specialized hospital-based intervention for older adults with mental health problems. A creative and rapid response is imperative and should be based on a continuum of geropsychiatric services that includes acute inpatient, partial hospitalization, and outpatient services. Because Medicare reimbursement for partial hospitalization is restricted to hospital-based programs, private psychiatric hospitals are uniquely positioned to assume a dominant role in the geriatric mental health service delivery system. This article details one hospital's specialized, intermediate-term partial-hospital program for older adults. Partial hospitalization is demonstrated to be an essential component of comprehensive geropsychiatric services that can overcome problems of cost-effectiveness, accessibility, and acceptability to consumers--all factors that presently restrict the development and use of such programs. Based on empirical findings, clinical adaptations to assessment and treatment procedures specific to older adults are presented.
