Lori Ball consults with medical teams at VUMC, and now VCH, to determine the best course of action for patients with psychiatric disorders. (photo by Dana Johnson)
Psychiatric case management services extended to VCH
Recently, Lori Ball’s role as coordinator and case manager for the Psychiatric Consult and Liaison (Psych CL) Service has expanded to include case management for Vanderbilt Children’s Hospital. This leaves medical or pediatric case managers to concentrate on managing the care of patients being treated for medical problems only.
Ball, R.N., M.S., serves as case manager and coordinates the Psychiatric CL Service for the general adult, geriatrics, addictions, and children and adolescents. Ball sees the extension of her responsibilities as an important step in the direction of optimum patient care.
A 16-year-old girl with diabetes refuses to take her medicine. Her behavioral symptoms go untreated, she continues to refuse her meds and develops potentially life-threatening diabetic ketoacidosis, requiring hospitalization. Her endocrinologist treats her, advises her of the importance of taking her medicine, and releases her. Now depressed, she continues to refuse to take her medication and is soon back in the hospital. In this case, the patient’s non-compliance in taking her medication is a symptom of a disease other than the diagnosed condition of diabetes. Not treating her now clinical depression will probably lead to more health issues for her. Without a psychiatric treatment plan, both initially and long-term, this young woman is likely to do irreversible damage to her health.
The Psych CL Service provides a needed service to the VUMC medical teams, consulting with them and providing specialized recommendations that go beyond the patient’s physical health requirements. Each team has a unique configuration of attendings, residents, and fellows and is designed not with the purpose of being a treatment team, but with the intent of making recommendations to treat acute psychiatric illnesses. They consult with the patient’s medical team to determine the best course of action for a patient displaying some form of psychiatric disorder.
There are four teams within the service, each specializing in a particular field. The general adult team focuses on patients 18 and older, while the geriatric team works specifically with the elderly population, many of whom suffer from depression that often goes untreated. There is an addiction team that offers recommendations for treating patients with addictive disorders. The children and adolescents team works with children who are suffering from a variety of mental illnesses including adjusting to chronic medical conditions, eating disorders, and suicide attempts.
Because there are so many specialties in medicine, it is sometimes difficult for a skilled physician to identify the psychological abnormalities presented by a patient being treated for a physical illness. For example, a cardiologist correcting heart damage done by years of cocaine abuse may be able to treat the damage, but will likely not know how to treat a patient with a serious addiction.
Comorbid conditions are quite common. Individuals with psychiatric illnesses such as schizophrenia, bipolar disorder, depression, addictions, or post-traumatic stress get sick and seek medical attention just like everyone else. Or, their condition may put them at higher risk for certain kinds of traumas, such as gunshot wounds, poisoning, or car accidents. Once they’ve been admitted, their behavior or cognitive processes may raise certain red flags to the medical professionals treating them. Some of these patients may have stopped taking their medications; others may have never been diagnosed at all. Once the medical team has recognized that the patient’s needs go beyond their particular area of expertise, they request a psychiatric consult, which Ball triages to the appropriate team.
Because psychiatric hospitals will not admit a patient without medical clearance, the Psych CL team recommends interventions to help manage the patient until they are discharged from the hospital. They may recommend a suicidal patient have a sitter in their room or they may simply initiate medication to control a psychosis until a more thorough treatment plan can be initiated by a dedicated outpatient psychiatrist or inpatient psychiatric hospital.
For Psych CL, the goal for the patient is to provide them with a safe environment while they are in the Medical Center and tend to their most immediate psychiatric needs. To treat acute, severe mental illness, a comprehensive evaluation, intense counseling, family involvement and thorough drug therapy are necessary and may only be found in a psychiatric setting.
“We could be compared to paramedics for the psych hospital,” said Ball. “We do whatever needs to be done to ‘patch’ a patient up until a full treatment plan is developed by a psychiatric team dedicated wholly to them.”
As a case manager, Ball works closely with the medical staff, the Psych CL team, as well as the patient and their family. A physician requesting a consult will complete an online request through the WizOrder system. This encrypted Internet-based system is highly secure and allows limited access. As soon as a new consult request is entered, Ball is beeped, letting her know to check the system. From that point, she triages the consult and decides which of the four teams to contact. Following the consult, Ball will work with the patient and family to initiate follow-up care, which usually includes guiding them through the tricky maze of insurance coverage and levels and types of psychiatric care.
Whether a patient needs ongoing psychiatric outpatient care or inpatient hospital admission, finding a provider and understanding what is covered by the patient’s insurance is complex at best, frustrating at worst. However, without the assistance of a dedicated case manager to guide them, many patients would simply fall through the cracks after being discharged from the Medical Center.
In the case of the 16-year old-depressed diabetic, without skilled case management, the patient’s caregiver may have been unable to navigate the rocky path of continuing psychiatric care. The depression then goes untreated, the patient continues to refuse her medication, and is readmitted to VUMC. This cycle is a clinical and economic nightmare. With a comprehensive “whole person” treatment plan, the prognosis for this young woman becomes positive and hopeful.
By being proactive in identifying psychiatric problems and then seeing that appropriate follow-up care is provided, the cost for repeat visits to the hospital is minimized as is the length of stay. Most importantly, the patient’s psychological and physiological condition is effectively treated.
Ball hopes to see the Psych CL Service continue to expand. Although taking on the case management responsibilities of the Children’s Hospital keeps her busy, she is encouraged by the work she does.
“We’re tending to their rights as patients and we involve the families,” Ball said. “We serve as a bridge between medicine and psychiatry—after all, the mind and the body are connected.”