It’s 9 a.m. on a frigid winter Friday. Ten members of Yale Medicine’s Behavioral Intervention Team (BIT) gather in a conference room for their morning meeting. They are doctors, advanced practice registered nurses, social workers, a psychiatric clinical nurse specialist and the patient services manager. Their task: to address the psychiatric issues that often complicate the medical care of patients at Yale New Haven Hospital.
They review the day’s cases. A man with kidney disease had been talking about suicide. “He has a lot of life stresses,” says Mark Oldham, MD, the psychiatrist leading the team. An elderly man with Alzheimer’s disease is recovering from pneumonia. “There’s nowhere for this patient to go,” a social worker says. A 34-year-old woman with a history of Munchausen syndrome has been purposely infecting her I.V. line. Those suffering from the syndrome feign illness or psychological trauma to draw attention or sympathy. “She’s a med school graduate. She knows enough to be dangerous,” Dr. Oldham observes.
The group brainstorms possible solutions for each patient—a change in medication, a referral to an outpatient treatment program, housing assistance. Each team member draws on his or her expertise to suggest ways to lessen patients’ suffering and ease their stay in the hospital.
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‘A bidirectional relationship’
Medical and psychiatric problems often go hand in hand. Psychiatric conditions affect 25 percent of adults in the United States, according to the U.S. Centers for Disease Control and Prevention. But some medical conditions can lead to psychiatric ones, and vice versa.
“It’s often a bidirectional relationship,” says Hochang B. Lee, MD, founding director of the Psychological Medicine Service, who oversees the Behavioral Intervention Team. For example, depression often follows heart surgery. Meanwhile, psychiatric conditions such as depression may present obstacles that keep a person from taking care of a medical condition. Sometimes, as with alcohol abuse and liver disease, the link is more direct.
In most U.S. hospitals, consultation-liaison psychiatrists get called in only when there is a crisis, such as for a patient with psychosis or for a suicide attempt. Often patients’ psychiatric needs go unaddressed during their hospital stay. In 2010, Yale Medicine psychiatrist William Sledge, MD, pioneered a new approach, one that is proactive and multidisciplinary.
"We screen every admitted medical patient at Yale New Haven Hospital for psychiatric issues that could be a barrier for receiving proper medical care,” Dr. Lee says. People with less obvious problems, such as mild-to-moderate depression, anxiety, substance abuse or an eating disorder, are offered personalized psychiatric attention along with the world-class medical care they receive. “It’s a more holistic approach to getting patients better,” Dr. Lee says.
In addition to the BIT, nine other specialty services involve a psychiatrist or a psychologist (or both) in outpatient care. These mental health professionals work with people being treated at the HIV clinic, the smoking cessation program and the cancer center, sleep medicine, geriatric medicine and even primary care. “We are the largest consultative psychosomatic medicine group in the country,” Dr. Lee says. “It’s a really great integrated approach.”
The efforts of the BIT have substantially increased the number of Yale New Haven Hospital patients who receive psychiatric care. This care may be costly to deliver, but it saves money by reducing lengths of stay and hospital personnel needs. For example, fewer of these patients need round-the-clock supervision of a hospital-provided “constant companion” to watch them so they do not endanger anyone, including themselves. The BIT’s work has been so successful that the Yale New Haven Hospital’s Saint Raphael campus, the Cancer Center and the Cardiology unit hope to add it to their services soon. The team has published its results in peer-reviewed journals.
And health care professionals have come to New Haven from across the world to learn how to replicate the model. Medical centers such as Johns Hopkins Hospital, the Dartmouth-Hitchcock Medical Center and Stony Brook University Hospital have adopted the BIT model.
One case at a time
At Yale New Haven Hospital, the BIT’s work starts early each morning, when a team member checks the previous day’s admissions for psychiatric diagnoses, looking for those whose records include words such as “substance abuse,” “agitation” or “suicide attempt.” Among the 40 or so new patients admitted to the hospital each day, about 10 cases are brought up for morning rounds discussion.
These psychiatric problems can get in the way of good medical care. Imagine a person with schizophrenia who comes in with chest pain, suggests Dr. Lee. Life stressors such as an emergency hospitalization can exacerbate schizophrenia symptoms, such as paranoia and hallucinations. Add to that the anxiety of dealing with nurses and doctors trying to draw blood or put a tube on his nose. “You could see that this paranoid schizophrenic will be very afraid and might misinterpret this,” Dr. Lee notes.
He describes how things may go awry. The patient might become upset or even become violent. “Maybe someone gets hurt while trying to help him,” Dr. Lee says. Security would be called, and the patient restrained. Blood work is not taken, or the patient may miss a procedure because he is so agitated. “For this patient, there is a critical delay,” Dr. Lee says, “and poorer quality of medical services provided as the medical staff tries to work around the psychiatric symptoms. He is not getting timely, lifesaving treatment.”
Instead of being efficiently treated and discharged, the patient might need to stay extra days or be transferred to the psychiatric unit. “You can see how a psychiatric issue can become a burden or barrier to the delivery of essential medical services,” Dr. Lee says.
The BIT identifies these issues up front and tries to avert problems by sending a team member to assist the patient, offer relevant medication or therapy and help nurses and doctors perform their duties. “Our presence is very reassuring to both the patient and the medical team,” Dr. Lee says.
The BIT in action
By 10 a.m., the morning assessment meeting typically come to an end. The team has decided which patients need screening and divvies up the cases.
“Screening involves going out to the unit and talking with the patient’s nurse or anyone involved in their care,” Nancy Li Atwood, a social worker on the BIT, says. “We’ll say, ‘How are things going with Mr. Jones?’ If they need our intervention, we ask the team if they’d like a consultation.”
If so, BIT members visit the patient. The psychiatrist handles difficult diagnoses, prescriptions and other tasks that require her expertise, such as evaluating whether a patient has the capacity to make sound decisions. The advanced practice registered nurses are essential to managing patients with complex medical conditions. The social workers address other issues the patient might be facing, such as domestic abuse or homelessness due to untreated mental illnesses. Meanwhile, the psychiatric clinical nurse specialist educates the hospital staff on how to interact with troubled patients to give them the best possible care.
“The medical staff and nursing staff are focused on the medical conditions,” says Nancy Tommasini, the psychiatric clinical nurse specialist. “We’re focused on the psychiatric conditions. So whenever a staff member is interested, I’ll pile on the articles and we’ll talk about the symptoms and how to intervene.”
Earlier that day, Tommasini had checked on a woman with delirious mania who was loudly cursing at the nurses. She had pulled out her I.V. line, so they couldn’t give her the medication she needed. “I went in and showed them that when a patient is screaming, you whisper and use very simple, concrete terms,” she said.
The next morning, when the team members reconvene, they’ll reassess each patient, tweak their medications, discuss staff education, pinpoint helpful outpatient and community resources and talk about discharge for those who are ready to go home—often earlier than they otherwise would have been.
“People get better care this way,” Dr. Oldham says. “It saves a lot of money, too, but I don’t care about the dollars and cents, to be honest. I like it because people get better care.”