Current Protocols in Psychiatric Care

Peter Salgo, MD: What protocols are in place right now, nationwide or in specific hospitals—even in your hospital, Joe Avelino—to make sure patients are identified when they enter an emergency department or an inpatient setting, to look early on at their eligibility for LAIs [long-acting injectables]? Or is this something that’s picked up haphazardly later? 

Henry Nasrallah, MD: In Europe they use LAIs much higher than us. In the United States, about 10% to 11% of patients with schizophrenia are receiving an LAI. It’s usually very late in the illness; they rarely give it to them early. That’s another tragedy. In Europe, 40% to 50% is not uncommon, and the reason—this is the incentive to give LAIs—comes from the higher authority, the funding agency. They have single payer, and the government says, “Oh, no, we’re not going to pay for the expensive inpatient rehospitalization again and again.” You’re going to get this injection if you get 1 episode after the first 1. If you get 1 relapse you’re going to get the injection, and all the physicians comply with that. 

In the United States, I wish Medicaid and Medicare would cover LAIs. It might be coming, actually. As you know, there is a penalty. Medicare does penalize hospitals that have a readmission in several medical conditions but not in psychiatry yet. They make penalize them . They make them pay money for a “relapse.” Perhaps when that comes to psychiatry, maybe then the system of care will adopt LAIs to avoid the financial penalty. Not because of the patient needs. I do it because they want to avoid the penalty.

Peter Salgo, MD: If you’re saying that what you really want to do is put a financial penalty in for readmissions, we do this for all kinds of diseases. We do this for pressure ulcers, and we do this for MI [myocardial infarction]. For lots of things. That would be 1 way to encourage this. But what’s in place right now? Is there anything in place to force the issue forward if you believe LAIs are the way to go? Is there protocol in the EMR [electronic medical record] anywhere that’s going to make this work? 

Rahn Bailey, MD, DFAPA: Unfortunately not. Not now, but as it was already pointed out, it’s timely. It’s unfortunate that it might take outside influences to make this happen, but the truth is it happens every day. I got the job I’m at about 2 years ago. When I came here, the new medical school tied to this hospital tried to implement some new plans and policies around care. We lost 3 doctors. Three doctors left the hospital because many doctors are against algorithms. But truly they may be against having to know the new data and implementing it in their overall practice. You see that in many settings.

I was a chairman at Wake Forest for 4 years before I came here, and we began implementing necessary changes. In those settings we were looking downstream to figure out what were some of the strategies that could lead to savings on cost because if a person goes back into the hospital, all the other company costs at a medical surgical hospital increase, not just psychiatrics. The reality is that psychiatric patients have other comorbidities, so they’re being treated for hypertension that may develop an arrhythmia or the case may get a little touch of pneumonia. Those overall costs are pretty striking if you bounce back in less than 30 days. How often in psychiatrics does that happen with our patients?

The downstream forces are likely to continue to grow. The problem for us, though, is we don’t want to lose the control of our profession. This is something we should do, and it should be evidence based. A discussion like that is essential because we have to find ways to do what you’re asking. How can we find strategies and protocols that not only encourage but force and, at some level, monitor and strategize for your physicians to practice in a more evidence-based way. In the places I’ve been, there’s really no teeth to it, and that’s been the problem.

Peter Salgo, MD: If you look at the way these strategies have been instituted in various subspecialties, it hasn’t been imposed on them from outside. Cardiologists did not wait for the insurance companies to say, “Do your CATs [computed axial tomography] right away.” They published articles and they all accepted this was good.

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Transcript Edited for Clarity