Institutional Best Practices for Treating Schizophrenia - Episode 1

Overview of Schizophrenia Treatment

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Joe Avelino, RN, BSN, MHSA, CPHQ, and Henry Nasrallah, MD, review schizophrenia and the needs of these patients.

Peter Salgo, MD: Hello and welcome to this HCPLive® Peer Exchange entitled, “Institutional Best Practices for Treating Schizophrenia.” I’m Dr Peter Salgo, I’m a professor of medicine and anesthesiology at the Columbia University College of Physicians and Surgeons. I’m an attending physician at New York-Presbyterian Hospital, and I’m associate director of surgical intensive care at New York-Presbyterian Hospital.

I am privileged to have joining me today in this discussion my colleagues: Joe Avelino, CEO, College Medical Center, Long Beach, California; Dr Rahn Bailey, assistant dean of education at Charles R. Drew University of Medicine and Science, Los Angeles, California; and Dr Henry Nasrallah. He’s vice chair and professor of psychiatry, neurology, and neurosciences at the University of Cincinnati College of Medicine.

Our discussion today focuses on understanding the benefits of long-acting injectables in the management of schizophrenia. We’re also going to discuss system protocols that are in place for the use of long-acting injectables in an institutional setting. I want to welcome everybody here, and without further ado, let’s get started.

Why don’t we start with an encyclopedic question? How big of a problem is schizophrenia, and what are some of the challenges and unmet needs that you face when you’re treating patients with schizophrenia? Joe, do you want to start us off?

Joe Avelino, RN, BSN, MHSA, CPHQ: Absolutely. Thank you, Peter. Let me give you a perspective from a hospital acute care setting, telling you a little bit of the lay of the land here at College Medical Center. We’re licensed for 221 beds: we’re an acute care hospital with a specialty in behavioral health services. From College Medical Center, we have about 500 admissions a month of patients with behavioral health issues. We have 250 of those admissions coming from the ED [emergency department], where we have approximately 1500 encounters a month. In our ED setting, our psychiatrists—which we typically have about 8 on our call panel of medical staff—they care for these patients, and typically do not need to refer to a primary care specialist. They would like to manage it themselves.

We also have protocols, or so-called order sets, that make it more efficient, especially with our ED doctors, so they don’t have to call the psychiatrist regarding the specific long-acting injectables. But prior to that, there’s a PET [positron emission tomography] evaluation, psychiatric evaluation by our team members, whether the patient meets the inpatient criteria to be on hold and to be placed in a 5150 code allowing involuntary detention for psychiatric hospitalization. Some of our psychiatrists do prefer the protocols and order sets, but there are also some of the old-school psychiatrists who prefer not to use them.

Some folks are challenged with using our EMR [electronic medical record system]. But the other challenge we have is with the homeless population we serve here—those who are not compliant, those who don’t have the resources or the support system to get through schizophrenia. It’s certainly a challenge. I would like to hear from my colleagues about how they’re addressing this matter.

Peter Salgo, MD: Let me ask a question to the group. What I heard you say is that you’ve got some very dedicated people and they’re very specific, and your center really is focused on psychiatric illness. But is this problem, the problem of schizophrenia in the population at large, small enough to be handled only by specialists, or can primary care physicians and more generalized physicians handle this problem as well? What do you think?

Henry Nasrallah, MD: No. Schizophrenia is probably the most severe psychiatric disorder, and that should not only be handled by a psychiatrist, but with a team. The best way to approach this population is with a multifaceted approach, a biopsychosocial approach. They need medications, social support, professional rehabilitation, and cognitive remediation. There are multiple things we should do for this group of patients, and 1 individual cannot do it. However, the primary care physician must be involved in collaborative care because this population has a lot of medical conditions that co-occur as part of their immune dysfunction.

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Transcript Edited for Clarity