Psych home care could be your next big focus
Experts say it has good outcomes, lower LOS
Psychiatric home care services could be a perfect match for hospital home care agencies that are looking for ways to reduce hospital length of stay (LOS) and improve patient outcomes.
Several national studies indicate that psychiatric home care services produce good outcomes while lowering costs.
Plus, a number of health care changes are increasing the need for home care services targeted to the mentally ill. For example, state-funded psychiatric hospitals increasingly are under pressure to cut costs, and one way to do this is to discharge some patients into the community where they can receive less costly care and case management through home care services.
"Essentially what is happening is most of inpatient psychiatry is moving to outpatient," says Mike Neale, PhD, clinical psychologist and project director of the VA Intensive Psychiatric Community Care project at the Northeast Program Evaluation Center of the VA Connecticut Healthcare Service in West Haven, CT.
Also, physicians and hospitals are obtaining more capitation contracts in recent years. These contracts force providers to focus on cutting costs and reducing health care service utilization because providers are paid a set amount per health plan member instead of being paid on a fee-for-service basis. So psychiatric home care becomes an attractive alternative to simply allowing mentally ill patients to boomerang back to the hospital.
Staff Builders Inc. of Lake Success, NY, for instance, has developed a comprehensive psychiatric home care program that is beginning to pick up steam because increasing numbers of hospitals and physicians are focusing on reducing utilization and costs.
"There’s a willingness to give us opportunities that a year ago [physicians] would not have given us," says Verna Benner Carson, RN, PhD, CSP, national director of behavioral health for Staff Builders Home Health and Hospice in Fallston, MD.
And, community mental health centers are moving away from their traditional direct service care to the less costly case management approach, which could be provided by home care agencies.
"So these centers are looking externally for service providers," says Gary Hoover, PhD, a psychologist with Healthcare Documentation Systems in Winston-Salem, NC. The company specializes in designing and producing computer-assisted documentation systems for psychiatric care.
Between 18% and 28% of people receiving home care services have a diagnosable mental illness, although many are not being treated for these problems, according to a 1995 study published by the American Psychological Association.1
According to utilization data from the Health Care Financing Administration (HCFA) in Baltimore, the home care population in 1996 included 88 million cases of depression, 65 million cases of dementia, and 36 million cases of psychosis.
What these figures add up to is a good new source of revenues for home care agencies that develop psychiatric care programs, Hoover says.
Here are two models for home care psychiatric services that some studies indicate are working:
1. Staff Builders Inc. trains aides to become mental health aides and requires competency testing for psychiatric home care nurses. The company’s psychiatric home care program is essentially an in-home crisis intervention program called Restore that is substituted for patients who otherwise would have been treated at the hospital.
A study published in CARING Magazine2 showed the Restore program with an average LOS of 10 visits, costing a total of $650 to $720 per psychiatric patient. Comparable psychiatric patients were hospitalized for an average LOS of 19 days, costing $8,550 to $14,250 per patient.
2. The Intensive Psychiatric Community Care (IPCC) model, employed by more than 40 United States Department of Veterans Affairs (VA) hospitals, provides intensive intervention community and at-home counseling services to veterans with severe mental illness. A 1996-97 study by the Department of Veterans Affairs in West Haven, CT, showed a reduction in psychiatric hospital days from 138.1 days to 50.8 days per veteran after 12 months of the IPCC program. This resulted in a total cost reduction of $31.6 million, or more than $33,000 per veteran, from what the veterans’ inpatient care would have cost during that same annual period. The program returned $2 for every $1 spent.3
With these types of successes why haven’t more home care agencies and hospital systems developed home care psychiatric programs?
Agencies reluctant to take on psych patients
Home care agencies are resistant to caring for psychiatric patients for two reasons: First, they fear such services will require too many visits, which may hurt them with the interim payment system (IPS) visit cap limits, and, secondly, home care professionals have personal prejudices about these types of patients, Carson says.
"People are afraid of psychiatric patients," Carson says. "They think the patients are suicidal or violent, and they don’t want to deal with it, and they’re afraid they’ll get calls all night."
Staff Builders agencies have found that psychiatric patients require fewer visits than the average medical-surgical home care patient. So the psychiatric program actually helps the agencies with their IPS cap limits. "Under IPS, these are very good patients, and that’s one thing we’ve worked on educating our own staff and branches about," Carson says.
"We don’t have a caseload of psychiatric patients that we see for years," Carson says. "A lot of people see psychiatric patients as extremely high utilizers, and they are if they are not managed well."
These patients may include chronically mentally ill patients who are not candidates for long-term institutionalization. So the key is to have a program that offers psychiatric services with a goal of stabilizing the patients.
The VA IPCC model, however, targets severely mentally ill patients, including schizophrenics who will need long-term services to improve their quality of life and to prevent them from having to be institutionalized, says Andrea K. Schroder, LCSW, team leader for the IPCC program at the VA Medical Center in Denver.
"The type of treatment we do, while it’s called home care, is different from medical home care," Schroder says. "With our program, the expectation is we’ll work with these chronically mentally ill, high utilization veterans for life, and we’ll do primarily psychosocial rehabilitation with them."
The VA program is based on Programs of Assertive Community Treatment (PACT), which resulted from work done in the 1970s and 1980s at a research unit of the Mendota Mental Health Institute, a state psychiatric hospital in Madison, WI.
While the Staff Builders model aims to stabilize mentally ill patients, who then will be served by physicians and other community providers, the IPCC model provides therapy and more intensive case management in an effort to reduce the number of inpatient psychiatric patients.
"The idea is to help people until they’re integrated into the community," Neale says.
"These patients are not physically homebound; it’s just that society has not been wanting to see them," Neale explains. "So we get them housing, medications, and we help to integrate them and that can take time."
Neale says the PACT and similar models are useful to health care systems that wish to reduce inpatient psychiatric days. However, PACT is a long-term approach, and governmental agencies increasingly are looking for even less expensive models of care. So there are studies under way to see if these severely mentally ill patients remain out of the hospital if they are given short-term, in-home care.
"There’s some good that can be done with a short-term approach, but it’s still early on those trials, and people don’t know what is going to happen with those patients when you take those services away from them," Neale says.
References
1. Gatz M, ed. Emerging Issues in Mental Health and Aging. Washington, DC: American Psychological Association; 1995.
2. Vanderhorst K, Carson V, Midla C. Psychiatric home care: Clinically valid and cost effective. CARING Magazine 1998; May:64-68.
3. Rosenheck R, Neale M, Baldino R, Cavallaro L. Intensive Psychiatric Community Care (IPCC): A New Approach to Care for Veterans with Serious Mental Illness in the Department of Veterans Affairs. West Haven, CT: Department of Veterans Affairs, VA Connecticut Healthcare System; 1997.
Sources
• Verna Benner Carson, RN, PhD, CSP, National Director of Behavioral Health, Staff Builders Home Health and Hospice, 2612 Gunpowder Farms Road, Fallston, MD 21047. Telephone: (410) 803-9571. Web site: www.staffbuilders.com.
• Gary Hoover, PhD, Psychologist, Healthcare Documentation Systems, P.O. Box 24516, Winston-Salem, NC 27114. Telephone: (336) 574-9563. Fax: (336) 885-3788.
• Mike Neale, PhD, Clinical Psychologist, Director, VA Intensive Psychiatric Community Care Project, Northeast Program Evaluation Center, VA Connecticut, 950 Campbell Ave., West Haven, CT 06516. Telephone: (203) 932-5711, ext. 3696. Fax: (203) 937-4762.
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