A private practitioner giues a personal account of discouering how to treat the long-term psychiatric patient.

A Comprehensive Private- Practice Approach to Treating the Chronically Mentally Ill Daniel A. Deutschman

In the mid 1970s, I developed a comprehensive, multidisciplinary approach to private-practice care of the chronically mentally ill in Cleveland, Ohio. My experience with this approach since that time is detailed here in the hope that it will stimulate other private psychiatrists to consider the professional and financial rewards that may accrue from working with chronically mentally ill individuals.

It is well known that the chronically mentally ill have been under- served in the mental health system. Private psychiatrists have often contributed to this situation by making themselves unavailable or too expensive, or by not offering services that could competently serve this population. Some private practitioners have unrealistically expected patients themselves to assume responsibility for compliance with treatment. Thus, psychiatrists-whose training should have educated them better-often participate in the general culture’s deeply rooted prejudice against, and stigmatization of, this group of patients.

The problems in treating these individuals are real. The chronically mentally ill often miss appointments and behave in bizarre, dishearten- ing, and threatening ways. They may be physically dangerous in some

C C . Beels and L L. Bachrach (cd5.1. Suruzual .Slrafegzea for Public Psychinfry. New Diieclions for Mental Health Servims, no i?. San Franrhrn: Jossey-Bass. Summer 1989 75

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situations. It is useless to try to relate to them by using the traditional model of dynamic psychotherapy. Indeed, the therapist must abandon therapeutic neutrality and instead must actively cajole, reassure, push, prod, and remind. It is work.

Since treating chronic patients in significant numbers leaves most traditional practitioners drained and eventually burned-out, I hope this chapter will encourage private psychiatrists to work in nontraditional ways with this population-ways that may be professionally and finan- cially rewarding for the psychiatrist and beneficial for the patients.

The private-practice treatment of chronically mentally ill individuals requires an open mind and innovative thinking. The physician must manage those areas of the treatment that require his or her expertise and delegate the rest to workers with special skills, temperaments, and interests. The traditional psychiatric skills required include medication, supervision, and hospital work, as well as the assumption of overall legal and medical responsibility for the conduct of the case. In addition, the private-practice psychiatrist who treats chronic patients is well advised to borrow concepts from modern public psychiatry practice: case manage- ment, outreach or pursuit, day programs, and patient advocacy.

The Private-Practice Program

In this model, the basic private-practice outpatient team consists of a psychiatrist, a nurse, and a clinical coordinator. As the team psychiatrist, I generally provide inpatient care (when that is necessary) as well as a small amount of direct outpatient service, particularly at the beginning of outpatient follow-up. However, most of the outpatient work is performed by a nurse under close supervision. Outpatient treatment is both directive and supportive, and usually involves contact with families and community agencies. Often a family member is included in the patient’s treatment session.

The clinical coordinator initiates outreach when the patient fails to appear for appointments. He or she is the communication link between all the parts of the system: the doctor, the nurse, the agency, the hospital, and special programs such as sheltered workshops and support groups. I personally supervise each aspect of the nurse’s and coordinator’s work, and I log that supervision daily into the clinical record.

Several features of this design combat the team’s tendency to burn out in the care of long-term patients. Three people with different functions and responsibilities are available to listen to each other’s experiences and support one another through discouraging periods. Personality traits are important here: team members must be able to avail themselves of the emotional support that others can provide. A very important element in that support is helping other team members to lower unreasonably high

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expectations they may have for the chronically ill patient. In addition, being able to vary the type of intervention from patient to patient provides team members with relief from the sense of doing the same thing every day. This is one of the advantages of a larger and more varied caseload.

The Cleveland program grew in a series of steps. In the beginning- like many of my colleagues-I tried to avoid the chronically mentally ill. However, when certain patients who were VIPs were referred to me, I was obliged to treat them in the hospital. It was there that I was struck by the upbeat nature of the inpatient environment, which contrasted sharply with what had become for me, in private practice, an isolating void filled with therapeutic neutrality. I was impressed with the effectiveness of the inpatient team, which eased my burden and enhanced the patient’s clinical care.

When my patients were discharged, I followed them closely. I became frustrated by the amount of phone time required to keep track of them, and I had trouble tolerating patients who showed prominent negative symptoms. Recalling the inpatient experience, I was inspired to ask a bright, nurtur ing assistant head nurse on the university hospital psychiatry unit to follow my growing number of chronically mentally ill outpatients. I indicated to her that we might try to duplicate the approach that had worked so well on the inpatient unit.

T h e nurse who joined me in this effort enjoyed the increased responsibility and the ongoing clinical contact with the patients, whom she saw in my office while I was making hospital rounds. I reviewed her detailed chart notes daily and wrote my suggestions in the record.

The patients, in turn, were enthusiastic. Family members were pleased because they now had easier access to nursing support. And community agencies appreciated the increased ease of communication.

Eventually, more and more patients entered the program. A larger office was obtained, and a part-time clinical coordinator was employed. This individual was extremely effective, and patients liked her imme- diately. She assumed the role of patient advocate and general coordinator, screened calls from the answering service, and generally helped shoulder the burden of working with a large group of chronic patients.

In time there were seven nurses working part-time in the program. Nurses with a greal deal of clinical experience and those with administra- tive background performed better than less experienced nurses. Some social workers had been hired, but, with a few notable exceptions, they seemed less suited to the required tasks than were the nurses. The positive ingredients seemed to be clinical experience and ease with patients who move slowly and have somatic complaints and many side effects of inedica tion.

As the program continued to grow, a full-time clinical coordinator

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joined the team. In addition to the functions described above, the clinical coordinator has frequent contact with the inpatient units, the courts, and the police departments, as well as with my psychiatric colleagues. She is in the office forty-five hours per week, has her own beeper, screens all the answering-machine calls, does home visits including intervention when we are concerned about suicide attempts, and coordinates hospital admissions around the clock. Although she came to the program with no health care background, her judgment is excellent, her energy boundless: she is a combination of the Lone Ranger and a Saint Bernard with a cask around her neck.

A peer support group for family members has not worked well for us, but peer programs for patients have been remarkably successful. We instituted a mini-day hospital but limited it to three hours on Saturday morning for several reasons: we found that patients could not tolerate a longer period, and family members who worked were able to bring patients there at that time. The day hospital program provided horticultural and recreational therapy and field trips. It was codirected by one of the nurses and an occupational therapist, under my supervision. The program was well attended and allowed patients to make gains in socialization that were unprecedented for them. Later we found it practical to turn the day program over to agencies in the community.

At the same time we began to develop rating scales and special data sheets for keeping track of patients’ progress. One of the hospitals provided funds for a half-time nurse to organize teaching conferences for the staff. Patients’ idiosyncratic prodromal exacerbation patterns became a focus of interest, and our expertise grew so that we were better able to prevent future episodes through early intervention.

It should be noted that we do not compete with community service programs, because we do not duplicate them. To the contrary, hospitals and mental health centers are glad to get our referrals to their day programs and other services.

Economics

Except for the coordinator, all personnel are paid on an hourly basis, so that there is no downtime. They are in fact paid at a higher rate than what they would earn in the hospital. Noncollectibles, my supervision time, and overhead come out of the savings.

Between 400 and 600 patients have been treated over the years, with 100 to 200 patients currently in active treatment. Some are seen every week for years; others fade in and out and are not seen for months at a time. Most of them have some form of insurance; the majority, who are young but disabled, are on Medicare. Patients without personal funds or some type of insurance must be referred away. Patients with Medicaid also are

not seen, because the reimbursement rates are very low and patients are not allowed to make up the difference even if they are financially able. Our minimum fee is currently $20 per visit, of which Medicare pays 62 percent.

Of our patients, 60 to 70 percent are white and 30 percent black. Very few Hispanics, Native Americans, or Asian Americans are referred. No more than 10 percent of our patients work, although some have held responsible positions in the past. Half live with or are supported by their families. Very few homeless people have been referred, although it appears to us that many of our patients would have become homeless if not for our program. We have a wide referral network: patients, families, nursing staff, probate court, and colleagues.

Reactions to the Program

Based on a comparison of our patients’ courses before and after involvement with our program, I estimate that hundreds of hospitaliza- tions have been avoided. In many cases we have had to locate guardians for patients who are without funds or families. This has been difficult, but we have been able to get attorneys to serve on a pro bono basis. We also place patients in nursing homes while pursuing vigorous follow-up from our office. Since we began our program, only four patients have required referral to a long-term state hospital because of unremitting suicidal or homicidal risk.

Some psychiatric colleagues have been critical of this private-practice effort because of what they regard as a lack of continuity of care due to my referring a patient to a nurse at the time of his or her hospital discharge. Patients and families have sometimes had this reaction initially. However, I explain to them that we more than make up for discontinuity by having services available around the clock and by working closely with families to establish social supports-guardians, day programs, outreach, and so on-for patients. As soon as families and patients come to know the nurse and the coordinator and understand that we communi- cate closely with one another, they prefer our approach to what they have previously experienced. Over the long haul, they realize that our care involves fewer relapses and cycles through the hospital, because we attempt to anticipate trouble and take proactive measures.

Guidelines

Private-practice psychiatrists who wish to expand their practices to include the care of the chronically mentally ill may learn from our experience. Starting up such a program is simple and straightforward, requiring only a small investment of time and money. Thus, if the

program does not seem to be achieving its ends, it may be dismantled quickly, particularly in the early stages when only a few patients are involved.

It is important to find a psychiatric nurse with tested clinical skills. In the beginning, he or she should see a few chronic patients under supervision in the psychiatrist’s office These first patients should preferably be individuals with whom the nurse has already worked on an inpatient basis, under the psychiatrist’s care. Charts and supervision routines must be established so that the physician and nurse can work well together. The nurse should have malpractice insurance, and the malpractice carrier should know about the program’s work. In fourteen years, I have never been sued and have had few dissatisfied patients.

As the program grows and other nurses and a clinical coordinator are added, care must be taken to choose team members who can function as a group with mutual respect and support. It is important to recognize incipient frustration in a team member who is unable to tolerate the continuous march of patients’ symptoms. Competitive strivings among team members must also be anticipated and resolved.

Working with chronic patients can provide private psychiatrists with challenge, satisfaction, and remuneration. A team approach eliminates rough spots. Private psychiatry’s lack of involvement with the chroni- cally mentally ill is a loss for patients and physicians alike. Starting one’s own private comprehensive treatment program is neither complicated nor risky. Come on in-the water’s fine.

Daniel A . Deutschman is in the private practice of psychiatry in Cleveland, Ohio.