Someone once offered me 50 million dollars to pursue an idea.
Let me start in the beginning. If you’ve ever worked or been a patient in a psychiatric hospital, you know about the problem: there’s no middle ground between the tight routine & support of being hospitalized and the toss-you-out-into-the-world discharge plan that follows. In simpler terms, when leaving a psychiatric hospital, people go from 24-hour structure and nursing care to… well, the real world. And they don’t do well.
Patients run out of medication. Their families aren’t always supportive. Community resources are scarce. Supportive housing even scarcer. And America is a lonely place; few people, especially those with mental illness, have enough support. Within months, or days, the seriously mentally ill person has fallen through the cracks, gone into crisis, and returned to the hospital.
This discharge-rehospitalization cycle happens over and over. In psychiatry we call this the “revolving door” phenomena. It’s tragic, and it’s expensive. Many psychiatrically ill patients depend on Medicaid for their health care. The public spends billions of dollars each year paying for these emergency room visits and hospitalizations.
Most countries have solved this issue by establishing a middle step between hospitalization and community: the rehabilitative or residential psychiatric hospital. Most countries, that is, except the United States.
Take Spain, for example.
In late 2004 one chilly morning I stepped through the doors of an old, beautifully architected, two-story building sitting against the backdrop of a small garden and busy city street (too much detail, I know, but I want you to get a clear image of the place). This was a rehabilitative psychiatric hospital in Asturias, Spain.
Behind unlocked doors I found a long hallway filled with patients cleaning out their rooms. Hired caregivers were directing them through the process, rapidly braiding one patient’s hair, patting another fellow on the back, while teasing a third about the laundry she’d hidden under her bed. Apparently they were late for their first class: dance.
The caregivers directed me to the gym. Here I found a medley of couples prancing around to upbeat music. Staff and patients danced together, a good hundred patients at least. I rested back in a corner until the dance was over (hoping nobody would ask me to prance), and the treatment team stepped over to introduce themselves: a head psychologist, couple of social workers, and a large group of nurses and caregivers.
“Many patients come here after they’re discharged from the hospital,” the psychologist explained. “Especially those who aren’t ready to live out there. They usually stay here a year, maybe two, and learn how to function in the real world before they have to live in it.”
The social workers added to the psychologist’s story. “Residents learn how to socialize properly, use public transportation, transition over to a group home or their own apartment, start a job, go back to school, get a hobby, whatever they need. After they leave, the doors are always open. They’re welcome to return here for some of the groups. They’re encouraged to keep in touch with one another. Friendship is very important.”
As an American psychiatrist, I was… what? Taken aback? Aghast, elated, confused? Staff dancing with patients? The “system” encouraging patients to maintain friendship after discharge? Open doors, open ticket to return whenever they want? And how was this affordable? Who paid for this? The details seemed fishy.
Later that day I buried myself in a search engine. Research revealed the truth: rehabilitative or residential psychiatric programs reduce emergency room and hospital usage. They save money. And having an intermediate level of care is better for patients. They reintegrate back into the community at a healthier pace and maintain stability over a longer period of time.
We’re missing something essential in American psychiatry. Outside the VA system, this level of care doesn’t exist. No one will pay for it. The irony is we’d save money if only we were willing to take that first step.
50 million dollars
So we’re back to that 50 million dollars.
It would have been a philanthropic venture, the establishment of a civilian psychiatric residential hospital in the United States, and boy I’d researched the topic thoroughly. I’d interviewed everyone willing to answer questions. Read every bit of literature I could find. Stayed up late pacing, thinking, wondering. I had fifty pages of notes back then. Here are the highlights.
(1) Admission criteria. Patients will need close screening for admission. Admission would be reserved for the severely mentally ill (SMI) population, those with Schizophrenia, schizoaffective disorder, bipolar, and depression. People with severe anxiety would be considered. This setting is inappropriate for individuals with borderline personality disorder. Care should be taken when accepting clients with substance use disorders, complicated medical issues, etc.
(2) Individualized care. Meet the patient where they’re at. Individualize care and long-term plan. Does the person need a group home with 24-hour supervision or their own apartment with a job and nighttime classes in calculus? Is the family supportive and healthy enough to be involved?
(3) Useful, achievement-oriented classes. Classes should set the patient up for success. They should also be useful. Start at one level lower than the patient’s current functioning and advance as possible. Classes can include:
- social skills
- money management (making change, maintaining a budget)
- basic reading and writing
- modern topic discussion
- deciphering a map or GPS
- using a cell phone/computer
- learning job skills
- looking for work and filling out applications
- maintaining a job
- gathering college-preparation skills
- seeking out appropriate housing
(4) Fun classes. There must be fun and soulful classes, like dancing, art, creativity, gardening, hiking, visiting the zoo, learning how to play an instrument, etc. People must have hobbies and passions.
(5) Community reintegration. As the patient progresses, they should transition into the community and gain more independence, like going for walks alone, catching buses to get around, using a cell phone, spending time at a potential group home, going to classes, working during the day, cooking meals, dealing with conflict, saving up for and choosing a car, and balancing their finances.
(6) Friendship and inclusion. We must encourage patients to make friends with other patients and, after discharge, return and participate in groups. We need to have room to make this happen. This idea — friendship between patients — will make many providers cringe, but encouraging that connection is actually the norm in many countries.
(7) Failure to graduate. Plans must be made for management of people who don’t graduate from the program; avoid becoming a nursing home or boarding house. Rehabilitation is the key.
(8) Contingency plans. Plans must be made for handling psychiatric crises, agitation and aggression, medication management (a psychiatrist could visit weekly or biweekly), medical emergencies, injury, death, accusations of abuse, and other potential incidents.
(9) Unanswered questions. There’s a lot we don’t know. Who would finance this, and how much money is needed to get it started/keep it going? What parts of patient life must they finance themselves? What kind of insurance would the facility need? How would the facility deal with HIPAA when the patients have cell phones and can take pictures of one another?
In the end, I turned down the 50 million dollars. I knew it wasn’t enough money, but more than that, I knew from the beginning it wasn’t my calling. As much as it pained me, I had other fish to fry.
But if there’s anyone out there who’s inspired enough to take this idea and run, please do. Tends of thousands of people will thank you.