LETTERS Letters from readers are welcome. They will be published at the editor’s discretion as space permits and will be subject to editing. They should not exceed 500 words with no more than three authors and five references and should include the writer’s email address. Letters commenting on material published in Psychiatric Services, which will be sent to the authors for possible reply, should be sent to Howard H. Goldman, M.D., Ph.D., Editor, Psychiatric Services, at ps [email protected]. Letters reporting the results of research should be submitted online for peer review (mc.manuscriptcen tral.com/appi-ps).
The Need for a “Mental Health Home” To the Editor: In the April issue Drs. Smith and Sederer (1) do a terrific job presenting a rationale for the “mental health home.” There is no doubt that our fragmented behavioral health system is inadequate for individuals most at risk. There is no reason to think that the public’s demand that general hospitals substantially improve both process and outcomes shouldn’t apply to the behavioral health industry. The coordination and delivery of behavioral health services must improve, and the mental health home concept warrants a close look. At the heart of the model the authors see “generalists working with the entire individual and coordinating care among a range of behavioral and rehabilitation service providers.” I couldn’t agree more, although an empathic relationship is a must, and no one framed this better than Deitchman (2), who felt that the “chronic client in the community needs a ‘traveling companion not a travel agent,’” or Lamb (3), who advocated for “therapist-case managers.” Coordination without an empathic worker-consumer relationship is bound to fall short of expectations for improved service delivery. PSYCHIATRIC SERVICES
Coordination will also fall short if the mental health home team’s added value is limited to advocacy. Advocacy is helpful but not adequate to overcome the system’s numerous structural weaknesses. Achieving continuity of care for individuals most at risk would require the team to have resources and authority to acquire services. In 2007 Jersey City Medical Center’s Behavioral Health Center established a “clinical home” pilot for adults with co-occurring disorders and histories of high recidivism and treatment nonadherence (I was vice president for behavioral health at the time). Every behavioral health program—partial hospital, outpatient department, emergency department, residential facility, and intensive case management—can function as a clinical home. The clinical home duties are above and beyond that program’s routine services and are considered “enhanced.” The pilot assigns “navigators” to consumers with high use of emergency or inpatient services who will not accept community-based services or are ineligible for intensive case management or assertive community treatment. The evidence to date is that the clinical home reduced recidivism and enhanced treatment adherence for consumers whom the system had given up on. The model is unique in that the clinical home clinician (or team) follows the consumer through all services. If the partial hospital accepts responsibility for a consumer and that consumer needs hospitalization, the partial hospital worker follows the consumer through the inpatient stay. If the emergency department is the clinical home and the consumer wants partial hospitalization, the emergency department worker escorts the consumer to the program until linkage is established. Consumer choice must supersede program and system concerns. One reason that the pilot works is that all the services are under one agency. No doubt this model would create potentially insurmountable turf issues in multiagency systems, but there can be no minimizing the
' ps.psychiatryonline.org ' July 2009 Vol. 60 No. 7
value of a mental health home, where one team has the resources and authority to acquire services valued by the consumer. Certainly the mental health home warrants significant demonstration project funding. James McCreath, Ph.D. Dr. McCreath is president and chief executive officer of Hall-Brook Behavioral Health, Westport, Connecticut.
References 1. Smith TE, Sederer LI: A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.” Psychiatric Services 60:528–533, 2009 2. Deitchman WS: How many managers does it take to screw in a light bulb? Hospital and Community Psychiatry 31:788–789, 1980 3. Lamb HR: Therapist-case managers: more than brokers of services. Hospital and Community Psychiatry 31:762–764, 1980
In Reply: Dr. McCreath raises important points that we wholly support. The establishment of a trusting, empathic relationship with a caregiver is essential to the success of any treatment and recovery plan and cannot be underestimated. Having a mental health home increases the likelihood of such a relationship because the client has an identified person and place as a starting point for developing a plan and as a “home base” for coordinating all subsequent services. Too often clients do not have a chance to form an effective treatment alliance because it is never clear whom the alliance should be with. Dr. McCreath also correctly notes that advocacy alone will not solve all the problems inherent in large, fragmented public mental health systems of care. Support and funding for service resource management are a must, and as noted in our Open Forum, demonstration projects will be critical to establish the level and degree of support necessary to develop the model and improve coordination of services and outcomes. One example of a potentially effective approach is the program that Dr. McCreath describes in his letter. This is exactly 993
LETTERS what we endorse—small-scale, datadriven efforts to define and test system reorganization efforts that are developed with the mental health home model. Dr. McCreath’s example is compelling and should serve as a model for other similar such efforts. Thomas E. Smith, M.D. Lloyd I. Sederer, M.D.
Documentation of Suicide Risk Assessment in Clinical Records To the Editor: Adequate assessment of individuals who attempt suicide can reduce further attempts (1) and help to determine the most appropriate treatment. Most guidelines for management of self-harming patients recommend direct discharge from the emergency department only after a psychosocial assessment has been conducted and an aftercare plan has been arranged (2). However, these recommendations are not always followed (3,4). Given clinicians’ apparent lack of adherence to these guidelines and limited knowledge about their actual practice (5), we analyzed the quality of clinical records of patients seen in four public university hospitals in Madrid after a suicide attempt. We selected seven indicators that would provide the minimum information needed to evaluate a patient’s risk of a subsequent suicide attempt: previous psychiatric treatment, suicidal ideation, suicide planning, medical lethality of the suicide attempt, previous attempts, attitude toward the current attempt, and social or family support. We investigated the presence of these indicators in 993 clinical records of 907 patients (600 women, 66%) between the ages of six and 92 (mean±SD= 37.2±15.3 years). These patients were seen from November 9, 2007, to March 8, 2008, in the emergency room after a suicide attempt in the community or in the hospital after an attempt in the inpatient setting. Institutional review board approval was obtained from the ethics committee of each hospital. 994
A total of 223 records (23%) documented all seven indicators, and 306 (31%) included documentation for six. Using the criterion that at least five indicators should be included, we found that 235 records (24%) could be considered incomplete. If a more restrictive criterion were used (a minimum of six indicators), only 529 assessments (53%) could be considered adequate. The indicators most often missing were previous suicide attempts and medical lethality of the current attempt. A score was created by adding the number of indicators present in the record (0, not present, 1, present). We found no significant differences in the total score between men (5.26±1.60) and women (5.30±1.53). Patients hospitalized (in psychiatric or medical units) had significantly more complete records (5.50±1.55) than those discharged from the emergency department (5.29±1.47) (z=2.73, p=.006), which might reflect a longer period during which to evaluate hospitalized patients. Information about previous suicide attempts was missing from 435 records (44%). For the 139 known first-time attempters (25% of the 558 records that included information about previous attempts), the total possible score was 6 (excluding the indicator for previous attempts). Records for first-time attempters were more complete (5.27 ±.95) than records for those who had made previous attempts (4.93±1.12) (z=3.51, p
The Need for a “Mental Health Home” To the Editor: In the April issue Drs. Smith and Sederer (1) do a terrific job presenting a rationale for the “mental health home.” There is no doubt that our fragmented behavioral health system is inadequate for individuals most at risk. There is no reason to think that the public’s demand that general hospitals substantially improve both process and outcomes shouldn’t apply to the behavioral health industry. The coordination and delivery of behavioral health services must improve, and the mental health home concept warrants a close look. At the heart of the model the authors see “generalists working with the entire individual and coordinating care among a range of behavioral and rehabilitation service providers.” I couldn’t agree more, although an empathic relationship is a must, and no one framed this better than Deitchman (2), who felt that the “chronic client in the community needs a ‘traveling companion not a travel agent,’” or Lamb (3), who advocated for “therapist-case managers.” Coordination without an empathic worker-consumer relationship is bound to fall short of expectations for improved service delivery. PSYCHIATRIC SERVICES
Coordination will also fall short if the mental health home team’s added value is limited to advocacy. Advocacy is helpful but not adequate to overcome the system’s numerous structural weaknesses. Achieving continuity of care for individuals most at risk would require the team to have resources and authority to acquire services. In 2007 Jersey City Medical Center’s Behavioral Health Center established a “clinical home” pilot for adults with co-occurring disorders and histories of high recidivism and treatment nonadherence (I was vice president for behavioral health at the time). Every behavioral health program—partial hospital, outpatient department, emergency department, residential facility, and intensive case management—can function as a clinical home. The clinical home duties are above and beyond that program’s routine services and are considered “enhanced.” The pilot assigns “navigators” to consumers with high use of emergency or inpatient services who will not accept community-based services or are ineligible for intensive case management or assertive community treatment. The evidence to date is that the clinical home reduced recidivism and enhanced treatment adherence for consumers whom the system had given up on. The model is unique in that the clinical home clinician (or team) follows the consumer through all services. If the partial hospital accepts responsibility for a consumer and that consumer needs hospitalization, the partial hospital worker follows the consumer through the inpatient stay. If the emergency department is the clinical home and the consumer wants partial hospitalization, the emergency department worker escorts the consumer to the program until linkage is established. Consumer choice must supersede program and system concerns. One reason that the pilot works is that all the services are under one agency. No doubt this model would create potentially insurmountable turf issues in multiagency systems, but there can be no minimizing the
' ps.psychiatryonline.org ' July 2009 Vol. 60 No. 7
value of a mental health home, where one team has the resources and authority to acquire services valued by the consumer. Certainly the mental health home warrants significant demonstration project funding. James McCreath, Ph.D. Dr. McCreath is president and chief executive officer of Hall-Brook Behavioral Health, Westport, Connecticut.
References 1. Smith TE, Sederer LI: A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.” Psychiatric Services 60:528–533, 2009 2. Deitchman WS: How many managers does it take to screw in a light bulb? Hospital and Community Psychiatry 31:788–789, 1980 3. Lamb HR: Therapist-case managers: more than brokers of services. Hospital and Community Psychiatry 31:762–764, 1980
In Reply: Dr. McCreath raises important points that we wholly support. The establishment of a trusting, empathic relationship with a caregiver is essential to the success of any treatment and recovery plan and cannot be underestimated. Having a mental health home increases the likelihood of such a relationship because the client has an identified person and place as a starting point for developing a plan and as a “home base” for coordinating all subsequent services. Too often clients do not have a chance to form an effective treatment alliance because it is never clear whom the alliance should be with. Dr. McCreath also correctly notes that advocacy alone will not solve all the problems inherent in large, fragmented public mental health systems of care. Support and funding for service resource management are a must, and as noted in our Open Forum, demonstration projects will be critical to establish the level and degree of support necessary to develop the model and improve coordination of services and outcomes. One example of a potentially effective approach is the program that Dr. McCreath describes in his letter. This is exactly 993
LETTERS what we endorse—small-scale, datadriven efforts to define and test system reorganization efforts that are developed with the mental health home model. Dr. McCreath’s example is compelling and should serve as a model for other similar such efforts. Thomas E. Smith, M.D. Lloyd I. Sederer, M.D.
Documentation of Suicide Risk Assessment in Clinical Records To the Editor: Adequate assessment of individuals who attempt suicide can reduce further attempts (1) and help to determine the most appropriate treatment. Most guidelines for management of self-harming patients recommend direct discharge from the emergency department only after a psychosocial assessment has been conducted and an aftercare plan has been arranged (2). However, these recommendations are not always followed (3,4). Given clinicians’ apparent lack of adherence to these guidelines and limited knowledge about their actual practice (5), we analyzed the quality of clinical records of patients seen in four public university hospitals in Madrid after a suicide attempt. We selected seven indicators that would provide the minimum information needed to evaluate a patient’s risk of a subsequent suicide attempt: previous psychiatric treatment, suicidal ideation, suicide planning, medical lethality of the suicide attempt, previous attempts, attitude toward the current attempt, and social or family support. We investigated the presence of these indicators in 993 clinical records of 907 patients (600 women, 66%) between the ages of six and 92 (mean±SD= 37.2±15.3 years). These patients were seen from November 9, 2007, to March 8, 2008, in the emergency room after a suicide attempt in the community or in the hospital after an attempt in the inpatient setting. Institutional review board approval was obtained from the ethics committee of each hospital. 994
A total of 223 records (23%) documented all seven indicators, and 306 (31%) included documentation for six. Using the criterion that at least five indicators should be included, we found that 235 records (24%) could be considered incomplete. If a more restrictive criterion were used (a minimum of six indicators), only 529 assessments (53%) could be considered adequate. The indicators most often missing were previous suicide attempts and medical lethality of the current attempt. A score was created by adding the number of indicators present in the record (0, not present, 1, present). We found no significant differences in the total score between men (5.26±1.60) and women (5.30±1.53). Patients hospitalized (in psychiatric or medical units) had significantly more complete records (5.50±1.55) than those discharged from the emergency department (5.29±1.47) (z=2.73, p=.006), which might reflect a longer period during which to evaluate hospitalized patients. Information about previous suicide attempts was missing from 435 records (44%). For the 139 known first-time attempters (25% of the 558 records that included information about previous attempts), the total possible score was 6 (excluding the indicator for previous attempts). Records for first-time attempters were more complete (5.27 ±.95) than records for those who had made previous attempts (4.93±1.12) (z=3.51, p
