Hospital-Based Guardianship Courts: One Solution to Reducing Avoidable Inpatient Days for Behavioral Health Patients

Abstract

Patient J.S. is admitted to the inpatient psychiatric unit of a community hospital with a diagnosis of Acute Stress Disorder, Post-Traumatic Stress Disorder.[1]  J.S. meets the admission criteria for active treatment per Center for Medicare and Medicaid Services (CMS).[2]  The hospital anticipates a twelve day inpatient stay and receives certification from the physician. An individualized treatment plan proves to be effective and the patient no longer meets admission (payment) criteria by the tenth day but will require a lesser level of care/monitoring.  Case Management identifies that the patient has no home address, no relatives or friends to assume care of the patient and therefore the hospital is unable to discharge.  The hospital arranges for J.S. to appear in District Court for a Guardianship appointment on the first available date - in three weeks.  The hospital has no option but to continue to board the patient without payment and, as a result, incurs potentially avoidable days.[3]  In the meantime, as a direct consequence of J.S.’s situation, the hospital is unable to admit a patient that has been in the Emergency Department (ED) for five days awaiting an available inpatient psychiatric unit bed.  When the day finally arrives for J.S. to appear in court, he is transported in wrist and ankle shackles as required by the Sheriff’s Department policy to the Courthouse 20 minutes away where the patient awaits his appearance in a foreign, potentially hostile environment.   

The secondary effects of an imperfect process can give rise to catastrophic results.  This common scenario negatively impacts community hospitals and patients across the country.  Statistics on both a national scale and specific to the rural state of New Mexico suggest that every state is struggling with the shortage of psychiatric hospital beds, and the availability of these beds continues to decline.  Advocates suggest at least 40 to 60 beds for every 100,000 people.  In 2016, the national average was 11.7[4]  notwithstanding a shortage of both inpatient psychiatric services and hospitals, patient care must be provided in an efficient manner and must include the ability of the patient to advance as quickly as possible to the next level of care.  Rather than subject psychiatric inpatients to foreign courtroom environments, prolonged wait times and civil rights indignities, Gerald Champion Regional Medical Center (GCRMC) has implemented a hospital-based Guardianship Court, the details of which will be provided at the conclusion of this paper.  By creating a court that exists at the hospital, GCRMC hopes to reduce the lengths of stay for inpatient psychiatric patients and to afford these patients a timely progression and quality of care.

[1] Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Section II: Diagnostic Criteria and Codes - Trauma and Stressor-Related Disorders, available at  https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596

[2] Centers for Medicare & Medicaid Services, Publication 100-02, Medicare Benefit Policy Manual - Chapter 2: Inpatient Psychiatric Hospital Services, Rev.223, May 13, 2016, pg. 3, available at:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.html

[3] Kristin Dillon and Darcie Thomsen, Reasons for Delays in Hospital Discharges of Behavioral Health Patients - Results from the Minnesota Hospital Association Mental and Behavioral Health Data Collection Pilot, July 2016, page 1, available at  https://www.mnhospitals.org/Portals/0/Documents/policy-advocacy/mental-health/MHA%20Mental%20Health%20Avoidable%20Days%20Study%20Report%20July%202016.pdf

[4] Michael Ollove, The Pew Charitable Trusts, Amid Shortage of Psychiatric Beds, Mentally Ill Face Long Waits for Treatment, August 2, 2016, available at http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/08/02/amid-shortage-of-psychiatric-beds-mentally-ill-face-long-waits-for-treatment