Latest / Becker’s Healthcare Podcast / Navigating Complexity: Schizophrenia Care in the Inpatient Setting

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Navigating Complexity: Schizophrenia Care in the Inpatient Setting · Becker’s Healthcare Podcast

• 0:00
  - Hi, everyone. This is Lucas Voss with the
• 0:02
  - Becker's Healthcare podcast.
• 0:03
  - Joining me for today's episode
• 0:06
  - is doctor Rachel Rose, who's an inpatient
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  - physician at a psychiatric center in Albuquerque, New
• 0:11
  - Mexico
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  - and also an assistant professor. Doctor Rose has
• 0:15
  - extensive experience treating adults with schizophrenia
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  - in the inpatient emergency room and outpatient
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  - settings.
• 0:22
  - Before we hop into our conversations, know that
• 0:25
  - this podcast is being sponsored by Bristol Myers
• 0:28
  - Squibb. Doctor Rose is not an employee of
• 0:31
  - Bristol Myers Squibb, but is being paid to
• 0:34
  - present on its behalf.
• 0:37
  - With that, doctor Rose, it's so fantastic to
• 0:39
  - have you. Thanks so much for being here.
• 0:41
  - Yeah. Thanks for having me. I'm excited for
• 0:43
  - us to have this conversation.
• 0:45
  - I wanna hop right in because there's there's
• 0:47
  - really so much to talk about. We touched
• 0:49
  - on it in your intro as someone who
• 0:51
  - has treated adults with schizophrenia
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  - in a variety
• 0:55
  - of settings.
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  - Where do you see the most critical gaps
• 0:59
  - right now?
• 1:01
  - Yeah. Good question. Well, you know, my first
• 1:03
  - overall goal for these patients from an inpatient
• 1:06
  - perspective is to stabilize them and then connect
• 1:08
  - them to outpatient care.
• 1:10
  - And I think the first barrier to that
• 1:12
  - is really just a general lack of access
• 1:14
  - to care. So, you know, I myself practice
• 1:16
  - in an area that's very resource poor.
• 1:19
  - A large percentage of my patients aren't even
• 1:22
  - being cared for properly and aren't even on
• 1:24
  - long term treatment.
• 1:25
  - Or if they relapse, they can't find their
• 1:27
  - way back into our health care system.
• 1:30
  - Even for my patients with consistent care, I
• 1:32
  - found that insurance restrictions can remain a real
• 1:35
  - barrier to optimal treatment.
• 1:37
  - So, you know, the range of antipsychotics
• 1:39
  - available to me in practice is often
• 1:50
  - unfortunately,
• 1:51
  - navigating coverage enrollment or
• 1:53
  - assistant programs isn't something I have the time
• 1:55
  - or staffing for.
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  - Another gap I've seen is that patients can
• 1:59
  - have a really hard time following up and
• 2:01
  - reengaging in care after discharge.
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  - So in my experience, that could be due
• 2:06
  - to the mental illness itself and even just
• 2:08
  - a general lack of social support.
• 2:10
  - Many patients with schizophrenia
• 2:12
  - may have once had people they could rely
• 2:14
  - on, but over time, these connections tend to
• 2:17
  - be lost or severed.
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  - Leaving patients really isolated are in our communities
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  - and without support.
• 2:23
  - So getting them to follow-up with care, take
• 2:26
  - their medications, that can be super challenging.
• 2:29
  - And, of course, another potential contributor to nonherence
• 2:32
  - is that sometimes patients just don't like side
• 2:34
  - effects in the way that medications make them
• 2:36
  - feel.
• 2:37
  - And last thing I'd like to say here
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  - with this question is the biopsychosocial
• 2:41
  - model of care. So I can help address
• 2:43
  - the biological
• 2:44
  - aspect with medication.
• 2:46
  - I can help with the psychological
• 2:48
  - aspect. You know, this is doing things like
• 2:50
  - explaining why symptoms happen, how to recognize them,
• 2:53
  - explaining how medications work, and validating the patient's
• 2:56
  - experience.
• 2:57
  - But the social part, and although we in
• 3:00
  - health care really try, a lot of that's
• 3:02
  - out our... Out of our control. And in
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  - my experience, that can really impact care for
• 3:06
  - my patients
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  - with mental illness and specifically schizophrenia.
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  - I I think that's such an important point
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  - that you just made there at the end
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  - as well.
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  - And I do wanna spend just a little
• 3:17
  - bit more time on the biological aspect of
• 3:19
  - the disease just for a little bit.
• 3:22
  - When you consider
• 3:24
  - treatment options for adults with schizophrenia,
• 3:28
  - what are the areas of concerns do you
• 3:30
  - seek to address across positive symptoms, negative symptoms,
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  - and certainly also symptoms of general psychopathology
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  - or or GPS?
• 3:38
  - Yeah. Another great question. Because in my experience,
• 3:41
  - patients have a broad range of symptoms. Right?
• 3:43
  - And this is evident
• 3:45
  - if you look at the positive and negative
• 3:47
  - syndrome scale or we say PANS for short.
• 3:49
  - So the PANS is a 30 item scale,
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  - and it's widely used in research settings to
• 3:54
  - evaluate patients with schizophrenia.
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  - In my clinical practice,
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  - we might not use the PANS formally very
• 4:01
  - much, but we assess many of the symptoms
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  - it includes.
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  - And we monitor these symptoms over time to
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  - track how our patients are doing. So
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  - positive symptoms, things like delusions, hallucinations,
• 4:12
  - conceptual disorganization,
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  - and the negative symptoms, you know, things like
• 4:15
  - emotional withdrawal, passive, and apathetic withdrawal, a blunted
• 4:19
  - affect.
• 4:20
  - And then the pan subscale representing symptoms of
• 4:22
  - general psychopathology
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  - or GPS
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  - includes things like lack of judgment, insight, depression,
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  - anxiety, as well as l... As well as
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  - elements that indicate disorder thought.
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  - So this subscale is intended to evaluate, you
• 4:36
  - know, a patient's overall psychiatric state,
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  - And it's worth noting that all three subscales
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  - include items that represent cognitive symptoms that patients
• 4:44
  - with schizophrenia experience.
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  - And I believe that regardless of the setting
• 4:49
  - a provider is treating in, they need to
• 4:51
  - be thinking across all of these types of
• 4:53
  - symptoms and not just focusing on the positive
• 4:55
  - symptoms.
• 4:57
  - And the... Although the disease course in schizophrenia
• 4:59
  - includes several phases, it's commonly described in terms
• 5:03
  - of the acute phase and the maintenance phase.
• 5:05
  - So when I work in a psychiatric ER,
• 5:07
  - for instance, or an inpatient, I'm really in
• 5:10
  - that acute phase, which may focus a lot
• 5:12
  - on the positive symptoms. I mean, these are
• 5:13
  - often the symptoms that get my patients admitted.
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  - Right? So we we often think, okay. So
• 5:18
  - we treat the positive symptoms in an inpatient
• 5:20
  - setting, and then we'll discharge to an outpatient
• 5:22
  - provider.
• 5:23
  - However, in an inpatient setting, we also really
• 5:25
  - try to consider negative symptoms and that GPS.
• 5:28
  - So I find that people with negative and
• 5:30
  - positive symptoms of schizophrenia
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  - may have a really hard time engaging with
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  - others, integrating into society,
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  - holding down a job,
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  - living a structured life, maintaining consistent care,
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  - all of which affect how they fare once
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  - discharged.
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  - And all of these symptoms should be considered
• 5:48
  - when treating folks in the hospital, in my
• 5:50
  - opinion.
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  - And there's a lot under the GBS subscale
• 5:54
  - that I also believe impact a patient's success
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  - after discharge. So an example here, when I'm
• 5:59
  - discharging a patient, I might consider,
• 6:02
  - how might challenges with judgment and insight affect
• 6:05
  - them after discharge?
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  - Because I've seen issues like this really lead
• 6:09
  - to readmission rates.
• 6:11
  - So if we consider many symptoms as possible
• 6:13
  - and try to address them over time, I
• 6:15
  - found that it can help better
• 6:17
  - support decision making by patients outside of the
• 6:19
  - hospital.
• 6:21
  - So, you know, for example, a patient may
• 6:23
  - choose better coping strategies to help manage stress
• 6:25
  - instead of relying on illicit substances in the
• 6:28
  - community.
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  - So by better supporting patient decision making outside
• 6:32
  - of the hospital,
• 6:33
  - we can hopefully improve engagement in their care
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  - as well.
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  - And when inpatients engage with their care, we're
• 6:39
  - better able to routinely check on them, engage
• 6:42
  - how they're doing across all symptom domains.
• 6:45
  - And we've touched on it in your intro
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  - as well. You've worked in so many different
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  - settings around this. I I do wanna focus
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  - on the inpatient setting a little bit too.
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  - You you just mentioned that as well. Can
• 6:56
  - you
• 6:58
  - share your perspective on sort of the key
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  - operational realities that shape schizophrenia
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  - care in the hospital today?
• 7:07
  - Yeah. You know, so so first, I'd like
• 7:09
  - to briefly just take a step back and
• 7:11
  - reflect on the history of of how society
• 7:13
  - has viewed and managed schizophrenia.
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  - So I'm thinking in particular about the way
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  - that schizophrenia and, you know, mental health more
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  - broadly has been stigmatized.
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  - And where we have wound up today, you
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  - know, unfortunately, is that I don't think our
• 7:27
  - country's inpatient facilities are set up for long
• 7:29
  - term care. You know? So for example, we
• 7:31
  - may get an inpatient on an appropriate medicine,
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  - get them at a therapeutic dose, but the
• 7:37
  - average length of stay might not be enough
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  - time to actually see improvements in the symptoms
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  - the patient's having.
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  - And if I had more time, ideally, I
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  - keep the patient on that therapeutic dose for
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  - weeks if needed, see how they're doing, and
• 7:50
  - then address just their treatment as appropriate.
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  - But, unfortunately,
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  - the reality is we end up just trying
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  - to quickly treat the patient's aggression and then
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  - say, okay. They're getting better, and now we
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  - move to discharge them. However, in my experience,
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  - we may not have the adequate time to
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  - help with all of the symptoms that the
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  - patient is having.
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  - So I think we really need the capacity
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  - within our health care system for longer lengths
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  - of stay.
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  - And, you know, bed capacity is also a
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  - big issue. I think it varies across institutions,
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  - you know, in general, but low bed capacities
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  - can be driven by things like limited staffing.
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  - You know, we know that working with patients
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  - who have severe mental illness can be challenging.
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  - It takes a special type of engagement,
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  - understanding, and and patience,
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  - and it it can be dangerous.
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  - And so all of that really leads to
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  - high staff turnover from from what I've seen.
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  - And when people think of a general hospital,
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  - you're
• 8:45
  - probably thinking you got a bed, you're hooked
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  - up to a monitor, the nurse comes in,
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  - checks on you every once in a while,
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  - but that is not what a psychiatric hospitalization
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  - looks like. So patients may not be safe
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  - on their own. They they they may require
• 8:59
  - a one to one staff member with them
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  - at all times.
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  - For even more stable patients, you know, nurses
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  - are on the Unit 247,
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  - and teams also have mental health techs who
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  - are there to keep patients and staff safe.
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  - So all of this means extra hands, extra
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  - staffing, which isn't easy to come by.
• 9:18
  - So we obviously have the the setting that
• 9:21
  - that you described, the the inpatient setting as
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  - well, but there's also transitions that are happening
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  - too. I wanna just spend a little bit
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  - of time on that, specifically with your experience
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  - as an inpatient provider with respect to patients'
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  - transitions to other settings of care. Can you
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  - speak to that a little bit in terms
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  - of, again, what that transition to other settings
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  - of care looks like?
• 9:43
  - Yeah. And that's such an important piece of
• 9:45
  - this.
• 9:46
  - So, you know, as you mentioned in my
• 9:48
  - introduction, I I work in a psychiatric ER
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  - as well as in an inpatient setting, and
• 9:52
  - then there's also the outpatient setting in my
• 9:55
  - facility, which I've spent time in.
• 9:57
  - I've seen very well optimized transitions between settings,
• 10:00
  - and then sometimes I've seen gaps. So my
• 10:03
  - perspective is that the transitions between these seven...
• 10:06
  - Settings, even from a medical ER to the
• 10:09
  - psychiatric ER, are such vulnerable times for patient
• 10:12
  - care.
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  - We have to make sure all handoffs are
• 10:15
  - done well, that the right communication happens.
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  - We really cannot lose important clinical information. So,
• 10:22
  - you know, anytime a patient's discharged
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  - has moved a physical location, has had a
• 10:27
  - change in diagnosis or medication,
• 10:29
  - we have to make sure that all of
• 10:31
  - this is communicated appropriately,
• 10:34
  - handoffs are done well, and that no clinical
• 10:36
  - information is lost.
• 10:38
  - You know, unfortunately, in our health care system,
• 10:40
  - I don't think we've quite figured out the
• 10:42
  - best way to bridge across settings. As one
• 10:45
  - example, in an outpatient setting, we may get
• 10:47
  - prior authorization
• 10:48
  - and get a patient a specific medication.
• 10:51
  - But then when they're hospitalized, if it's not
• 10:53
  - on the formulary,
• 10:55
  - then that represents another challenge.
• 10:57
  - And there can be issues also with documentation.
• 11:00
  - So, you know, if patients remain within a
• 11:02
  - single health care system, information transfer is pretty
• 11:05
  - straightforward.
• 11:06
  - But, obviously, different hospitals use different electronic
• 11:10
  - medical records.
• 11:11
  - So if a patient who was cared for
• 11:13
  - at another facility,
• 11:15
  - you know, when they come to me, I
• 11:16
  - might not be able to access their record.
• 11:18
  - Another example is a patient in and out
• 11:20
  - of incarceration
• 11:22
  - that can create record access issues too.
• 11:25
  - And if I don't have my patient's whole
• 11:26
  - history and medication records,
• 11:29
  - that affects how quickly we can get them,
• 11:31
  - care for them,
• 11:32
  - and and provide them a successful discharge.
• 11:36
  - You know, post discharge phone calls can also
• 11:38
  - be challenging,
• 11:39
  - so not every patient has an access to
• 11:42
  - phone nor willing to answer one. You know,
• 11:44
  - this is why if there's a family member,
• 11:46
  - a friend, a treatment guardian, or group home
• 11:49
  - involved,
• 11:49
  - we have someone to connect with, say, seven
• 11:52
  - days after discharge and ask, hey. How how
• 11:54
  - is the patient doing? Do you have any
• 11:56
  - questions? How can I help?
• 11:58
  - You know, I'm really fortunate in my institution
• 12:00
  - to have a dedicated psychiatric ER that
• 12:03
  - provides patients with access to care twenty four
• 12:06
  - seven. And in my role, I'm even more
• 12:08
  - lucky because I get to see them, you
• 12:10
  - know, through the ER and then throughout their
• 12:13
  - inpatient journey.
• 12:14
  - They come through our psychiatric ER, then they're
• 12:17
  - admitted to the inpatient unit, and then ultimately
• 12:20
  - discharged.
• 12:21
  - And this really limits the gaps, you know,
• 12:23
  - or communication breakdown between settings that creates vulnerabilities
• 12:27
  - for patients.
• 12:28
  - Unfortunately, though, you know, this isn't the structure
• 12:30
  - everywhere, and that can really contribute to challenges.
• 12:34
  - And as I mentioned before, families,
• 12:36
  - because we really try to prioritize education, not
• 12:39
  - just for patients, but families, friends, treatment guardians,
• 12:43
  - really whoever a patient has in their life
• 12:45
  - and in their corner
• 12:47
  - because the patient's symptoms may affect their ability
• 12:50
  - to really advocate for themselves after discharge.
• 12:53
  - Yeah. And you mentioned the importance of phone
• 12:56
  - calls, for example, of that follow-up to be
• 12:59
  - able to facilitate
• 13:01
  - some of this.
• 13:02
  - Can you just talk a little bit more
• 13:04
  - about the limitations
• 13:06
  - on patient follow-up that you've observed after hospital
• 13:09
  - discharge?
• 13:11
  - Yeah. So... Well, you know, first of all,
• 13:14
  - we know that the initial period after discharge
• 13:17
  - is such a vulnerable time for our patients
• 13:19
  - in terms of relapse and readmission.
• 13:21
  - So, ideally, patients are seen as soon as
• 13:23
  - possible after they leave the hospital.
• 13:26
  - But there may be, you know, very few
• 13:28
  - general providers in the community who have clinical
• 13:31
  - experience with schizophrenia or feel comfortable treating these
• 13:34
  - patients.
• 13:35
  - There may also not be social workers or
• 13:37
  - caseworkers
• 13:38
  - available to help. And, you know, just due
• 13:40
  - to the nature of the patient population itself,
• 13:42
  - we have a high no show rate.
• 13:44
  - So it can be extremely difficult to ensure
• 13:47
  - that adequate follow-up that we want post discharge.
• 13:50
  - When patients, you know, don't get that care
• 13:53
  - post discharge, I find that they oftentimes
• 13:55
  - end up right back in the ER.
• 13:58
  - And in my experience, this is often due
• 14:00
  - to medication nonadherence,
• 14:02
  - potentially reengagement and illicit substance use.
• 14:05
  - So, really, you're seeing the cycle just repeats
• 14:07
  - itself over and over because we don't have
• 14:09
  - a place for them to receive that true
• 14:11
  - longitudinal care and stabilization.
• 14:14
  - And this brings up a point. I think
• 14:16
  - assertive community treatment can be incredibly helpful for
• 14:20
  - patients.
• 14:21
  - So so this is a team based approach
• 14:23
  - where the care team actually meets the patient
• 14:25
  - with mental illness out in the community, you
• 14:27
  - know, in their home setting
• 14:29
  - to help them integrate into their community,
• 14:32
  - maybe navigate the system, and regularly see a
• 14:34
  - provider.
• 14:35
  - There's also forensic
• 14:37
  - assertive community treatment because some patients, unfortunately,
• 14:40
  - go back and forth between hospitalization
• 14:43
  - and incarceration.
• 14:44
  - They're kind of just living in that loop.
• 14:47
  - But programs like this really help the care
• 14:49
  - team meaningfully engage with these patients.
• 14:52
  - And that could, you know, also mean working
• 14:54
  - with local law enforcement to help ensure patients
• 14:56
  - get to their probation officer, for example,
• 14:59
  - helping them ensure that they're doing what they
• 15:02
  - need to do and they're checking in.
• 15:05
  - Because, you know, obviously, for patients living with
• 15:07
  - mental illness, it can be really hard to
• 15:09
  - organize yourself and do all of that by
• 15:11
  - themselves.
• 15:13
  - And lastly, you know, some institutions
• 15:15
  - have things like walk in clinics to help
• 15:17
  - make it easier for people to get follow-up
• 15:19
  - care.
• 15:20
  - Ideally, of course, every person after they discharge
• 15:23
  - is established with their own provider and appointment.
• 15:27
  - And I love that you've highlighted a lot
• 15:29
  - of these resources that are available and what
• 15:30
  - some organizations are doing. I I just wanna
• 15:33
  - talk a little bit more about some of
• 15:35
  - the other resources that are available, especially from
• 15:37
  - your
• 15:38
  - experience, what you've seen. Can you just talk
• 15:40
  - a little bit about some of the other
• 15:42
  - resources that are available to patients that may
• 15:45
  - be available to patients with
• 15:47
  - schizophrenia and and any challenges again around that
• 15:50
  - access that you've described?
• 15:53
  - Well, another important resource is psychosocial
• 15:56
  - rehabilitation,
• 15:58
  - just because just relieving the patient's symptoms is...
• 16:01
  - It's not enough. You know? We need to
• 16:03
  - help patients learn how to function, how to
• 16:05
  - contribute to society, how to earn a living
• 16:08
  - if possible.
• 16:09
  - Psychosocial rehabilitation
• 16:11
  - is is great. It's where people with schizophrenia
• 16:14
  - can go, learn how to engage with others,
• 16:16
  - cook for themselves,
• 16:18
  - potentially gain employment, you know, all types of
• 16:20
  - things like that.
• 16:22
  - We know it can be incredibly hard for
• 16:24
  - patients with schizophrenia to motivate themselves to go
• 16:26
  - out, apply for a job, and even think
• 16:29
  - about getting through a job interview. That takes
• 16:31
  - a lot of executive functioning
• 16:33
  - past completion.
• 16:35
  - Then there are other team members such as
• 16:37
  - peer support workers. You know, these are people
• 16:40
  - with the lived experience of having the disease,
• 16:43
  - and they can help others with it. There's
• 16:45
  - also community support workers who will actually pick
• 16:48
  - up patients, bring them to appointments.
• 16:51
  - Communities may also have crisis triage centers
• 16:54
  - and providers or places that provides patients with
• 16:58
  - a safe place to stay,
• 17:00
  - assistance with social work,
• 17:02
  - and places they might actually be able to
• 17:03
  - stay for up to a few weeks.
• 17:06
  - One thing I've seen that really interferes with
• 17:09
  - access to support is the overlap between schizophrenia
• 17:12
  - and substance use, including stimulants, which may be
• 17:15
  - frequently used.
• 17:16
  - For patients who are dealing with this, it
• 17:18
  - means the care they need just extends beyond
• 17:21
  - that antipsychotic
• 17:22
  - treatment.
• 17:23
  - The behavioral change required to address substance use
• 17:27
  - can add a whole other dimension of complex
• 17:29
  - complexity to this already very challenging clinical picture.
• 17:32
  - But in general, there is just a lack
• 17:34
  - of support or funding for this and other
• 17:36
  - types of helpful resources.
• 17:38
  - I think, like I had mentioned before, this
• 17:41
  - really goes back to that stigma surrounding mental
• 17:43
  - illness
• 17:44
  - and this perception that people with schizophrenia
• 17:47
  - engage in violent behavior.
• 17:49
  - That stigma translates
• 17:51
  - directly into fewer people willing to step into
• 17:53
  - advocacy,
• 17:54
  - community support, and patient champion roles.
• 17:58
  - And compared with many other diseases, we simply
• 18:01
  - just don't see the same level of organized
• 18:03
  - advocacy.
• 18:05
  - Yeah. Doctor Rose, it's such an incredibly complex
• 18:09
  - space. And, again,
• 18:11
  - especially when we talk about schizophrenia
• 18:13
  - care in the inpatient setting, it does get
• 18:15
  - complicated as you've described throughout our conversation.
• 18:18
  - Doctor Rose, it's so great to have you.
• 18:20
  - Thank you so much for taking some time
• 18:21
  - for us.
• 18:22
  - Yeah. This was wonderful. Thank you so much
• 18:25
  - for having me.
• 18:26
  - And I also want to let our listeners
• 18:28
  - know that a second podcast
• 18:31
  - in this series
• 18:32
  - will be posted after the Becker's chief pharmacy
• 18:35
  - officer summit in
• 18:37
  - November,
• 18:38
  - and
• 18:39
  - you can also connect with the Bristol Myers
• 18:41
  - Squibb team there at the summit. And, certainly,
• 18:43
  - for more information about the company, you can
• 18:46
  - visit b m s dot com.
• 18:49
  - Thank you so much again, doctor Rose, for
• 18:51
  - being here, and thank you to our listeners
• 18:53
  - for listening in.