BACKGROUND: Medicine Team I is an inpatient service at Parnassus Heights for patients whose acute medical needs have resolved but have a prolonged length of stay (average LOS 75.59 days)due to discharge barriers related to behavioral disturbances, grave disability or placement. 86% of Team I patients have a neurocognitive or mental health disorder with associated severe behavioral disturbances which require regular evaluations, recommendationsand treatment by a psychiatrist.  

Psychiatric management of these patients is labor intensive requiring frequent evaluations, psychotropic medication adjustments, capacity assessments, and regular multidisciplinary rounding to address safety and treatment concerns. Many also require a psychiatrist to complete court petitions for conservatorship and/or medical procedures and to attend related court hearings. These behavioral disturbances when untreated also pose a safety risk for the patients themselves and staff. In some instances, staff have been seriously injured and patients have died. (insert WPV data here once obtained) 

Currently, the UCSF Psychiatry Consultation and Liaison (Psych CL) team serves as the consulting service for all Adult Services (Excluding L&D and Mother and Baby services). Withthe current staffingof 1.9 FTE for an estimated 5383 consults in the current fiscal year, there is limitedcapacity for their daily consult census of 30-40 patients. ED and new inpatient consults with acute psychosis and behavioral crisesare prioritized over consultations for longitudinal psychiatric medication management and equivocal decisional capacityassessments. 14-24 patients are not being seen daily, there is little continuity of care due to different attendings on different days and huddles & complex disposition take 5 hours/ week minimum.  

We demonstrated 424 avoidable inpatient days for the Team I patients in the calendar year 2023 while they awaited these nonacute longitudinal and court-petition-related psychiatry consultations, not including the days awaiting the court response back. 

In addition, in January 2024, Senate Bill 43 (SB43) was passed which expands the criteria for grave disability to include personal safety and necessary medical care and allows for conservatorship of patients with substance use disorders. The passing of SB43 is expected to increase the number of patients hospitalized with psychiatric and substance use disorders while they await conservatorship. As this inpatient volume increases, services like Medicine Team I can expect their avoidable days and length of stay to proportionately increase if no intervention is put in place to support the psychiatric needs of these vulnerable patients. 

TARGET – Our goal is to reduce the avoidable days related to delays in psychiatric treatments, evaluations, and court proceedings over a 12-month periodby 50% as compared to calendar year 2023 for Medicine Team I patients who have asevere mental health or neurocognitive disorder associated with behavioral disturbances. 

With a reduction in avoidable days, we expect a related decrease in stay length (LOS), direct costs, and workplace violence incidents. While difficult to measure in this target population (patients with severe mental health and neurocognitive disorders), it can be assumed that a decrease in unnecessary hospitals days would improve the patient’s experience, as many of these patients suffer the negative mental, physical, and emotional impacts of prolonged social isolation that can occur in an acute inpatient hospital. 

GAPS – There are multiple barriers to care of patients with neurocognitive or mental health disorders with behavioral disturbances.Using the Fishbone Gap analysis tool, we identified some root causes in various categories of: 

PEOPLE:  

INTERVENTION – Based on our root causes, we are choosing to focus on a countermeasure related to the shortage of longitudinal inpatient psychiatric consultation for the Medicine Team I patients.  

We propose to staff a Per Diem UCSF Psychiatrist consultant 6 hours a week for 12 months specifically assigned to Medicine Team I. This Team I assigned psychiatrist would  

The psychiatrist consultant would be available longitudinally to evaluate patients already assigned to Medicine Team I (Daily census of 7 patients) and Medicine I waitlist patients (On average, waitlist is 2-5 patients awaiting transfer to Medicine Team I).   

Psych CL is actively hiring more faculty and moonlighters. A per diem faculty credentialled through the division of Psychiatry would serve as the assigned psychiatrist for the team I patients.   

The intention of having an assigned Per Diem Psychiatrist to Medicine Team I is to provide continuity of care for the longitudinal needs of these patients, avoid delays due to competing with new psychiatry consults for their psychiatric evaluations, which cause delays in discharge. Additionally, these delays create health inequities, as this population of patients experiences delays in treatment and experiences the negative effects of prolonged social isolation. In some cases, patients have died while hospitalizedbecause of progressive deterioration while in isolation.  

This intervention is intended to close the gap on these inequities by adding consistent psychiatric support to expedite evaluations to reduce delays in decision-making and treatments. While there is internal interest in the UCSF Per Diem Psychiatrist position, there is a potential barrier of not being able to staff this rotation consistently every week. Additionally, there may be some role confusion between the Medicine Team I Psychiatrist position and the Psychiatric CL service. However, these barriers and the adverse impacts on the service and its patients can be avoided with a detailed staffing/coverage plan and scope of work for this new position developed in collaboration with the Hospital Medicine and Psychiatric CL leadership teams.  

PROPOSED EHR MODIFICATIONS  

RETURN ON INVESTMENT (ROI)

• Improve Inpatient Access to Care: Decrease the delay in careof patients awaiting stabilization from a psychostroc and behavioral standpoint. 
• Improved patient outcomes, safety and experience: While difficult to measure in this target population (patients with severe mental health and neurocognitive disorders), it can be assumed that a decrease in unnecessary hospitals days would improve the patient’s experience, as many of these patients suffer the negative mental, physical, and emotional impacts of prolonged social isolation that can occur in an acute inpatient hospital.  
• Increased staff and provider satisfaction and safety (e.g. decreased Workplace Violence incidents related to patients with behavioral disturbances) 

SUSTAINABILITY – If successful, a proposal outlining the ROI and qualitative outcomes of this project will be prepared for executive leadership within the Division of Hospital Medicine and Adult Services to request that UCSF Per Diem Psychiatrist hours be budgeted in the upcoming fiscal year to support this vulnerable Hospital Medicine population and the staff who care for them.This program could also serve as the model for expansion of limited but dedicated psychiatric consultation at our other campuses. This would support our strategic expansion of care of hospital medicine patients at our recently acquired campuses especially our long stay patients who donot require other tertiary or quaternary specialty care and are currently occupying a bed at Parnassus Heights.   

BUDGET ($50,000) – UCSF Per Diem Psychiatrist hourly rate = $160. Estimate of 6 hours per week (based on current Medicine Team I demand) for 12 months = $49,920.This per Diem position would not require paid benefits.Anticipate reporting and supply costs covered by Adult Case Management and External Care Cost Centers, as part of CARTDash implementation.