A Psychiatric Unit Becomes A Psychiatric-Medical Unit: Administrative and Clinical Implications zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONM Barry S. Fogel, M.D. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Director, Inpatient Psychiatry, Rhode Island Hospital, Assistant Professor of Psychiatry and Human Behavior, Brown University Abstract: Increasing awareness of the frequent concurrence of medical and psychiatric illness has led to a resurgence of interest in psychiatric-medical units. This paper describes the conver- sion of a 29-bed general hospital psychiatric unit to a psychi- atric-medical model. The conversion involved hiring a full-time chief and changing priorities for elective admission, buf did nof involve major changes in staffing; community-based psychia- trists continued toadmit the majority of patients. Arrangements were made for medical house staff coverage of emergent medical problems, while daily medical care remained in the hands of the psychiatrists and their private medical consultants. In the year following the transition numerous patients with combined acute medical and psychiatric illness not treatable in the previous model were accepted and successfully treated. Quantitative study of annual statistics from the pre- and posttransition years revealed the following: 1) The average age of patients increased from 46 to 54 years. 2) The proportion of patients over 65 increased from 19% to 34.9% . 3) The proportion of patients with identified concurrent medical diagnoses increased from 54.7% to 69.1% . 4) Dispositions to nursing homes and chronic care facilities decreased from 10.5% to 8.9% . 5) Length of stay increased from 19.3 to 23.1 days. 6) The average daily hospital bill for psychiatric inpatients rose by 24.6% , compared with a hospital-wide average increase of 26.3% . Although the change in model appeared to offer effective treatment to previously underserved patients, it implied a significant zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA shifting of pafienfs and of costs. Administrative implications are discussed, and a list of preconditions for a successful conversion are suggested. Introduction Physical disease is highly prevalent among psychi- atric inpatients. Hall et al. [l] demonstrated that 80% of a group of new psychiatric admissions with- out previously diagnosed medical illness had a 26 ISSN 0163-8343/ 85/ $3.30 medical illness that either contributed to or caused the mental symptoms, or that independently re- quired treatment. Other studies, by Marshall [Z], Herridge [3], Maguire and Granville-Grossman [4], and Johnson [5], established a point prevalence of at least one-third for physical illness in new psychi- atric admissions. These studies demonstrate the importance of a careful physical evaluation of all psychiatric inpatients. Some have gone so far as to call medical clearance a myth [6] and to call for more frequent use of subspecialty neuropsychiatric con- sultation [7]. Thus, if a psychiatric unit is to deliver comprehensive care of mental disorders, it must, to some extent, be a psychiatric-medical unit. How- ever, even units that carefully screen apparently functional patients for organic illness may discour- age admission of patients with known medical ill- nesses, particularly if patients are medically acute, require medical-surgical nursing procedures, or are impaired in ambulation or self-care [8]. Thus, patients with active medical illness in addition to psychiatric disorder may end up being treated in a medical setting where the psychiatric treatment may be inadequate. These patients would better be served by a unit that offers integrated psychiatric and medical care. Another group that would benefit from a com- bined psychiatric-medical treatment setting con- sists of patients with acute medical-surgical illness combined with depression. There are many such patients in every general hospital [9,10] and their depressions are likely to be undertreated on non- psychiatric services. This is due both to non- Generat Hospitoi Psychiatry 7, Z-35, 1985 0 Elsevier Science Publishing Co., Inc., 1985 52 Vanderbilt Avenue, New York, NY 10017