A disproportionate number of patients who suffer from severe mental illnesses (SMI) such as bipolar or schizophrenia rely on the ER for care. The PCIC intervention team strives to help improve the overall health of these patients by coordinating their care.
As a Nurse Practitioner experienced with vulnerable populations, I joined PCIC to help coordinate the work of the Intervention Team. In reviewing charts to assess for patient eligibility for PCIC’s Intensive Care Management program, I noticed that patients with SMI are more frequently using the ER.
Imagine how difficult it is for someone with schizophrenia, a condition characterized by a limited ability to organize and poor social skills, to effectively manage several chronic diseases including diabetes with daily insulin injections and management of diet. Add a diagnosis of severe lung disease requiring the use of oxygen and a reduction in stamina. These combinations of complex illnesses provide insight as to why patients with SMI frequently visit the Emergency Room.
When a current PCIC patient who suffers from the conditions described above was urgently hospitalized for respiratory problems, he was not able to recall his medications. However, he told the pharmacist to call "Andy" and provided a phone number. Andy is a PCIC care coordinator and she was able to provide the information the pharmacist needed in order to reconcile the medications taken by the patient. Once the patient was discharged from the hospital the PCIC team conducted a home visit to go over the changes in medications. The patient was confused about which medications he was supposed to take, and the discharge prescriptions had been sent to a different pharmacy. The team spent a great deal of time straightening out the problems and negotiating goals with the patient to continue improving his overall health. The team members noted that although progress has been slow, the patient has increasingly become more engaged in working with the team towards improving his health.
PCIC helps patient like this who are suffering from severe mental illnesses get organized to manage their own health. What other factors are contributing to patients with SMI using the ER more frequently? Poor access? A broken system? Lack of communication between healthcare providers meeting with the patient in different settings? PCIC is working on solutions to resolve these problems. The Intervention Team works on care coordination and the Tech team is working on developing a platform for communication for access to all providers
