A psychiatric unit becomes a psychiatric-medical unit: administrative and clinical implications

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 conversion of a 19-bed general hospital psychiatric unit to a psychiatric-medical model. The conversion involved hiring a full-time chief and changing priorities for elective admission, but did not involve major changes in staffing; community-based psychiatrists continued to admit 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: The average age of patients increased from 46 to 54 years. The proportion of patients over 65 increased from 19% to 34.9%. The proportion of patients with identified concurrent medical diagnoses increased from 54.7% to 69.1%. Dispositions to nursing homes and chronic care facilities decreased from 10.5% to 8.9%. Length of stay increased from 19.3 to 23.1 days. The average daily hospital bill for psychiatric inpatients rose by 24.6%, compared with a hospital-wide average increase of 16.3%. Although the change in model appeared to offer effective treatment to previously underserved patients, it implied a significant shifting of patients and of costs. Administrative implications are discussed, and a list of preconditions for a successful conversion are suggested.