**This week’s blog posts are dedicated to advocating for effective mental health treatment and educating patients, family, and friends in all areas of inpatient psychiatric care. The perspectives shared here are not that of a mental health professional, but rather someone with lived experience. Information shared may not align with every circumstance or viewpoint of readers, but is meant to offer guidance in an area that is often confusing and holds little resources.**

When the day finally arrives for the patient to be discharged from the hospital and return home, reactions from everyone involved can vary tremendously. The most common reaction is worry. Is she really ready to be released? Will he stick to the treatment plan? Am I being honest about feeling better to the hospital staff or do I just really want to leave and be in the comfort of my own home? The typical length of hospital stay in the United States is now a week or less. Is this enough time to assess, treat, and stabilize a person who was a harm to themselves or others just last week?

I have spent the majority of this week focused on practical matters to consider when you or a loved one is in inpatient psychiatric care. While I still want to provide that today, I feel there is a significant elephant in the room that needs to be discussed as well. For that reason, the second part of today’s blog will talk about the possibility of readmission due to inadequate length of stay in the hospital.

Getting out of the hospital may seem like the top goal in the minds of family and friends, but even more so in the mind of the patient. While there is the occasional patient who feels safe and comfortable and want to remain in the hospital longer, for the most part, asking when they will be released comes up regularly during their stay. Be aware that in any situation involving suicidal thoughts, plans, or behaviors, legal involuntary hospitalization becomes a factor and when to leave the hospital is not something the patient can decide for themselves.

Several factors appear to influence the length of stay for a patient. Mental state, including suicidality, are assessed continuously and weigh into the decision. Unfortunately, one of the other factors at play is the approved length of stay for the individual’s insurance policy whereby payment is agreed to be made. I have encountered a person who had been in hospitals frequently and said their stays were always exactly 9 days, regardless of how they were doing, when they realized this was the maximum number of days insurance paid. In any case, the date of discharge is largely out of the patient or family’s control.

In the days leading up to discharge, the facility will work to satisfy requirements for release. This includes scheduled appointments for follow-up outpatient care with a psychiatrist and therapist. The timeframe these must occur varies from state to state and even location to location, but typically a psychiatrist visit is set for within a week of discharge and a therapist within one month of discharge. This is in order to transfer the prescribing of medications to an outside doctor. In some cases, patients do not have the funds, transportation, or support system to make it to these appointments, thus having no refills of medications used to stabilize their condition, and starting what has been coined “the revolving door” effect.

As far as practical advice, here is the little I have to offer: Maintain expectations – The purpose of inpatient care is to address the immediate need of safety of the individual or others. It is not to see through to complete recovery of the current condition. This means, for the most part, people leaving a facility will still have many depression and anxiety symptoms that need to be addressed. Do not expect this person to re-enter their daily routine of work, child care, homemaking, or social lifestyle. While it is important to try and create an environment of normalcy, don’t carry any expectations and instead take cues from the person who was in crisis as to level of activity. It is sometimes helpful to transition slowly by maintaining the same schedule they had in the hospital for several days and focusing on setting up the treatment plan.

Below is some fascinating context provided for a large-scale study on readmittance of psychiatric patients within 30 and 180 days of discharge:

• In 1955, the peak of state hospitalization, there were 560,000 beds available for an estimated 3.3 million American adults living with serious mental illness and other disabilities. By early 2016, after more than half a century of deinstitutionalization, there were slightly fewer than 38,000 beds for 8.1 million people with the same conditions.
• Psychiatric hospitalization is the single greatest direct cost of serious mental illness. In 2013, schizophrenia hospitalization alone cost the United States $11.5 billion, of which $646 million resulted from readmission within 30 days of discharge.
• Releasing patients faster creates more bed capacity without requiring new beds. Under the influence of widespread psychiatric bed shortages and pressure to reduce hospitalization costs, length of stay has been shrinking for decades. In 1980, the median LOS for an acute episode of schizophrenia was 42 days. By 2013, it was about 7 days.
• More people are competing for an ever smaller number of inpatient psychiatric beds, where they stay ever shorter periods of time, after which they are more likely to be readmitted to the same hospital within weeks to six months of discharge.

Taken from the Executive Summary of the report:

“The analysis found a statistically significant association between shorter hospital stays and
rapid rehospitalization across the states. Among the findings:

• Patients in states with the shortest LOS were nearly three times more likely to be re-admitted into a state hospital within 30 days or 180 days of discharge than patients in states with the longest LOS.
• Eleven states had a median LOS of two weeks or less. In those states, 1 in 10 patients (10.8%) was rehospitalized within 30 days of discharge, and slightly more than two in 10 patients (22%) were readmitted within 180 days.
• Nine states had a median LOS of four months or more. In those states, 2.8% (fewer than three in 100) patients were readmitted within 30 days of discharge, and 7.9% (fewer than eight in 100) were readmitted within 180 days.”

Some limitations of this study are they were conducted only in public state hospitals and only counted one readmission to the original admitting facility and did not factor in multiple readmissions. In my opinion, readmissions often occur to a different facility and private facilities are driven more by insurance standards. I believe these statistics to be under-reported with relapse and readmittance being more common than we know.

I wish there was more call to action I could present here. The only way for forward progress is unfortunately through the legislative system. Currently, Medicare excludes payment in any institution for mental disease (IMD) with more than 16 beds. This has resulted in the above 2016 statistic where there are only 12 beds per 100,000 people with a mental illness diagnosis. This is unacceptable and discriminatory. I suggest becoming active in advocacy and speaking to your local legislators to influence change. If you need suggestions on where to get started, please message me and we can work together towards a change to this system.