Best Practices: Transitioning from Inpatient to Outpatient

Peter Salgo, MD: Joe, let us transition from patient care protocol upon discharge from the inpatient setting to the outpatient setting. You are managing this every day. How do you manage these protocols, the processes, the best practices to ensure that a patient leaving the inpatient setting continues to get the best standard of care?

Joe Avelino, RN, BSN, MHSA, CPHQ: There are two scenarios here. No. 1, the use of—for lack of a better word—a home health nurse or community nurse, because some of these patients do not have families. We even have home health that accepts Medi-Cal, and they can be followed up by a home health nurse, so they can adhere to these LAIs [long-acting injectables]. Second, working with the homeless population, working with the shelter, we usually have a liaison or someone who is a worker, and we’d work with them to make sure these homeless patients follow this regimen accordingly. It really is challenging, as Henry and Rahn alluded to, of medication regimen adherence. But those are some of the things we put in place here, making sure that the family members—we talked about this earlier— get involved as part of the plans, not just the patient but their support system as they’re discharged from the facility.

Peter Salgo, MD: I come back to the question, Joe. Hard-and-fast protocols. I know doctors have their own order sets, and I know they might like their own order sets. But at the end of the day, if you are letting some patients leave your setting and go to a less controlled outpatient setting, are there hard-and-fast protocols that doctors must adhere to, to be sure their patients get the best care?

Joe Avelino, RN, BSN, MHSA, CPHQ: Not that I am aware of.

Henry Nasrallah, MD: Nothing mandated. Nothing is mandated for psychiatry that I know of. They leave it up the psychiatrist to prescribe what they want, to monitor when they want, to discharge the patient on what they want. The outcomes are very variable. There are physicians who do the right thing and others who do not, but there is no consequence. This is a very loose state of affairs.

Rahn Bailey, MD, DFAPA: It’s a very important point. It has clinical and forensic implications. I trained in forensic psychiatry, and early in my career, I spent about 6 years not on a board of medical examiners but as a consultant to the board. What I’m ultimately struck by is that it is not when physicians get in trouble with the board. It often started with some difficulty on their job. We are people who often put a lot of our self-esteem, self-identity in our profession, our career, and our job. Too often difficulties occur because a person started doing the wrong thing. Having some degree of oversight is useful or beneficial. That is what algorithms allow because you are following some protocol or some regular set of rules or regulations, so you are online with everybody else. Often these troubles occur when you get off the beaten path—you are off-kilter, and you are not at a practice with a colleague who is going to pull you back and say, “You’re not doing that correctly.” It is to the doctor’s benefit to have some train tracks, to remain in sequence. All too often, when we lose someone, it is because they have gotten too far away from normative practice.

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Transcript Edited for Clarity