A Psychiatric Primary Care Clinic for Chronically Ill Veterans

Schizophrenia, bipolar disorder, and severe recurrent major depression are devastating psychiatric illnesses that frequently require acute inpatient psychiatric admission. Although patients with these diagnoses suffer from comorbid medical problems at rates equal to or higher than those of the general population, in most health care systems psychiatric care for these patients is delivered in isolation from general medical care. The usual separation of psychiatric and medical care brings with it the risk of poor coordination of care, high use of inpatient and outpatient resources, and poor compliance with medical and psychiatric treatment.

In 1995 the Albuquerque Department of Veterans Affairs (VA) Medical Center created a psychiatric primary care clinic with the goal of providing both comprehensive psychiatric and general medical care to veterans suffering from chronic mental illness. The clinic team included a physician who was board certified in family medicine and psychiatry, a physician's assistant, and three social workers and two clinical nurse specialists who provided case management services to enrolled patients. Continuity of care and communication between team members was strongly emphasized. Patients were monitored as outpatients in the same clinic space and by the same providers for both psychiatric and medical problems. The team was also involved in the management of the patients when they were hospitalized.

This arrangement provided us with the opportunity to study how enrollment in the clinic affected use of services among a large group of persons with severe mental illness. Because the clinic is fairly expensive to operate, and because psychiatric hospitalization contributes significantly to the overall financial burden of caring for this patient group, we studied the potential effect of the clinic on psychiatric hospitalization by comparing the average number of inpatient psychiatric hospital days and the rates of inpatient psychiatric hospitalization for patients in the one-year periods before and after they enrolled in the program.

We studied a sample of 171 veterans who were treated at the VA medical center for a minimum of one year before they enrolled in our clinic and who subsequently completed at least one year of treatment at the clinic. Their mean age was 51.7 years. Only seven were women. Their primary diagnoses were schizophrenia (77 percent), bipolar disorder (14 percent), and severe and recurrent major depression (9 percent). Data on their use of psychiatric inpatient services were obtained from the hospital's database.

Our preliminary results suggest that combined ambulatory psychiatric and medical care as provided in our clinic may contribute to a decrease in the use of acute inpatient psychiatric treatment. Both the average number of inpatient psychiatric hospital days per patient and the total length of stay per patient decreased significantly a year after enrollment in the clinic. The admission rate was unchanged. Perhaps the ability to establish intensive follow-up more efficiently allowed shorter inpatient stays, but without preventing readmission. About half of the patients actually enrolled at our clinic had no psychiatric hospitalizations during the year before or the year after enrollment. For this subgroup, our study provided no information on the effect enrollment had on service use.

The effects of adopting a primary care model and implementing medical management for this group of patients may have been an important component of the intervention. At the same time, greater access to outpatient services might have resulted in a higher readmission rate.

Variables such as the frequency of follow-up, case management, types of pharmacotherapy, compliance with treatment, disease severity, and medical comorbidity should all be considered as potential variables affecting use of both psychiatric and medical services as well as outcome. Our results thus far are promising. The provision of services by this type of clinic deserves further study.