New Hampshire Hospital (NHH) is a 152-bed subspecialty hospital caring for individuals assessed by community providers and found to pose a danger to themselves or others as a result of mental illness. Patients are referred from local emergency rooms, county jails, and the Secure Psychiatric Unit (SPU) (part of the Department of Corrections) at the New Hampshire state prison. NHH staff is charged with management of increasing numbers of patients with a history of violence or who face significant legal charges. Finding a disposition to the community for these patients is challenging (1–3).
Introduction by the column editor: The authors are to be congratulated for their commitment to the best practices process over time. This column presents a one-year follow-up to their original report (Best Practices, Psychiatric Services, July 2010) in which they described theimplementation of an Administrative Review Committee to review high-profile, high-risk patients treated in a state hospital setting. They now report on the work of this committee and its impact on clinicians and patients. In so doing, the authors have generated a unique information set that has important implications for best practices with this patient population.
Assessing an individual's potential risk for future violence is increasingly important in mental health settings, and clinicians are faced with completing this difficult task every day (4–6). Actuarial models have been designed to help clinicians assess the risk of imminent aggression or violence of patients discharged from a psychiatric inpatient setting (7–9).
In a previous publication in this column, we reported on the successful implementation of an Administrative Review Committee (ARC) to review high-profile, high-risk patients in order to provide a risk management process to mitigate potential liability to NHH and the clinicians caring for these patients (10). We now present a one-year follow-up, describing characteristics of cases reviewed by the ARC. To our knowledge, this type of review has not been described for any other hospital setting.
The ARC policy was implemented on August 1, 2009. We tracked all individuals presented to the ARC in the year after its implementation. Patients were tracked by means of the ARC referral data sheet submitted by the treating clinician before an ARC meeting. [The ARC referral data sheet is available online as a data supplement to this column.]
Of 2,350 patients admitted to NHH over the study period (August 1, 2009, to August 1, 2010), 206 were referred to the ARC for review. Patients were noted to fall into four mutually exclusive groups: those not discharged during the study period (34 patients), those removed from ARC oversight while hospitalized at NHH (28 patients), those discharged from NHH and readmitted to NHH during the study period (68 patients), and those discharged from NHH and not readmitted to NHH during the study period (76 patients).
Patterns distinguishing these groups emerged. Patients who were not discharged during the study period typically had been transferred from the SPU and had been found not guilty by reason of insanity. This group included patients charged with murder, attempted murder, arson, pedophilia, aggravated felonious sexual assault, and aggravated assault. The group of patients removed from ARC oversight had the largest proportion of patients with substance use disorders; this group also prompted the largest percentage of ARC meetings to address management issues in discharge plans for chronically suicidal patients. The group discharged and readmitted to NHH during the study period had the highest percentage of patients with concurrent axis I, axis II, and substance use disorders and the highest percentage of patients with charges of assault (not including sexual assault or murder), which points to impulse control issues (11,12). The group discharged and not readmitted to NHH during the study period had a large proportion of patients with recent suicide attempts of lethal intent (hanging, firearms, jumping, drowning, or carbon monoxide poisoning); this group had a high percentage of patients with an axis I diagnosis of affective disorder and a substance use disorder. [Four vignettes presenting clinical features of patients in these groups are available in the online data supplement, along with reasons for ARC consultation pertinent to these groups and a breakdown of axis I and II diagnoses and substance use disorder diagnoses in each group.]
ARC policy mandates a review of patients who meet specific criteria. All clinicians follow this policy, and no resistance to this mandate has been noted. An interesting finding, however, is that a large number of ARC reviews are conducted at the request of an attending psychiatrist, even when these patients do not meet any of the mandated criteria. These nonmandated requests typically involve reviewing risk management issues involved in discharge plans for chronically suicidal patients. These requests reflect clinicians' perception of the ARC as an important venue to present significant risk management issues and obtain consultation and guidance.
The ARC is not used as a clinical tool for consultation. It is seen as a useful venue for discussing challenging risk management cases in an attorney-client-privileged setting that is not open to discovery. This allows for open, productive discussions that focus on risk management of high-profile, high-risk patients, rather than on the clinical care or treatment plans of these patients. Clinicians do not perceive the ARC as a group of administrators making clinical decisions. This minimizes any resistance to its operation and increases its acceptance as an asset rather than an administrative burden.
It is not surprising that the patients whose cases were reviewed and who were not discharged during the study period included a high percentage of patients with extended hospital stays resulting from a plea of not guilty by reason of insanity. All these patients faced serious legal charges. The severity of the event leading to this plea repeatedly precluded discharge of these patients to a less restrictive setting, even when they were deemed clinically stable for a significant period. Such patients face extremely challenging barriers to a safe discharge to the community. Caregivers must face the fact that many such patients are held at a higher level of care than may be medically necessary. Research in this area is badly needed.
The group of patients who were discharged and not readmitted contained the highest percentage of patients admitted because of a suicide attempt with lethal intent. Many of these patients had a concurrent affective disorder and a co-occurring substance use disorder. These suicidal patients with co-occurring disorders required intensive clinical oversight, which was presumably the reason for their hospitalization. When these individuals were linked to solid outpatient services, they were safely discharged after ARC review and did well in the community without need for readmission.
The work of the committee has significant clinical, policy, and administrative implications. Community mental health centers (CMHCs) to which the ARC patients were discharged gradually became aware of its existence, and some CMHCs have begun to work proactively with NHH staff to develop more extensive services, such as placing some patients on the caseloads of assertive community treatment teams. The increased communication between inpatient and outpatient treatment teams led to a more coordinated treatment plan for these patients and a sense of shared risk. The continuing challenge, however, is to address the multiple factors that lead to rehospitalization, such as treatment nonadherence, substance abuse, aggressive behavior, worsening psychiatric symptoms, housing issues, and legal entanglements. NHH and CMHC staff formed a multidisciplinary group that meets regularly to present challenging patients, many of whom were reviewed by the ARC. Such meetings allow for discussion and input from inpatient and outpatient providers about additional services needed to decrease a patient's risk for rehospitalization. The task of justifying these added services in a climate of fiscal restraint remains difficult, but the fact that these issues are discussed is encouraging.
The ARC referral process highlighted the significant number of patients contending with serious legal issues. This increased clinicians' awareness of the importance of consulting the hospital's legal counsel sooner rather than later to clarify any legal questions that arise during a patient's hospitalization. NHH clinicians work with the legal counsel to more quickly obtain the appropriate legal documents (for example, judicial orders from district, probate, or superior court judges; police reports; and competency evaluations) needed to present to the ARC. These documents allow for a more complete presentation of a patient's risk management issues. Clinicians have learned to incorporate a patient's legal issues into their overall clinical assessment and understanding of the patient's needs.
Legislators also became aware of the ARC's existence, and some wrote legislation specifying that certain high-risk patient groups needed to be reviewed by the ARC before their discharge. This development allowed NHH administration to educate legislators about the importance of the ARC risk management process in mitigating potential liability to the hospital and clinicians, as well as to stress the potential increase in community safety when high-risk patients are appropriately reviewed. Ensuing discussions with legislators have addressed balancing community safety, individual civil liberties, and the need for effective psychiatric treatment. These interactions led to further opportunities to educate legislators about the complexities involved in treating patients who are deemed not guilty by reason of insanity or incompetent to stand trial for serious offenses. The specific criteria required for ARC review of a patient needed to be emphasized in order to mitigate attempts to expand these criteria.
The high prevalence of substance use disorders among patients reviewed by the ARC reinforced the importance of developing and sustaining substance abuse treatment programs in the community. Policy makers were made aware of the significant percentage of high-risk patients with mental illness who have co-occurring substance use disorders and how legislators can help by funding programs that provide comprehensive, coordinated mental health and substance abuse treatment. NHH administrators began reviewing mental health and substance abuse treatment programs in the hospital, with a goal of streamlining the options available for all patients.
A direct result of the ARC's involvement in reviewing every patient sent to NHH from the SPU was the development of a joint committee of NHH and SPU staff that reviews all potential transfers to NHH, which has led to closer ties and more open communication between these institutions.
NHH successfully implemented an ARC as a risk management process in caring for high-risk, high-profile patients. The ARC is now an integral part of the NHH culture, accepted by clinicians as an added element of support and guidance in treating these challenging patients.
This one-year review of cases presented by clinicians to the ARC has identified groups and patterns. The findings point to the variety of psychiatric risk management issues that NHH staff members deal with on a daily basis.
The development of the ARC is a best practice that has significant clinical, policy, and administrative implications and that helps improve the care of high-risk patients. A continuing challenge is to further enhance strategies that permit the safe discharge of these patients to the community.
The authors acknowledge the assistance of Susan Searah, C.P.S., in tracking the ARC review requests.
The authors report no competing interests.