May 1st, 2010

The changing role of the hospital-based psychologist

While incidence of mental health-related hospitalizations hasn’t diminished, the model of inpatient care is shifting. Shrinking budgets, bed elimination and community-based care is creating a new treatment paradigm and changing the role of some psychologists who work in hospitals.

In March, Eastern Maine Medical Center (EMMC) in Bangor laid off approximately 50 full and part-time staff because of financial issues and declining patient census. The cuts did not involve psychologists, according to Jill McDonald, B.S., MA, APR, EMMC’s vice president of communication and market development. “We do have a few psychologists on staff at EMMC in some outpatient capacity, but to my knowledge none of them have been laid off,” she says.

McDonald adds, “We have a sister hospital that handles behavioral health and addiction medicine exclusively. We contract with them for initial services in our emergency department and the psychiatric patients move to The Acadia Hospital for treatment.”

“In addition, Acadia has just opened an Outpatient Observation Unit, which will reduce the need for those contracted services by moving these patients to Acadia immediately after a medical clearance is accomplished in our ED. Acadia has had no layoffs to date,” says McDonald.

According to Doreen Elnitsky, RN, administrative director of behavioral health at Waterbury Hospital in Waterbury, Conn., her staff has had to make “considerable adjustments and changes in how we provide care” in the past several years.

With an average length of stay at slightly less than six days, Elnitsky points out that patients are not hospitalized long enough nor are they in any condition to sit for a psychological evaluation. “We don’t call in someone from the outside. We wait until the patient is discharged,” she says. “Now we refer anyone in need of an evaluation to an outpatient psychologist.”

One of the most drastic changes occurred a few years ago when all psychologist positions on the service were eliminated, Elnitsky explains. While this action affected inpatient behavioral health care, these cuts more directly impacted Waterbury’s psychology fellowship program with Yale University, which cost between $50,000 and $100,000 to run. Elnitsky says, “We first eliminated part of the fellowship and went from three psychology fellows to two. That was five years ago.” She reports that the program was completely eliminated a couple of years ago. Without the presence of students and the need for mentorship, the psychologist positions were unnecessary, she adds.

Since many services are being outsourced, Elnitsky cites the need for private practitioners in the community. “For patients who come into the emergency room who need a therapist, there are very few resources, particularly if a patient needs medication. The challenge is to get people to the next level of care,” she says.

In contrast, Butler Hospital in Providence, R.I. has not seen any significant attrition. In fact, Paul F. Malloy, Ph.D., assistant clinical director and director of psychology, says, “The number of psychologists has grown,” a situation he attributes to Butler’s affiliation with nearby Brown University, a strong research-focused institution.

It’s for this reason that Butler’s fellowship/internship program has also flourished. Part of the consortium of all Brown University-affiliated hospitals, which includes those within the Care New England and Lifespan health systems, Butler runs the “biggest program in the country,” according to Malloy. “We currently have 22 interns and have had as many as 50 post-docs in the program.”

Financial support for these student programs comes from grants, many from the National Institutes of Health (NIH), and others from Butler. Malloy says, “I have a post-doc student who does 20 percent research, that’s one day a week. The other four days, she does clinical onsite services. This comes out of hospital bed revenues.” Some of the studies conducted at Butler receive funding from pharmaceutical companies and/or medical device manufacturers, adds Malloy.

Psychologists at Butler also participate in the many clinics and studies the hospital directs. “We see many outpatients in our memory clinic and in our alcohol clinic,” says Malloy. “Almost everyone is in one or more studies.” He notes that Butler is currently conducting at least 10 studies on Alzheimer’s disease and has other trials involving several different psychiatric disorders.

Malloy admits that some psychologists have left Butler. “Ten or 12 years ago, the trend was to develop a continuum of services – inpatient, outpatient and partial programs,” he says. “Our outpatient program was losing so much money we couldn’t support it, given the reimbursement rate in Rhode Island.” He adds that hospital overhead and complying with Joint Commission standards and other federal regulatory bodies had strained Butler’s finances. “Overall, though, we’ve been very lucky,” Malloy says, praising the hospital for its foresight and planning.

Other Ocean State health care facilities also report a positive outlook for psychologists. Linda Shelton, Lifespan’s director of media relations, says, “Rhode Island Hospital and The Miriam Hospital have added psychologist positions over the past year, and Bradley Hospital is also looking to hire more psychologists.”

By Phyllis Hanlon

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