Having done most of my clinical clerkships in New York City, I came to Boston for residency expecting a similar experience in another metropolitan city. The culture of the Psychiatric Urgent Care units I observed in NYC consisted of a triage system in which some patients would be discharged and some, with enough evidence (suicidal ideation, homicidal ideation or severe psychosis) would be admitted.
Some patients would be in that area between admission and discharge. For those in-between situations, there was a statewide program available in some, but not all, hospitals called the Comprehensive Psychiatric Emergency Program (CPEP), essentially an observation and holding area. To my surprise, during one of my first few calls as a resident I witnessed an incredible reality. “This is mainly a detox and humanitarian transfer. The patient is homeless and suffering from long term alcohol dependence,” my senior resident said.
Humanitarian admission due to alcohol dependence and homelessness. I wondered? This is not a hotel, it is a hospital. Right?
During rounds the next morning, I heard the attending speak of our “mission to end homelessness.” As a new physician, I was still in the inquiry mode, thinking like an engineer, wondering what is the problem we are treating and why is our homeless and alcohol-dependent patient still here?
As much as I liked that mode, however, the attending’s words resonated with another part of me, which I had, perhaps, ignored for a few years. This situation took me back to my public health training days and my idealistic dreams as a graduate student. My mentor, who works on impact of health policy on the homeless helped instill the same vision in me – eliminate homelessness.
While skeptical about the practice of medicine I had just witnessed, I thought about other idealistic “what ifs”. What if I could securely access my patient’s records all day, every day, and anywhere in the world so that I could make myself available to oversee their care regardless of where I was in the world? What if I could assure my patients’ continuity of care in any state as long as they walk into a hospital and request for help? What if I could access the notes from multi- disciplinary medical professionals to know what they were doing for my patient as well? What if I could share my notes with other providers by just looking them up and “tagging” them on my notes much the same way you tag a person on a Facebook photo, and maybe even get them to acknowledge receipt of my note by an electronic signature?
What if I had a system that would automatically send me alerts (again like Facebook) when people wanted me to read a note or when things were wrong? What if I could click a button and see all the medications my patient had tried in the past? Instead of suggestions or referral with a business card, what if I could place outpatient consults that would generate automatic appointments for my patients and those specialists could also read my patient’s history?
What if. What if?
And what if I told you that while the elimination of homelessness has not yet occurred, the rest of the “what ifs” are already the reality of today’s VA healthcare system. A system that has existed long before Facebook ever did and mainly due to the nationally available, VPN connected, and tightly monitored and secured electronic medical record system.
During these months I further learned to think less like an engineer and more like a psychiatrist: one who considers the “bio,” the “psycho,” and the “social” aspects of the patients. I learned that in order to carryout care in a holistic manner, continuity of care, history, collateral information, and communication between providers are essential elements. I witnessed that the VA’s success in delivering mental healthcare is owed to the organizations major strength towards provision of care that all honorably discharged veterans receive quality care regardless of disease, severity, and socio economic status (notice insurance companies have been minimized in this system—a separate debate not discussed here.)
No matter where one lies on Obama’s Affordable Care Act, providing an “all-inclusive quality of care to all US citizens” is nothing more than an idealistic dream by most providers, yet provision of care to all honorably discharged veterans is a reality for VA Clinicians.
The VA system of mental health is one which caters to patients’ needs, even if that need is to be “taken in and taken care of” at any stage. This system has invested heavily in preventive, rehabilitative and population-based care. It is a public health model that deserves further discussions for adaptation by other healthcare institutions. “You are not alone, we are here to help” is what I learned to say to my patients after the end of my first year as a resident in the VA system, and I meant it.
The VA’s mental health system operates in a way that all healthcare systems should: It focuses on the long-term, as opposed to looking only at short-term solutions. It looks at the bigger picture and addresses the core of the problems. The VA mental health care system expects and delivers higher quality of care and comprehensiveness that is a standard of care nationwide.
“Who will pay for this?” you may ask.
The hospitals, healthcare providers, government, and taxpayers pick up the tab left by those undertreated. We are the ones who fund public programs, such as Medicaid, which will ultimately pay for the circular cost of ‘band aid care.’ Therefore in one-way or another, we are all paying for our healthcare system. What we should aim for is efficiency and cost-effectiveness. These goals are achieved through coupling technology with comprehensive care. The VA system for mental health care successfully manages and caters to some of the most complex and seriously mentally ill patients using this motto. And we have a lot to learn form them.
While many aspire to look to outside countries such as Canada or the United Kingdom, to piece together the good in order to reform our healthcare system, one should not forget to look at the VA system and especially the mental health division of this system. The model we should further study and learn from when we think of “reform for provision and continuity of care” is as American as the Federal Government’s VA system and has been a very large “pilot” here at home.
It is advanced culturally and technologically, has passed the test of time, and it works by making life better for providers through making it better for patients.
Edwin Raffi, MD, MPH is a resident physician at the Harvard South Shore Psychiatry training program and a Member In Training co-leader for the Massachusetts Psychiatric Society VA Committee.