Navigating and Understanding the Adult Inpatient Hospital System
Many people find the process of psychiatric inpatient hospitalization frustrating and confusing. This document explains the process of admission to a psychiatric acute inpatient hospital and provides tips to help make a hospitalization a bridge to long term recovery. The information provided below applies only to adults at least 18 years old.
This page includes:
- Preparing for a Crisis
- How to Get an Evaluation for Admission to a Psychiatric Hospital
- The Psychiatric Evaluation
- Types of Psychiatric Admissions in Pennsylvania
- Types of Inpatient Hospitals
- Locating a Loved One Admitted to a Psychiatric Hospital
- Care Providers in the Inpatient Hospital Setting
- How to Contact Care Providers
- Information the Inpatient Team Will Need
- Family Meetings
- Discharge Planning
Preparing for a Crisis
It is easier to respond quickly and appropriately to a crisis if you have identified your local resources before a crisis. Take some time before a crisis develops, to identify the nearest emergency room that has mental health professionals on-site. Consider calling the local police department to notify the department that your loved one has a mental illness. For additional advice, see http://namibuckspa.org/crisis-info/
How to Get an Evaluation for Admission to a Psychiatric Hospital
This section focuses on the procedures in Philadelphia County. The facilities available for evaluation for admission to a psychiatric hospital may be different in other counties; some additional information for other counties in southeastern Pennsylvania is available in the links provided below.
Individuals experiencing a mental health crisis can also go to any hospital emergency department. Emergency departments vary in the services available. Some emergency departments have mental health professionals on-site who can perform psychiatric evaluations and admit individuals to inpatient psychiatric hospitals if they feel this is appropriate. There are also emergency departments that do NOT have mental health professionals available. Physicians in these facilities will instead assess individuals to ensure that they are medically stable and will then refer the person to another facility for psychiatric evaluation. Depending on the circumstances, the person may be transported by ambulance to a psychiatric facility for evaluation or the person may be given information about where to go for psychiatric evaluation.
Psychiatric Inpatient Hospitals
There are also psychiatric hospitals that have intake or admission centers and individuals can go to these centers for evaluation by a mental health professional and direct admission to that hospital if a bed is available. Some hospitals require or prefer that you call to schedule an intake for admission to ensure that the hospital has an appropriate bed available.
The Psychiatric Evaluation
A mental health professional will evaluate an individual who goes to one of the above facilities and will determine whether the patient is appropriate for an inpatient psychiatric unit. Acute inpatient psychiatric hospitalization is intended for individuals whose thoughts and behaviors pose a substantial risk to themselves and/or others. The information provided by the individual seeking treatment and information provided by family and/or friends can be considered when determining the most appropriate treatment setting.
Types of Psychiatric Admissions in Pennsylvania
Voluntary admission (also known as a “201”) to an acute inpatient psychiatric hospital occurs when a person goes for psychiatric evaluation and the evaluating mental health provider and patient agree that the patient would benefit from hospitalization and meets criteria for hospitalization. The patient is required to sign a consent form that is sometimes called a “201.” The 201 form documents the patient’s rights and describes the inpatient hospital experience. By signing the form, the patient agrees to being hospitalized on a locked unit. If the patient later requests discharge, the hospital can hold the patient on the unit for up to 72 hours until a mental health professional can evaluate the patient for safety concerns. The patient will be discharged if the evaluating mental health professional determines that the patient is safe for discharge. If the mental health professional evaluates the patient and feels that he/she is at risk of harm to self/others or unable to care for self, the mental health professional can convert the admission to an involuntary admission (“302”). The patient will then be brought to mental health court within 5 days and the court will determine whether the patient can be legally held on a psychiatric unit. A patient may also be voluntarily admitted for a subacute inpatient hospitalization.
Involuntary admission (also known as a “302”) to an acute inpatient psychiatric hospital occurs when the patient does not agree to hospitalization on a locked inpatient psychiatric unit, but a mental health professional evaluates the patient and believes that, as a result of mental illness, the patient is at risk of harming self or others, or is unable to care for self. The person must pose a “clear and present danger” to self or others based upon statements and behavior that occurred in the past 30 days.
There are two parts to a 302: evaluation and admission. Any person (including police and doctors) can petition or request an involuntary psychiatric evaluation for another person. The person requesting the evaluation is known as the “petitioner.” The petitioner will describe the behavior that is concerning. It is important for the petitioner to think about what he/she will write ahead of time. The petition must include specific witnessed behaviors and statements in the past 30 days that show the patient poses an imminent danger to self or others. This description will then be reviewed by the Office of Mental Health and the petition for evaluation will either be approved or denied. Petitions by police officers and doctors do not require approval by the Office of Mental Health. If the petition is approved, the petitioner will be given further instructions about how to have the person transported to a Crisis Center for an involuntary psychiatric evaluation (patients are usually transported by police). The person will then be evaluated by a mental health professional and the mental health professional will determine whether the person meets the requirements for an involuntary admission to an acute inpatient psychiatric hospital. A full description of the process of involuntary admission is beyond the scope of this article (please see http://www.alleghenycounty.us/Human-Services/About/Contact/MH-Commitment.aspx and http://namipamainline.org/wp-content/uploads/2016/09/MentalHealthProcedures-ACT-Checklist.pdf for information about the 302 and other types of commitments including the voluntary and involuntary admission of children and adolescents in Pennsylvania).
If a person is admitted involuntarily, the patient will either be discharged within 5 days or brought to mental health court within 5 days (120 hours) to request a longer commitment (a “303”). The decision to discharge the patient or request a longer commitment is made by the treatment team based on concerns for safety of the patient or others. The mental health court will determine whether the patient can be legally held and treated on a psychiatric unit. The proceedings at mental health court may be called a “commitment hearing.”
Hearings are non-public and confidential. If the patient objects to having family present and the family did not petition the 302, the family may not be permitted to attend the hearing. If the patient wishes to have a family member present, the person may be admitted to the hearing as an observer. If family members want to provide information supporting the hospitalization, they are encouraged to give the information to the hospital presenter and let the presenter provide the information at the hearing. This process helps to reduce conflict between the patient and family members. If family members have information supporting the discharge of the patient from the hospital, they should give this information to the lawyer or advocate who is representing the patient and this person will present the information at the hearing.
Commitment hearings are administrative hearings. This means that they are much less formal than judicial hearings and formal legal rules, such as the rules of evidence (i.e., hearsay information), do not apply. The purpose of the hearing is to gather as much information as possible so the court can decide whether probable cause exists to believe that the person is a danger to self, danger to others, or unable to care for self.
The 302 petitioner is expected to be present at the hearing and the judge or administrative hearing officer will likely request from the petitioner additional information about the events leading to the commitment.
It is the responsibility of the hospital presenter to explain to the court: (1) the events and the patient’s behavior leading up to the patient’s hospitalization; (2) the patient’s behavior during hospitalization which illustrates his or her mental disorder and his or her dangerousness or grave disability; (3) previous psychiatric history; (4) living arrangements before hospitalization and plans after discharge; (5) the patient’s diagnosis; and (6) the medications currently prescribed and whether the patient is taking these medications.
It is the responsibility of the lawyer or advocate who is representing the patient to present the patient’s point of view and to make the best possible case for the patient’s discharge from the hospital.
If the judge or administrative hearing officer determines that there is probable cause for the patient to remain in the hospital based upon one or more of the certification criteria, he or she will inform the patient of this decision and the reasons for it.
If the judge or administrative hearing officer determines that there is no probable cause to believe the patient meets one or more of the certification criteria, he or she will inform the patient and hospital representative of this decision and will explain the reason for it. If the hospital and the patient agree, the hospital then may accept the patient as a voluntary patient. If not, the patient must be discharged from the hospital.
For additional information about the Delaware County Mental Health Court see http://www.delcohsa.org/mh_adult/mh_court_brochure.pdf.
Types of Inpatient Hospitals
Acute inpatient psychiatric units are locked psychiatric units that treat people who are struggling with depression, mania, psychosis, self-harm, and suicide as well as other psychiatric conditions. People can be admitted to these units voluntarily or involuntarily. The units are locked for the safety of the people being treated on these units.
Dual diagnosis units are a type of acute inpatient psychiatric unit. They are locked and they treat people who are struggling with BOTH addiction and depression, mania, psychosis, etc. These units have a lot of experience treating drug and alcohol withdrawal symptoms and may have therapeutic groups that focus on addiction. Some of these units are also able to treat people who do not struggle with addiction.
Inpatient detoxification and rehabilitation (detox and rehab) units are NOT locked. People can only go to these units voluntarily. These units are intended for people primarily struggling with addictions. The groups on the unit focus on addiction and the staff is experienced in managing withdrawal symptoms.
Subacute inpatient hospitalization consists of treatment at a facility that may be unlocked. People can only go there voluntarily. This type of hospitalization is often useful when an issue at a person’s residence is contributing to the person’s worsening symptoms but there is NOT an acute safety concern. Some insurance plans do NOT cover subacute inpatient hospitalization.
Locating a Loved One Admitted to a Psychiatric Hospital
When a person is hospitalized, the family is often NOT notified of where a person has been hospitalized. All psychiatric units have phones that are available to patients for use if the patient wishes to contact family. Alternatively, one can call area psychiatric hospitals. The psychiatric hospital staff will likely state that it cannot confirm that the person is admitted to the hospital. A family member can request that his/her contact information be provided to the treatment team if the person is admitted to that hospital. A family member can also request that his/her contact information be provided to the patient so the patient can call.
Care Providers in the Inpatient Hospital Setting
Attending physicians/attending psychiatrists are the doctors who supervise the resident physicians and medical students. The attending physician makes the final treatment decisions. The attending physician may be on the unit for only a few hours each day. He/she sees the patients each day and then discusses the plan with the resident physicians and medical students. Some hospitals only have attending psychiatrists and do not have medical students or resident physicians.
Resident physicians/psychiatrists are doctors who have completed medical school and are now training in psychiatry. The “resident” physician is training in a specific area of medicine (for example: psychiatry) under the supervision of more experienced physicians (“attendings”). The resident physician is on the unit most of the day and is usually the doctor who calls patient’s families and outpatient doctors.
Medical students are people who are in medical school and may or may not go into the field of psychiatry. They often have more time than the attending and resident to have longer conversations with families. If families provide information to the students, the students will pass that information along to the resident and attending.
Nurse practitioners and Physician assistants are mental health providers who are supervised by a psychiatrist.
Nurses are on the unit 24hrs a day and they are a wonderful resource. The nurses can provide information about how a patient is doing and the name of the doctor caring for the patient. They can also notify the doctor that a family member called and would like to speak with the doctor.
Therapists are often on the unit throughout most of the day and facilitate both individual and group therapy sessions. They can be a valuable resource to patients, as well as their family members and the rest of the treatment team by helping patients to learn coping skills to better manage symptoms and stress upon discharge from the hospital.
Social workers are available on all acute inpatient psychiatric units. They play a very important role in determining what resources the patient will need upon discharge. They may assist patients in obtaining housing (for example: boarding homes, shelters). They can submit applications for case management services, partial hospital programs, extended acute care, and many other services. The services they can obtain for any individual are limited by insurance and eligibility criteria.
How to Contact Care Providers
The Health Insurance Portability and Accountability Act (HIPAA) and state and local mental health laws limit the mental health treatment information that can be released to families without the patient’s consent. The law does NOT prohibit treatment providers from receiving information from families. Unfortunately, it can be difficult to provide information to hospital staff because the hospital will not acknowledge that a person is admitted without consent from the patient to release this information. To share information in this circumstance, you can go on the hospital’s website to locate a relevant fax number or email address and send your information that way. You can also mail information (though this method may be too slow to be helpful). Hopefully, the hospital will get the information to the appropriate provider.
The main hospital operator can give you the nursing station number (unless the patient requested that this information not be shared). You can then call the nurse’s station and request the name of the patient’s provider and request that the provider call you. Weekdays, during business hours, are the best times to call to speak with a mental health provider. There is always a mental health provider available to patients 24 hours a day, but the provider available on the weekends and overnight is responsible for many more patients than the daytime providers. The overnight/weekend provider is also not the provider making the most important decisions about treatment and discharge. Medical students and resident physicians are great resources for families and patients. If you have concerns that the medical students and residents cannot answer, you can always ask to speak with the attending physician.
Information the Inpatient Team Will Need
Individuals may not be able to provide an accurate history when they are in crisis. It is very helpful when families can provide information about what medications the hospitalized person was prescribed at the time of the hospitalization, and the medications the person has been on in the past and why they were stopped (side effects, did not help). It is also very helpful when families can provide information about medical history, allergies, substance abuse, the stressors that may have contributed to the crisis, contact information for the person’s outpatient psychiatrist, and any history of violence, threats of violence, self-harm, and/or suicide attempts.
During the first few days of a hospitalization, the best way to communicate with the inpatient team is usually the phone. People who have recently been admitted are sometimes too ill to have a meeting with their inpatient team and family in order to plan for the future. But it is useful to notify the team early in the hospitalization that the family would like to have a family meeting when the patient is more stable. As an individual begins to recover and to prepare for discharge, it can often be helpful for the patient, family and treatment team to meet and discuss the plan for treatment and housing upon discharge. Family members (or any support person) can ask the treatment team for a family meeting. It is rare for this request to be denied but it is important to note that the hospitalized person needs to consent to the meeting.
Acute inpatient hospitalizations are often short. In most cases, individuals are discharged when the treatment team believes the patient is safe for outpatient treatment. There are many different types of outpatient treatment including but not limited to partial hospital programs, intensive outpatient programs, assertive community treatment, case management, treatment by a psychiatrist and therapist, and treatment by a psychiatrist only.
The patient will likely still have symptoms at the time of discharge. Family involvement is very important during discharge planning. Family members know a lot about how the hospitalized individual functions outside of the hospital and how much support the person may need on discharge. It is important to talk with the inpatient team before discharge to ensure that the patient and a support person understand the medications prescribed at discharge and where the patient will be getting treatment after discharge. It may be helpful to have a family member or support person pick the patient up from the hospital. At that time, the nurse will provide written instructions for follow up and a list of medications. If the patient and/or support person have any questions that cannot be answered by the nurse, they can ask to speak with the doctor. Discharge planning is often the most important part of a hospitalization because changes (for example, changes in medication) that were made during the hospitalization and found to be helpful, will have to be continued by the patient, support persons, and outpatient providers after discharge in order to maintain stability and increase the likelihood of continued improvement.