Lost in Transition: Overcoming Challenges in Coordinating Psychiatric Care for Patients with High Suicide Risk

MD Media/AdobeStock

Navigating mental health care coordination becomes particularly challenging when patients traverse various levels of care. Patients with high suicide risk, in particular, frequently find themselves in transitions among different facilities and systems of care. This article seeks to shed light on the critical need for a more seamless handoff process to maximize patient safety during care transitions. Drawing from a real case in California, the case example not only highlights the vulnerabilities exposed but also proposes actionable improvements in the patient care chain.

A key concept relevant to this case is the term 5150 psychiatric hold, which refers to a section of the California Welfare and Institutions Code (CWIC), specifically Section 5150. California counties authorize certified designees to involuntarily detain an individual for a 72-hour period to obtain psychiatric evaluation when they are deemed to be a danger to themselves (DTS), danger to others (DTO), or gravely disabled (GD) due to a mental disorder.¹ Different counties within California vary in implementing this law in terms of training process, choice of designees, and the administrative authority of the hold. In the county where this case took place, law enforcement officers and clinicians acquire qualification to initiate psychiatric holds through specialized training provided by a particular county institution. This process may limit clinicians designated with this authority to issue holds at a specific location only, and not at other locales in the county, while law enforcement officers retain this authority across the county. The individual placed on hold is usually taken to a county-designated psychiatric facility (either the county-operated psychiatric facility or one of many local private psychiatric hospitals), emergency department, or crisis stabilization unit (a short-term facility for urgent mental health crisis) for an assessment by mental health professionals. The 5150 hold is a legal mechanism used to provide short-term, emergency psychiatric intervention for individuals in crisis. Similar laws and procedures exist in all US states, although the specific legal codes and terminology differ. There is an additional legal hold in California that serves a similar purpose—1799 hold, which is a 24 hour hold that can be placed on a patient by a licensed physician or staff (not necessarily a psychiatrist) at a general medical hospital for involuntary detainment for danger to self, danger to others, and/or grave disability (the same terms as in CWIC 5150) for up to 24 hours, pending a psychiatric evaluation, until a 5150 hold can be obtained.² 

Case Example

“Jennifer” was a 34-year-old woman with history of schizoaffective disorder who presented to community residential program (CRP) after recent psychiatric hospitalization for paranoia, suicidal ideation, and command auditory hallucinations (CAH) in the setting of medication noncompliance due to her having been homeless and without access to medications. She was referred directly from the psychiatric hospital after stabilization and was accepted for intake by the CRP. The CRP is a community program for recently discharged psychiatric patients or walk-in patients from the mental health urgent care facility. All patients there are voluntary and not under conservatorship or guardianship.

On her intake interview, Jennifer was disorganized and unable to provide a timeline of events leading up to her hospitalization. She endorsed that her CAH had been worsening and telling her to kill herself. She endorsed feeling very distressed from these symptoms. She had 2 dolls to help her cope. She told staff that, "People are out to get me." She thought that staff at the hospital had been poisoning the food and water, and she had only been drinking Ensure and eating food items that were sealed. Jennifer stated that she continued to be concerned about poisoning of food items and that she would refuse all food except packaged food and Ensure at the CRP. She shared that she tried to drown herself at the hospital in the bathroom sink due to CAH telling her to drown herself, and she continued to endorse such hallucinations. This information was not documented in the discharge summary from the hospital she came from. This writer was concerned for her safety and offered to readmit her to an inpatient psychiatric facility for stabilization. However, Jennifer stated she would reach out to CRP staff if she had thoughts to harm herself. Her discharge medication regimen was continued upon intake at the CRP: prazosin 2 mg QHS, oxcarbazepine 300 mg BID, aripiprazole 20 mg QAM, paliperidone long acting injectable (LAI) 234 mg every 4 weeks (she received first loading dose immediately prior to discharge).

Jennifer was put on observation every 15 minutes by staff and to be reassessed the following day. In the interim, she left the program by walking out of the building with her stroller. Staff went searching for her all over the neighborhood and found her a few blocks away from the CRP facility. She stated that she was trying to go to her mother’s house but could not provide an address. The staff brought Jennifer back to the facility voluntarily. During interview the following day, she stated she did not feel safe around people and the voices were telling her to be alone. Hence, her plan was to go to a “safe house,” and she could not disclose the location because then it would be unsafe. Jennifer stated she would walk there via freeways, and she was not afraid to get hit by cars because, she was “an angel.” At this point, this writer decided that Jennifer needed a higher level of care and therefore she should have been placed on 5150 DTS/GD hold.

However, given the institutional restriction on writing the 5150 hold as described previously, this writer could only write holds at the facility the certification was issued (the county mental health inpatient unit) and could not place such hold outside of the that facility even in the same county that 5150 certification was issued. Therefore, the CRP staff called 911 and an ambulance was dispatched to transport Jennifer to the emergency department (ED) of the local University Hospital for the purpose of having the medical center clinicians place a 5150 hold and arrange for repeated inpatient hospitalization. Jennifer attempted to drown herself in the bathroom sink of the CRP while awaiting the ambulance because she did “not want to go back to the hospital.” Jennifer was transferred to the ED with her belongings.

While ambulance was en route to the medical center, this writer called the medical center operator for a “warm hand-off” message for the ED staff that included Jennifer’s psychiatric history, her recent presentation, and attempt of self-harm on site at the CRP. Per hospital operator, such a message could be delivered to the ED triage nurse but not the mental health social workers, who are the only clinicians in the ED empowered to write a 5150 hold. At the University Hospital, the workflow is that the mental health social workers conduct first round of psychiatric evaluation on patients, assessing if they meet 5150 hold criteria. Social workers can then put patients on holds, in which case psychiatry service will later see the patient. If the social workers decide that patients do not meet hold criteria, patients are be discharged from the ED without having been seen by a psychiatrist. Both decisions are made without consulting with the psychiatry service. This writer also secure-messaged the medical center senior psychiatry residents on the consultation-liaison service and the behavioral health unit to anticipate Jennifer with details of her situation. These residents acknowledged the situation and were anticipating Jennifer’s arrival.

The following day, this writer was informed by CRP staff that Jennifer denied suicidal ideation while in the ED when being evaluated by mental health social workers. Because the social workers evaluated Jennifer based only on the her presentation and facts she shared in the ED, Jennifer was deemed to not meet hold criteria. Thus, she was not placed on a hold but instead discharged to the street. This writer reviewed her medical center chart for the ED visit and found a brief note from triage nurse which did not include details of the hand-off provided, especially the history of Jennifer’s attempt to drown herself while in the CRP and the high risk for self-harm recommending 5150 DTS/GD hold by a psychiatry physician (this writer, who is a psychiatry resident at the University Hospital). There was no direct hand-off process between the ED triage nurse and the social worker. Therefore, even if the hand-off information had been included, it would require the social worker combing through every note to find it. The note from the mental health social worker stated, “the patient denies acute suicidal ideation” and she was therefore discharged with her belongings.

Two weeks later, Jennifer was brought to another local ED by police after being seen disorganized on the street. A new 5150 hold was placed by the police officer and she was waiting for inpatient hospitalization placement. This writer was on overnight call at the county mental health hospital and Jennifer’s packet was presented for admission at the county hospital. This writer approved admission knowing her history and appreciating the current clinical acuity. However, county mental health unit staff expressed concern that the acute risk for self-harm would cause administrative and staffing burden such as 1:1 monitoring and did not admit her. There was no follow up information for Jennifer afterwards.

Discussion

There was a lack of standardized documentation from the discharging psychiatric hospital. In this case, the staff at the crisis residential program had no knowledge of the self-harm attempts during Jennifer’s hospitalization upon the initial interview for acceptance. The community program team might have declined to accept her because the program does not have the staffing capacity to provide 1:1 care for patients with high suicide risk and cannot accept committed patients.

In addition, Jennifer was refusing food due to paranoia and still had CAH, which qualify her for 5150 GD criteria. Frequently, patients who are discharged from inpatient psychiatric settings are still too acutely ill for the community setting, and in the event when a hold is warranted, it cannot be done due to the CRP being a “voluntary” facility and limitation of the CRP physician not having the authority to write a 5150 at that facility.

Some additional complicating factors include lack of local inpatient psychiatry beds. It is also possible that health insurance companies will stop payment for inpatient care if the patient no longer shows improvement, and/or the patient has limited room for improvement. These barriers might lead to patients being discharged to the community when a higher level of care could be justified.

There are institutional boundaries related to 5150 authority that create challenges for psychiatrists working in different settings, which is the case for many residents and faculty members. In this case, the University Hospital Department of Psychiatry physicians (faculty and residents) are granted 5150 authority by the county only for their clinical duties at the medical center or the county psychiatric facility, not county-wide, which limits their options in that they cannot commit patients who are not physically on site at the medical center or county facility. It is reasonable to speculate that if Jennifer had been transferred to the University Hospital ED with a hold already in place by this writer (had I had the authority to do so), there would have been a higher likelihood of her being retained in the ED and eventually readmitted to an inpatient psychiatric facility, even though she denied acute suicidality during the PES evaluation.

This leads to an additional issue: the lack of direct communication from the psychiatrist or psychiatry resident working at outside facilities to the ED social workers at the medical center. This writer attempted to provide a warm hand-off directly to the social workers, but the current system requires going through 2 additional staff members: the hospital operator and ED triage nurse. Each additional step in relaying information introduces opportunities for lost information and miscommunication, as evidenced by the notes from the triage nurse and PES indicating that the handoff did not occur as intended.

A multifaceted approach is proposed to tackle the identified challenges. Inpatient psychiatric hospitals should not prematurely discharge patients who are still dangerously symptomatic and unstable for the community. Consider discharging to intermediate level of care programs or a step-down program, such as a locked facility with staffing capacity for 1:1 monitoring who accept patients that might need to be on a hold and/or conserved. On the other hand, hospital discharge summaries could highlight significant events during hospitalization, such as self-harm attempts. This would enable clinicians and staff at lower levels of care facilities to be fully aware of the patient's risk when evaluating them for intake.

To minimize inter-institutional barriers between the university and county facilities, an agreement could be considered between the University Hospital and county-affiliated facilities. This agreement could allow psychiatrists and psychiatry residents who work in multiple settings to initiate 5150 holds in all county care settings, even if they are initially certified in only 1 of the systems. Alternatively, the state of California could streamline the training and certification process to minimize inter-county and inter-facility variability and recognize the jurisdiction to write 5150 hold state-wide regardless of the facility affiliation and location.

A direct form of communication between psychiatrists and ED social workers would be beneficial when the psychiatrist is working off-site from the University Hospital and needs to send patients to the hospital. Options such as a secure chat group could be explored to eliminate relaying information through a middleman and potentials for miscommunication.

Finally, it would significantly improve outcomes if patients’ psychiatric histories were accessible through an EMR or another shared clinical database. Currently, upon intake at the county inpatient psychiatric hospital, patients are provided with a paper referral packet of 40 to 80 pages, containing their most recent hospitalization and medication information. After being reviewed, the paper charts are scanned into the chart as a large PDF file and the documents are shredded. The PDF file does not allow “search function” for future chart review and important information is often lost in the massive number of pages. While clinicians can search within the system for prior episodes of care, this is limited to the institution as the University Hospital and county facilities use different EMRs that do not include information from other hospitals in Sacramento or neighboring counties. Therefore, it is often impossible to evaluate a patient’s full psychiatric history, despite patients having had multiple hospitalizations and medication trials. At county psychiatric hospitals, psychiatrists often have no choice but to “start from zero” given lack of history. This inevitably disadvantage our underserved population, who already have poor access to care, and the care they receive is impacted by poor coordination among hospital systems. In this case, the county could greatly promote equity of care if inpatient facilities, especially county affiliate facilities, all adopt EPIC as EMR, which enables psychiatrists to access full psychiatry history and provide quality care in all patient populations.

Dr Song is a former psychiatry resident at UC Davis Health.

References

1. Law section 5150. Legislature.ca.gov. Accessed January 9, 2025. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=WIC&sectionNum=5150

2. Law section 1799. Legislature.ca.gov. Accessed January 9, 2025. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1799.111.&lawCode=HSC