Saturday, November 18, 2006

Medical Director made to resign for speaking up for teen murder suspect stuck in the ER

There's really nothing good about this story at all. But I'm interested in it from the access-to-care angle.

A 16 yo kid in California, two days after being taken to a priest for help with voices, is being accused of beating his mother to death, and was being held in the psychiatric ER for over a week, waiting for an adolescent psych bed for further evaluation. Apparently, no one had been able or willing to take him in on their unit.

The psychiatric unit at Contra Costa Medical Center is reported to only be licensed for adult beds. According to the news article, the unit medical director, Scott Weigold, made a stink about the kid's clinical needs trumping policy constraints. Sounds like he made no secret of his concerns (broadcasting the email to staff), was accused of insubordination (are they in the military?), and is essentially being told to not let the door hit him on his way out.

He e-mailed Dr. Jeff Smith, the hospital's executive director, saying he planned to admit Mantas to the hospital's adult inpatient unit.

"I explained in very ham-fisted and emotional manner, that I was desperate to prevent a young man needing psychiatric hospitalization from being required to live in (psychiatric emergency services) for another week or more," Weigold wrote in a letter distributed to his colleagues this week. "I demanded that potential licensing and regulatory issues ... are not sufficient to prevent us from providing this young man the only form of inpatient treatment available."

[...] Contra Costa acute-care facilities for adolescents accept only people who meet strict criteria for being held against their will, including being gravely disabled by mental illness or posing an acute danger to themselves or others, Smith said.

Contra Costa Regional Medical Center is not licensed to provide inpatient treatment to youths and does not have staff members credentialed to do so, he said.

Smith e-mailed back to Weigold, accusing him of insubordination and stating that he considered the e-mail to be Weigold's resignation.

I don't have much to say about the kid, but I do understand Scott's frustration. We see less burdensome kids in ERs for a week or more around the state. It does sound like he went about making his case in a less-than-effective way. However, I'm guessing that there is more to this story than mentioned here. For example, Contra Costa was in the news last week about closing down nearly half of their psychiatric beds, citing insufficient community need (this hospital is in the San Francisco area). But advocates are crying foul:

[Danville resident and advocate Nancy] Thomas raised questions about a loss of federal money for the psychiatric unit because of a dispute involving the qualifications of people overseeing it.

The Times reported last week that the U.S. Centers for Medicare and Medicaid Services will deny a higher Medicare reimbursement rate for this year, a rate the county has received since at least 1998.

To obtain the higher rate, the federal agency said the director of inpatient psychiatric services should be a psychiatrist -- he is a licensed clinical social worker -- and the unit's nursing director should have a master's degree in psychiatric and mental health nursing or comparable experience in caring for the mentally ill.

"Why would you leave $2.8 million on the table to just slip away?" Thomas asked county officials. "Why not keep those beds open?"

They were also in the news yesterday being accused by CMS of inappropriately transferring uninsured patients with psychiatric problems to other facilities... the article suggests that Scott started that policy. CMS said it would terminate its Medicare contract if the problems did not get fixed soon.

Getting clearer now... Most inpatient units have a medical director; in part, because of the above reason, but also because it just makes good clinical sense to have the person setting the rules be one with full medical training. Apparently, the social worker runs the show. Now, I'm not knocking social workers, but an inpatient unit providing medical treatment and medications should have medical oversight. N'est pas? Perhaps this was merely Scott's last straw.

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BTW, I also note that Scott backed up Dr. A 5 years ago in an exchange on an antipsychiatry site ( Wonder if it's the Dr. A we all know and love.

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