The hennepin county medical center program in medical psychiatry: Addressing the shortened lifespan of patients with mental illness

It was early 2011. We had just concluded a program in which hospitalists were assigned to the Psychiatry inpatient service at Hennepin County Medical Center (HCMC). It was a dismal failure. The psychiatry wards, without oxygen in the walls, IVs in the rooms, or tourniquets for blood drawing, were not designed to provide medical care. Meanwhile, the outpatient psychiatric Day Treatment patients needed primary care, as the patients would not travel across campus to the unfamiliar Medicine Clinic. We then had a large influx of chronically ill poor patients with psychiatric and medical illness, brought to HCMC as part of a statewide change in insurance coverage. The Medicine Clinic was not prepared to provide mental health services for these complex patients. Finally, on the Medicine Inpatient Service, there were frequent transfers to Psychiatry of medical patients after the medical illness was stabilized; but once transferred, the medical problems often became hard to manage and the patients were sent back to Medicine. All was not right with medical psychiatric care at HCMC. The three of us thought a new direction was needed. We forged a collaboration—between the Chief of Psychiatry (Dr. Popkin), a senior general internist (Dr. Coffey), and the new Director of General Internal Medicine (Dr. Linzer). We decided to seek to establish a Center of Excellence in Medical Psychiatry. We would develop new processes for education and medical care on the Psychiatry wards, an internal medicine presence in Day Treatment, a mental health core in Medicine Clinic, and advanced training for Medicine ward nurses to manage behavioral issues. We would seek funding to support these endeavors. And we would not stop until patients with coexisting psychiatric and medical conditions had care at a level equal to their need. We were driven not only by our own experience of chaos, but also by the increasing national attention to the heightened mortality of patients with mental illness.1 Among the multiple issues contributing to this mortality gap are lack of self-care, exposure to violence, accidents, suicide, lack of primary care, and adverse metabolic consequences of psychotropic medications. In a 2006 editorial, Thornicroft2 said, “even in three Scandinavian countries that provide among the best quality and most equitably distributed health care in the world, this mortality gap has narrowed only by a modest extent over the past two decades… Medical staff, guided by negative stereotypes, often tend to treat the physical illnesses of people with mental illness less thoroughly and less effectively.” At HCMC, a safety net hospital where 65 % of our patients are persons of color, 20 % are immigrants and refugees, and upwards of 30 % of our patients have comorbid mental and physical illnesses, we began to ask such questions as: where should we care for bipolar patients with severe electrolyte abnormalities? And, who will detect and manage a psychiatric outpatient’s elevated cardiac risk? We decided that a comprehensive approach was needed to promote better systems of care while simultaneously developing a new workforce comfortable with the care of these complex patients. We saw this as a mission to reverse an inequity hiding in plain sight: health care disparities between patients with mental illness and those without.