Author: David Soskin
Date of Publication on http://www.opensourcepsychiatry.com on 09/02/17
The Hobbesian Bias: Can We Increase Access to Care?
I. Background & Rationale
Currently, many outpatient psychiatric clinics in the U.S. do not have the capacity to provide the type of access to care that we, as providers, would wish for our own patients, friends, or family members. Although demand (for healthcare) will likely always exceed supply, healthcare administrators can seek to correct the misalignment of incentives between clinical providers and system demands, which manifests as a phenomenon I am calling here, the Hobbesian bias, after the famous philosopher, Thomas Hobbes (5 April 1588 – 4 December 1679), who underscored the natural human tendency to act self-servingly.
In a healthcare context, the Hobbesian bias describes our natural tendency to gravitate toward working with patients, who respond to treatment, and away from patients, who do not respond, and, who may also have behaviors (e.g. substance use) and traits (e.g. Cluster B) that interfere with treatment. Operationally this bias translates into a natural tendency for medical providers to schedule patients we like working with for return visits more frequently than may be clinically indicated and to schedule patients we dislike and/or who frustrate our efforts to treat them effectively less frequently than may be clinically indicated. For example, I may ask one of my “success-patients,” who suffers from schizophrenia but has now had a remission of positive psychotic symptoms on 4 mg of risperidone monotherapy for 10 years, to return to clinic every 3 to 6 months rather than every year. Assuming this patient has good communication skills and will contact me if he’s having difficulty, my scheduling decision would have the following negative consequences:
To counteract the Hobbesian bias, administrators can take a recovery-oriented approach to stratifying levels of care and create a “Wellness Clinic,” which correlates patient severity with the appropriate duration of follow up frequency.
II. Specific Aims
1. To transition clinically appropriate stable patients with severe mental illness (SMI) to a lower level of care (=the Wellness Clinic);
2. To increase access to care for newly referred patients with SMI;
3. To create system fluidity through bidirectional referral pathways between the Wellness Clinic and higher acuity SMI Clinics; if a patient in the Wellness Clinic experiences a recurrence of illness, he or she can be rapidly referred back to his or her previous higher acuity SMI Clinic.
III. Design and Methodology
Inclusion Criteria for Wellness Clinic:
1. Patient has demonstrated stabilization of symptoms and achievement of recovery goals for 1 year or greater.
2. Patient has been on the same medication regimen - meaning no new medications and no dose changes of existing medications - for 1 year or greater.
3. Patient has a stable and viable source of income.
4. Patient has a stable and viable social support system.
5. If the patient has a history of substance use disorder within the past 5 years, he or she must be actively engaged in substance use treatment.
6. Patient has demonstrated good communication skills e.g. will contact his or her treating therapist or psychiatrist if not doing well.
7. The decision to refer the patient to Wellness has been discussed and agreed on by the treatment team, which may include a therapist, case manager, psychiatrist, and their supervisors.
Exclusion Criteria for Wellness Clinic:
1. Patient has been hospitalized (psychiatrically) within the past 2 years.
2. Patient has visited the psychiatric emergency room within the past 1 year.
3. Patient has experienced active suicidal or active homicidal ideation within the past 1 year.
4. Patient has been homeless – secondary to his or her mental illness – within the past 6 months.
5. Patient is prescribed multiple benzodiazepines or takes a benzodiazepine in combination with an opioid.
Monitoring and Treatment Protocol for Wellness Clinic:
1. The higher acuity SMI Treatment Team presents the patient to the Wellness Clinic Team at a weekly intake meeting.
2. If possible, the case manager attends the first patient’s first visit at the Wellness Clinic Team and has the primary responsibility for ensuring that the patient makes his or her first appointment.
3. The Wellness Clinic Team then begins Phase 1 of treatment, which consists of 2 to 5 visits with the Wellness prescriber (NP or MD) and the Wellness Clinic therapist to achieve the following transition goals:
4. If the patient completes Phase 1 of treatment, he or she then progresses to Phase 2 of treatment at the Wellness Clinic, which consists of longitudinal monitoring and recovery-oriented treatment:
Year 1:
Year 2:
Year 3:
IV. Proposed Analyses
To test Aim 1 above - that the Wellness Clinic will provide a lower intensity but equally effective level of care for stable patients with SMI – we can query our EMR to compare the following outcomes measures in this population 1 year prior to versus 1 year after the transition to the Wellness Clinic: a) rates of psychiatric hospitalization; b) rates of psychiatric ED/Crisis Visits; and c) rates of other adverse outcomes, including complete suicides, interpersonal violence and incarceration.
To test Aim 2 above - that the Wellness Clinic will increase access – we can a) compare the total number of new patients seen 1 year prior to versus 1 year after implementation of the Wellness Clinic; and b) time to first visit for newly referred patients with SMI 1 year prior to versus 1 year after implementation of the Wellness Clinic.
V. Significance
The results of this proof-of-concept study would enable us to evaluate the hypothesis that administrative intervention 1) to counteract the Hobbesian bias; and 2) to operationalize a stratified, recovery-oriented system of care may benefit both the patient and the system.
Date of Publication on http://www.opensourcepsychiatry.com on 09/02/17
The Hobbesian Bias: Can We Increase Access to Care?
I. Background & Rationale
Currently, many outpatient psychiatric clinics in the U.S. do not have the capacity to provide the type of access to care that we, as providers, would wish for our own patients, friends, or family members. Although demand (for healthcare) will likely always exceed supply, healthcare administrators can seek to correct the misalignment of incentives between clinical providers and system demands, which manifests as a phenomenon I am calling here, the Hobbesian bias, after the famous philosopher, Thomas Hobbes (5 April 1588 – 4 December 1679), who underscored the natural human tendency to act self-servingly.
In a healthcare context, the Hobbesian bias describes our natural tendency to gravitate toward working with patients, who respond to treatment, and away from patients, who do not respond, and, who may also have behaviors (e.g. substance use) and traits (e.g. Cluster B) that interfere with treatment. Operationally this bias translates into a natural tendency for medical providers to schedule patients we like working with for return visits more frequently than may be clinically indicated and to schedule patients we dislike and/or who frustrate our efforts to treat them effectively less frequently than may be clinically indicated. For example, I may ask one of my “success-patients,” who suffers from schizophrenia but has now had a remission of positive psychotic symptoms on 4 mg of risperidone monotherapy for 10 years, to return to clinic every 3 to 6 months rather than every year. Assuming this patient has good communication skills and will contact me if he’s having difficulty, my scheduling decision would have the following negative consequences:
- For the patient, it would contribute to his or her dependence on me and take away from the autonomy he has achieved through the recovery process;
- For the system, the difference between scheduling 1 patient every 6 months versus every 12-months has a profound impact on access to care. For example, if 100 clinicians with 100 “success-story” patients schedule these patients for 2 visits per year rather than 1, the system loses 10,000 potential access appointments for new patients or 5,000 appointments if we factor in a 60 minute intake rather than a 30 minute follow up time slot.
To counteract the Hobbesian bias, administrators can take a recovery-oriented approach to stratifying levels of care and create a “Wellness Clinic,” which correlates patient severity with the appropriate duration of follow up frequency.
II. Specific Aims
1. To transition clinically appropriate stable patients with severe mental illness (SMI) to a lower level of care (=the Wellness Clinic);
2. To increase access to care for newly referred patients with SMI;
3. To create system fluidity through bidirectional referral pathways between the Wellness Clinic and higher acuity SMI Clinics; if a patient in the Wellness Clinic experiences a recurrence of illness, he or she can be rapidly referred back to his or her previous higher acuity SMI Clinic.
III. Design and Methodology
Inclusion Criteria for Wellness Clinic:
1. Patient has demonstrated stabilization of symptoms and achievement of recovery goals for 1 year or greater.
2. Patient has been on the same medication regimen - meaning no new medications and no dose changes of existing medications - for 1 year or greater.
3. Patient has a stable and viable source of income.
4. Patient has a stable and viable social support system.
5. If the patient has a history of substance use disorder within the past 5 years, he or she must be actively engaged in substance use treatment.
6. Patient has demonstrated good communication skills e.g. will contact his or her treating therapist or psychiatrist if not doing well.
7. The decision to refer the patient to Wellness has been discussed and agreed on by the treatment team, which may include a therapist, case manager, psychiatrist, and their supervisors.
Exclusion Criteria for Wellness Clinic:
1. Patient has been hospitalized (psychiatrically) within the past 2 years.
2. Patient has visited the psychiatric emergency room within the past 1 year.
3. Patient has experienced active suicidal or active homicidal ideation within the past 1 year.
4. Patient has been homeless – secondary to his or her mental illness – within the past 6 months.
5. Patient is prescribed multiple benzodiazepines or takes a benzodiazepine in combination with an opioid.
Monitoring and Treatment Protocol for Wellness Clinic:
1. The higher acuity SMI Treatment Team presents the patient to the Wellness Clinic Team at a weekly intake meeting.
2. If possible, the case manager attends the first patient’s first visit at the Wellness Clinic Team and has the primary responsibility for ensuring that the patient makes his or her first appointment.
3. The Wellness Clinic Team then begins Phase 1 of treatment, which consists of 2 to 5 visits with the Wellness prescriber (NP or MD) and the Wellness Clinic therapist to achieve the following transition goals:
- Further evaluation of the patient’s appropriateness for the Wellness Clinic and close monitoring for any decompensation triggered by the transition;
- Creation of a connection: the patient should feel known and cared for by his or her new team; the team should develop a good understanding of the patient’s history, level of recovery achieved, and the environmental and individual factors contributing to his or her wellness.
4. If the patient completes Phase 1 of treatment, he or she then progresses to Phase 2 of treatment at the Wellness Clinic, which consists of longitudinal monitoring and recovery-oriented treatment:
Year 1:
- 6 month to yearly visit with NP or MD + prn visits for illness roughening;
- Access to a weekly 1-hour drop-in group for medication management with the NP or MD;
- Appointments every 3 months with the therapist; these can be done by phone, telemedicine, or in-person based on the shared decision of the patient and Wellness Treatment Team.
Year 2:
- Yearly visit with NP or MD + prn visits for illness roughening;
- Access to a weekly 1-hour drop-in group for medication management with the NP or MD;
- Appointments every 6 months with the therapist.
Year 3:
- Same as year 2 except that visit frequency with the therapist can decrease to every 6 to 12 months.
IV. Proposed Analyses
To test Aim 1 above - that the Wellness Clinic will provide a lower intensity but equally effective level of care for stable patients with SMI – we can query our EMR to compare the following outcomes measures in this population 1 year prior to versus 1 year after the transition to the Wellness Clinic: a) rates of psychiatric hospitalization; b) rates of psychiatric ED/Crisis Visits; and c) rates of other adverse outcomes, including complete suicides, interpersonal violence and incarceration.
To test Aim 2 above - that the Wellness Clinic will increase access – we can a) compare the total number of new patients seen 1 year prior to versus 1 year after implementation of the Wellness Clinic; and b) time to first visit for newly referred patients with SMI 1 year prior to versus 1 year after implementation of the Wellness Clinic.
V. Significance
The results of this proof-of-concept study would enable us to evaluate the hypothesis that administrative intervention 1) to counteract the Hobbesian bias; and 2) to operationalize a stratified, recovery-oriented system of care may benefit both the patient and the system.