The number of psychiatric beds has declined precipitously in American over the past several decades. Some think that the decline is primarily due to insurance companies. Others blame Reagan and other politicians. I will discuss the multiple factors in another post. In part 1 of this series of articles, I shared how I learned what Critical Access Hospitals are and how earning that designation can save a hospital while reducing beds, including psychiatric beds. In part 2, I shared how budget and safety issues can force one to argue for a reduction in the number of psychiatric beds. Here, in part 3, I share a fictionalized version of multiple conversations that show how a system can decide not to increase the number of psychiatric beds and still provide excellent care.
2011
I am working at VA hospital, less 10 miles away from another VA, where I did part of my residency. I’ve been here for less than a year. But I have already observed a bunch of differences between where I trained. I decide to speak to the Chief of Psychiatry about it at the next opportunity I get. I make a brief appointment to talk to him.
“How come the other VA has twice as many psychiatric beds as we do?” I ask.
“Let me tell you how that came about,” replies the Chief, adding, “When I first took this role of Chief of Psychiatry, the director of the hospital called me. She asked me to write up a proposal for doubling the number of psychiatric beds to address the increased demand for services as a result of the influx of Iraq war veterans into the VA system. I failed.”
“What do you mean, you failed? You are still here. You are well respected.”
“What I mean is that I didn’t just write the proposal she asked me to. Instead, I prepared a different proposal. I calculated the cost of creating a new psychiatric unit with the necessary safety features. I estimated the cost of appropriately staffing it 24 hours a day, 7 days a week, year after year. Then I wrote an alternate proposal showing that for the same annual operating cost, we could more than quadruple our total outpatient psychiatric staff. I convinced the director that that is the route to go. It is due to this that we have one of the largest contingents of outpatient mental health staff of any VAs. And it is partially because of that that we have one of the lower veteran suicide rates across the VA system.”
“Looks like you have achieved what deinstitutionalization was supposed to do nationally — reduce beds while providing robust outpatient services.”
“Yes. I always thought that at a national level, we had failed to realize the promise of deinstitutionalization due to a lack of sustained, robust funding for outpatient care. I wanted to avoid that for our veterans.”
“Don’t you feel nervous that this funding could be easily cut. It’s a lot easier to reduce outpatient services rather than closing inpatient units. I learned that at my last job.”
“That’s true. That was also part of the reason that I didn’t want another inpatient unit. It does place a greater responsibility on me to defend adequate funding for outpatient services constantly. But I am prepared to make that case every single day rather than support increasing inpatient beds.”
“We are lucky to have someone like you as chief,” I say. I thank the boss for his insights and leave to see my next patient.
