By MARY-CATHERINE SEGOTA, Psy.D.

Reducing hospital readmissions is a national priority seeking to improve health outcomes and enhance care at lower costs. The transition from the hospital to the next care setting can be unsafe, inconsistent, rushed, confusing or ineffective. This point is where patients are the most vulnerable and failures cost most. Have you ever wondered why patients with the same general medical conditions can have vastly different outcomes? Every case is unique, and medical comorbidities complicate the picture, but more often than not, psychological and behavioral issues are overlooked when assessing readmission risk. From 2009 to 2011, about 21.7 percent of patients with psychiatric comorbidity went back to the hospital within 30 days of discharge, compared with 15.5 percent of those without such diagnoses, said Brian Ahmedany, PhD, LMSW, of the Center for Health Policy and Health Services Research at the Henry Ford Health System in Detroit in Psychiatric Services in Advance. One sure-fire way to impact readmission is to address underlying behavioral health factors that your patient is experiencing.

Behavioral Health factors that have a negative impact on medical outcomes include:

• Co-existing chronic psychological diagnoses such as depression, anxiety, and bipolar disorder
• Co-existing conditions such as substance abuse disorders or personality disorders
• Social isolation or lack of caregiver support
• Social Determinates such as economics, housing, and food instability

It is more important to know what sort of person has a disease than what sort of disease a person has….Hippocrates

Nearly all psychological conditions have physically manifested symptoms, and nearly all medical conditions are impacted by psychological conditions. It is important to understand how these factors interact with each other to ensure the most optimal outcomes.

How do psychological conditions directly affect outcomes?

An individual who experiences clinical depression may have difficulty with energy, sleep disturbance, and motivation. This may translate into medication irregularities, missed follow up appointments, and decreased physical activity, which will lead to exacerbation of their medical condition. An individual who experiences panic disorder may find it difficult to differentiate between an episode of panic vs. a cardiac event or COPD flare up, bringing them frequently back to the ER. An individual with a long-standing personality disorder may present with difficult interactions with medical staff, including confrontational dialogue, avoiding or denying personal accountability, or outright rejecting medical recommendations or treatment. An individual who becomes hypersensitive to their physiological symptoms may misinterpret sensations of normal healthy functioning and seek additional care or services. An individual who is disconnected from their psychological distress may present repeatedly with vague physical complaints, or shifting symptomology, making it difficult to identify any underlying medical condition, if one is present. An individual whose identity surrounds their illness, as compared to an individual who sees themselves as separate from and coping with an illness that does not define them, will be less likely to integrate behavioral change that will facilitate wellness and will reinforce behaviors that will maintain their ‘sick patient’ identity. It is important to remember that most people with behavioral health issues have never participated in therapy and have not developed coping skills to manage their symptomology. Additionally, people with behavioral health issues often lack insight into their illness making it worse.

As their clinician, what can you do?

• Assess the patient’s understanding of their own medical condition. (Ex. Does the patient understand what it means to have diabetes and what lifestyle modifications are necessary for survival?)
• Assess the patient’s appraisal of their medical condition. (“I will always be sick.” “I will only feel better when I am 100 percent pain free.”)
• Assess the patient’s need for community resources (food banks, shelter).
• Assess the patient’s existing coping skills (adaptive and active vs. passive and avoidant).
• Assess caregiver support (and caregiver burnout).
• Assess secondary gain and maintaining behavior. (Ex. “If I get better, I lose my disability benefits.” “If I get better my spouse won’t give me the love and attention I get now.”)
• Refer to mental health therapists that are trained in working with individuals with chronic medical and pain conditions.

Integrating mental and behavioral health treatment addresses those issues that are barriers to a positive treatment outcome. Targets for behavioral health interventions include:

Psychological symptom reduction

Active (vs passive) coping strategies

Adaptive (vs maladaptive) cognitive appraisals

Medication compliance

Improved sleep hygiene

Nutrition/eating compliance

Activity pacing

Adaptive appraisals about health and wellness.

Improved social support

Facilitating optimism

In the age of COVID, individuals with underlying psychological diagnoses are experiencing an exacerbation in symptoms due to extended isolation, financial hardship, and losses in multiple domains. While telehealth is an important tool, it does not entirely replace that which is provided by face to face visits. This means it is more important than ever to ensure that patient psychological, behavioral, and social issues are adequately identified either through thorough history taking or utilization of standardized inventories. By incorporating mental and behavioral health services with your patients, you will ensure that the symptoms that cause barriers to wellness behaviors and treatment adherence are identified and addressed, leading to a decrease in rapid rehospitalization rates and an improved outcome for your patients.

With a doctorate in clinical psychology and over 20 years of experience in the field, Dr. Segota has conducted university-based behavioral medicine research, acted as a consultant to professionals and organizations, and worked with a diverse number of psychological and medical conditions. By identifying unique needs, the source of distress, and what’s perpetuating the problem, she will help develop the tools to overcome seemingly insurmountable circumstances. She offers an environment where patients will become empowered and achieve maximum personal and professional growth, through therapy, testing, biofeedback, mediation, and coaching. Visit www.CounselingResourceServices.com