The Medical-Psychiatry Unit: The Moment Has Arrived

MPUA complexity intervention unit (CIU) is a specialized inpatient unit for managing patients with complex, comorbid medical and psychiatric diagnoses as well as health care system and social issues that make it challenging to deliver the highest quality health care. I still like to call it a “medical-psychiatry unit” (MPU) even though my old teacher, Dr. Roger Kathol, prefers “CIU”. You’ll find “CIU” all over his web site, Cartesian Solutions – Care Delivery Systems.

Roger G. Kathol, M.D., C.P.E.

Roger G. Kathol, M.D., C.P.E.

You will also find the term mentioned on the Academy of Psychosomatic Medicine (APM) web site, where it counts as  one of the most important interventions in the wave of the future of integrated care systems, Health Reform: Toolkit for Promoting PM. Dr. Kathol created the MPU here at The University of Iowa Hospitals and Clinics (UIHC) in the 1980s. It is highly respected and the most popular model we all point to as the best example of how to provide integrated care in a hospital setting. Hospital representatives from around the country and lately, from over seas as well, travel here to learn how to implement the MPU in their own systems. And it’s a great training setting for learners in the Medicine-Psychiatry Residency Program, Internal Medicine-Psychiatry Residency.

Just for fun, I did web searches for “complexity intervention unit”. Can you guess what I found at or near the top of the hit list, using Safari, Firefox, Google Chrome, and Bing? If you guessed my name, you guessed right. I prefer the name “MPU” to “CIU”, so I’m not sure why it looks like I’m the only one talking about it, according to the world-wide web.

I’ve also got a couple of YouTube videos about the MPU on my YouTube channel, James Amos – YouTube. You can see another video about it at link, Still Enthralled – The Practical Psychosomaticist. I worked as a co-attending on the MPU here at UIHC for about 17 years. I can tell you, in my opinion, it’s the best way to provide excellent clinical care to patients who have complex, comorbid psychiatric and medical problems.

The remarks above are to reinforce my support of the MPU, just in case anyone doubts that after I point out some of the practical challenges to making this square peg work in the round hole of our present health care delivery and payer systems. The MPU concept has always been ahead of its time. Many of us who have been in the trenches have known that. However, now could be the best time for patients, clinicians, insurers, and health care policy-makers to make the integrated care model the law of the land. There has never been a greater need for it when we consider the skyrocketing health care costs in America, compared to other nations.

Here are some of my thoughts about what might make the MPU more widely adaptable and readily adopted.

large_PayingforHealthInsuranceThe current payer system is at the top of the list of what needs to change. Practically speaking, depending on the physician’s specialty, insurers may bill only for a single medical problem per physician per day. In fact, in the model in which a doctor, board-certified in both internal medicine and psychiatry staffs the unit, psychiatry billers may not even submit a bill. In a co-attending model, a general psychiatrist may submit bills for managing the psychiatric disorder, while an internist bills for the medical side.  But in some academic medical centers, the internist need only co-sign a trainee’s notes. On the other hand, the psychiatrist must create notes for each and every patient on the unit, and on average the patient census can be 12 or more. If the fragmented, siloed billing and documentation practices could be replaced by a smarter system, this would attract more general psychiatrists to work in MPUs. This isn’t such a far-fetched notion these days, because there is a push to develop alternative payer systems in this age of research showing the effectiveness of integrated care systems that are population-based.

sleep deprivedThere can be a lot of wear and tear on physicians who must triage patients for admission to the MPU. It is unrealistic to expect combined-specialty physicians and general psychiatrists to do 24/7 call from 8:00 AM to 8:00 AM for weeks at a time. Methods to spread this responsibility around many physicians would go a long way toward improving quality of life for doctors, for whom burnout can be a reason to leave a practice. The task of triage cannot be relegated to trainees or nurses because of the extensive knowledge one must have about the medical, psychiatric, and legal issues involved in the admission process to a locked MPU. The organization of a rational triage system is currently being emphasized at UIHC, where the MPU has been championed for many years.

collaborating docsA close working relationship with all medical professionals who believe their patients might benefit from admission to an MPU is essential. Patients are candidates who have both acute, active medical and psychiatric problems and whose behaviors make it a potentially unsafe proposition for management on an open general medical or surgical unit. It can be unwise to admit patients who have little more than placement issues and who have chronic behavioral challenges that don’t require management on a locked unit. This would tend to fill beds, leaving none available for the patients who need them most. While delirium can be an appropriate indication for admission, not all patients who are delirious need an MPU. In fact, Delirium Prevention Programs run by teams of health care professionals, including a specialist in Psychosomatic Medicine, an internist or family medicine provider, clinical pharmacists, and nurses can help manage the problem of delirium in the general hospital. A Delirium Prevention Program has been in place since 2011 here at UIHC. You can read more about its growing pains at Delirium Project Chronicle – The Practical Psychosomaticist.

These are just some of my thoughts about the MPU, an idea that has always been ahead of its time… and now the time is right for it to truly fly.

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