The healthcare issue addressed at Bergen New Bridge Medical Center Paramus, NJ (BNBMC) entails timely access to aftercare either in telepsychiatric partial hospitalization, (PHP) intensive outpatient (IOP), or outpatient (OP) level of care. The Accountable Care Act (ACAs’) focus on increasing and improving healthcare systems remains an issue at BNBMC (Broom & Marshall, 2021). The ACA goal for healthcare in the United States to enhance healthcare access to health rather than disease is germane to expanding resource availability. PHP, IOP, and OP remain limited at BNBMC. PHP evaluations are only available Monday, Wednesday, and Friday. Therefore, a request to expand available PHP appointments to more than three and IOP and OP appointments for evaluations to more than two per week. The inadequacy puts patients at high risk for relapse after leaving the emergency department and in need of inpatient hospitalization.
The leadership proposal is to expand virtual appointments for evaluations for all outpatient levels of care mentioned as needed. Furthermore, the request is for hiring additional staff to accommodate the need for timely appointments to evaluate and have patients begin treatment within the same week they have presented to the emergency department due to a psychiatric crisis. Moreover, the purpose of this paper is to demonstrate the benefits of telepsychiatry in outpatient levels of care, such a PHP and IOP (Hom et al., 2020). Not only is this modality of treatment a viable form of follow-up treatment but, it enhances the provision of care well beyond the COVID-19 pandemic as a quality and effective level of care that improves outcomes (Hom et al., 2020). Additionally, the paper’s purpose encompasses supporting the achievement of the Quadruple Aims goals of making healthcare more accessible as telepsychiatry does without the need to commute and decreasing cancellations or no-shows (Broom & Marshall, 2021). Besides, telepsychiatry care is more affordable for patients by diminishing the cost of the commute and time away from work or family (Broom & Marshall, 2021). Improvement in quality of care is supported by providing a view into the patients’ home environment and how it translates into patients’ behaviors, therefore giving substance to accurate treatment planning (Broom & Marshall, 2021). Lastly, creating flexibility for the clinicians to work around their home responsibilities achieves improved work-life balance addressing the fourth aim (Boom & Marshall, 2021). A review of two recent studies regarding the effectiveness of virtual psychiatric care will follow.
Efficacy and Effectiveness to Expand use of telepsychiatry
A broad study of literature found the COVID-19 pandemic has initiated extraordinary
healthcare system adjustments benefiting psychiatric care for one through telepsychiatry (Chen
et al., 2020). The pandemic propelled insurance payment for telepsychiatry by reducing
regulations previously prohibiting the same (Chen et al., 2020). The research findings show
effectiveness, and at times telepsychiatry demonstrates above-average benefits than in-person
psychiatric treatment (Chen et al., 2020). Again, psychotherapists and psychiatric clinicians note
the advantage of seeing a glimpse into the patients’ lives while in their home environment
through virtual treatment connections (Chen et al., 2020). Psychiatric clinician reviews of their’
experience of conducting telepsychiatry provide communication to the leadership of additional
needs to effectively provide care (Chen et al., 2020). Some of those needs include additional
supervision, support and validation, and ongoing research on telepsychiatry care (Chen et al.,
2020). Furthermore, advocacy for the expansion of additional outpatient providers to be hired in
psychiatry to comply with enhancing healthcare access to focus on health rather than disease is
pertinent to expanding resource availability at BNBMC.
Efficacy and Effectiveness to Expand use of telepsychiatry
Transition from in-person to psychiatry’s virtual format during the COVID-19 pandemic came as a thrust upon the healthcare community. The experience has demonstrated the capability of healthcare services to be creative and resilient. Once considered limited out of necessity in remote locations has become the dominant form of outpatient psychiatric treatment. One facility readily adapted to the development of a virtual psychiatric PHP of patients and clinical staff. Clinical staffs’ creation of protocols for evaluation with the inpatient clinical team to determine patient appropriateness for virtual PHP became routine (Hom et al., 2020). Based on a basic assessment of the patients’ capability to use a smartphone or iPad, focusing and engaging mentally and emotionally came first. Confirmation that the patient had established an outpatient therapist and psychiatric clinician was necessary for the patients’ emergency needs during off-hours (Hom et al., 2020). Patients accepted into the PHP were given an orientation while still inpatient to accessing the virtual environment in addition to a packet of written orientation material with a schedule (Hom et al., 2020).
Gathering treatment outcome data and patients’ evaluations to determine the effectiveness of this essential modality of treatment will further inform of overall strengths and feasibility to continue virtual PHP, IOP, and outpatient treatment post-COVID-10 pandemic (Hom et al., 2020). These activities will serve well to inform leadership and the payor sources of the same. Again, the need to expand virtual psychiatry is at hand to accommodate those patients in need who may otherwise fall through the cracks when discharged without a follow-up plan.
National Healthcare Strategy Issues/Stressors Impact
The national healthcare issue of COVID-19, while striving to reach the ACA focus to increase and improve healthcare systems, remains an issue at BNBMC. The problem existing at BNBMC to accommodate patients discharged from the emergency department with a timely appointment in PHP, IOP, or OP levels of care requires attention. The experience of lack of timely follow-up appointments in virtual psychiatric PHP and IOP within seven days of inpatient psychiatric hospitalization discharge is often inadequate for those who meet the criteria.
The psychiatry department at Massachusetts General Hospital identified the massive issue encountered of limited technological capacity with the existing platform concerning the enormous demand for telepsychiatry in March 2020 at the beginning of the COVID-19 pandemic (Chen et al., 2020). The leadership approved the transition to the use of phone calls and commercial platforms such as doxy.me, Doximity, and Zoom (Chen et al., 2020). The psychiatric department outpatient had a 22% hike in productivity (Chen et al., 2020). BNBMC has kept virtual telepsychiatry at a level they can manage. Increasing capacity to manage the number of patients in the population needed through creative measures such as done at Massachusetts General Hospital.
BNBMC does need to expand its ability to accommodate a more significant number of patients with telepsychiatry. There could be financial restraints due to the pandemic.
The hospital inpatient census has been decreased by not admitting as many patients as usual to minimize exposure to COVID-19 during the second wave. McClean Hospital / Harvard Medical School Belmont, Massachusetts remark on the need to explore the continuation of virtual PHP in the long-term concerning onboarding new staff (Hom et al., 2020). Historically new clinicians shadowed seasoned clinical staff (Hom et al., 2020). New procedures developed to accommodate the training of new staff creation began. Similar procedures are needed by having new clinical staff observe and eventually conduct groups with the observation by supervising them.
BNBMC has been letting staff go due to decreased census since the pandemic’s first wave. Lockdowns have impacted canceled elective surgery, fewer emergency trauma hospitalizations, and some illnesses. When the pandemic is under control, the determination of the expansion of telepsychiatry continuing will influence expansion.
Competing needs for patient follow-up appointments and facilities challenges remain.
BNBMC has heeded the need to implement telepsychiatry since the beginning of the COVID-19 pandemic, much like most facilities nationally and internationally. The use of telepsychiatry has seen an astounding increase of 4347% since the COVID-19 pandemic began, per data (Mahmoud et al., 2020). The stunning increase in implementation has come with challenges related to facilities’ ability to effectively implement the service (Mahmoud et al., 2020). Reports of challenges need thorough documentation to develop improved planning and implementation of telepsychiatry programs (Mohmoud, 2020). BNBMC historically has been a county psychiatric hospital serving the disadvantaged individuals in the community. They often treat patients such as homeless, jobless, and without benefits. The state does supplement the facility for treating these patients. Just the same revenue is less than ideal for implementing progressive programs such as telepsychiatry’s technical needs. Furthermore, indigent patients do not all have a smartphone and are so compromised with dual diagnosis’ thus creating barriers that are difficult to bridge even with the advantages of use of technology. Psychiatric care is poorly funded compared to medical/surgical care.
The challenges noted for BNBMC are one side of the coin. On the flip side is the potential for improving care for this population with telepsychiatry availability. Advantages mentioned previously include ease of access with supported smartphone provision. In Chicago, Illinois, The Josselyn Center, a community mental health center, deal with similar problems due to treating those who have insurance coverage and those who can not afford to pay (Mahmoud et al., 2020). They too suffer from shortages in staff and psychiatric prescribers due to limited funding to hire (Mahmoud et al., 2020). An additional challenge is finding psychiatric providers willing to work in community mental health centers due to having the choice of working in private practice in the suburbs (Mahmoud et al., 2020).
Policy and practice
The advent of a crisis in this century of such magnitude has created transformation at a speed not considered viable pre-COVID-19 (Sinsky & Linzer, 2020). Regulators and payors approved at record speed needed for the trade-off between costs and benefits to implement telepsychiatry and telehealth (Sinsky & Linzer, 2020). Practice and policy got temporarily implemented with the experience of informing all stakeholders of the actual benefits outweighing the drawbacks seen and some encountered (Sinsky & Linzer, 2020). The experience has brought to light the significance of protecting health care professionals’ work-life, cognitive capacity, and emotional resilience capacity for caring for patients (Sinsky & Linzer, 2020). Alternatively, instead of utilizing resources on unnecessary tasks and technology better spent on practices and policies recreated through a revolution out of need (Sinksy & Linzer, 2020). Note, through changes in practice and policy during the COVID-19 pandemic it is postulated they continue post-pandemic with the resulting improvement in reduction of administrative burden, while simultaneously improving care, thus furthering achievement of the Quadruple Aim (Sinksy & Linzer, 2020). BNBMC practice and policy got replaced with a hybrid form of psychiatric PHP according to their ability to function with the resources. They have made progress simply by making the transition to telepsychiatry. Transition to predominantly telepsychiatry will take time to achieve. PHP psychiatric residents are at the beginning of the learning process of becoming a clinician. Confidence will need to be built with safety and development of effectiveness in a beginner to handle treating this psychiatric population. Another challenge noted is multicultural clientele and novice clinicians, perhaps further conflicting with the teaching facilities’ full transition to telepsychiatry.
Critique of the policy for ethical considerations
BNBMCs’ policy to limit the number of psychiatric PHP openings available does indicate an adherence to a policy based on an ethical principle. Nurses recognize ethical awareness at BNBMC who have experienced the patient population (Milliken, 2018). BNBMC psychiatric PHP accepts the number of patients they can realistically handle based on the number of experienced clinicians available. Fundamentally, the nurses in PHP psychiatric hospitalization are equipped to manage a limited number of patients. The patients treated at BNBMC often have violent history towards themselves and or others. Patients need to have support on off hours from the treatment day. That includes a therapist and psychiatric prescriber. These patients often do not have established providers, and newly assigned providers often would not commit to patient responsibility where there is no therapeutic relationship established. The ethical implications for nurses, outpatient clinicians, and psychiatric prescribers are high risk, therefore, understandable (Miliken, 2018). The policy to limit the number of psychiatric PHP patient acceptances is valid with a critique of the policy at BNBMC.
Recommended policy/practice changes
BNBMC policy of limiting the number of telepsychiatry PHP evaluations and admissions from the emergency department needs explanation. A recommended change in policy is monthly communication on exactly what the reasons are for limited admissions. The nursing and social work discharge planners are left in the dark to speculate on reasons for referrals only accepted Monday, Wednesday, and Friday. Seamless care delivery requires transparency (Broome & Marshall, 2021). Teamwork in the emergency department would prosper with coordination between the psychiatric outpatient departments and the state of affairs explained weekly (Broome & Marshall, 2021). An integrated care model’s advantages can improve outcomes and reduce unnecessary conflicts between team members, spoken and unspoken (Broome & Marshall, 2021). Understanding the issues care management run into from limiting the search for an appropriate alternative telepsychiatry PHP is needed. Wasted time and angst diminish, accomplishing improved patient care and care management success with knowledge of the facts.
Ethical issues can apply to accessing the appropriate care level to offer the patient before discharging the patient (Milliken, 2018). To assist the patient in obtaining care recommended and accepted, the nurse care manager needs to know what options are available. Maintaining updated knowledge of the psychiatric outpatient departments’ availability of telepsychiatry PHP and outpatient care appointments allows the nurse care manager to uphold the ethical duty to diligently locate the next available appointment elsewhere without delay or be at risk of loss of accommodations for the patient.
In conclusion, this paper reviewed the unexplained limited telepsychiatry PHP appointment availability for discharge planning from the emergency department at BNBMC. The Quadruple Aim of providing access to the care needed and managing healthcare costs would decrease the risk of relapse, and re-admit to an inpatient level of care is noted (Broome & Marshall, 2021). The patient’s maintenance in the healthcare system stepped down, allowing for continued accurate information flow in the electronic health record (Broom & Marshall, 2021). Organized teamwork with transparent communication of affairs between departments diminishes burn out of healthcare workers (Broome & Marshall, 2021). Notation of the rapid transformation of healthcare during the COVID-19 pandemic with the creation of telepsychiatry and telehealth for outpatient levels of care. Analysis of telepsychiatry’s benefits and the challenges encountered with suggestions for policy change to facilitate improved telepsychiatry functioning in the outpatient level of care.
Broome, M., & Marshall, E. S. (2021). Transformational leadership in nursing: From ex-
pert clinician to influential leader (3rd ed.). New York, NY: Springer.
Chen, J. A., Chung, W. J., Young, S. K., Tuttle, M. C., Collins, M. B., Darghouth, S. L.,
Longley, R., Huffman, J. C., Razafsha, M., Kerner, J. C., Wozniak, J. & Huffman, J. C. (2020). COVID-19 and telepsychiatry: Early outpatient experiences and implications for the future, 66, General Hospital Psychiatry. www.elsevier.com/locate/genhospsych.
Hom, M. A., Weiss, R. B., Millman Z. B., Christensen, K., Lewis, E. J., Cho, S., Yoon, N. A.,
Meyer, J. D., Shavit, E., Schrock, M. D., Levendusky, P. G. & Bjorgvinsson, T. Development of Virtual Partial Hospital Program for an Acute Psychiatric Population: Lessons Learned and Future Directions for Telepsychiatry, 30(2), Journal of Psychotherapy Integration. http://dx.doi.org/10.1037/int0000212
Mahmoud, H., Naal, N., & Cerda, S. (2020). Planning and Implementing Telepsychiatry in a
Community Mental Health Setting: A Case Study Report, Community Mental Health
Miliken, A. (2018). Ethical Awareness: What it is and why it matters. OJIN: Online
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Schnurr, P. P. (2020). Virtual Mental Health Care in the Veterans Health Administration’s Immediate Response to Coronavirus Disease-19, American Psychologist, Online First Publication, American Psychological Association. http://dx.doi.org/10.1037/amp0000751
Sinsky, C. & Linzer, M. (2020). Practice And, Policy Reset Post-COVID-19: Reversion,
Transition or Transformation? Health Affairs, 39(8), COVID-19, HOME HEALTH &
Assignment: Developing Organizational Policies and Practices
Competing needs arise within any organization as employees seek to meet their targets and leaders seek to meet company goals. As a leader, successful management of these goals requires establishing priorities and allocating resources accordingly.
Within a healthcare setting, the needs of the workforce, resources, and patients are often in conflict. Mandatory overtime, implementation of staffing ratios, use of unlicensed assisting personnel, and employer reductions of education benefits are examples of practices that might lead to conflicting needs in practice.
Leaders can contribute to both the problem and the solution through policies, action, and inaction. In this Assignment, you will further develop the white paper you began work on in Module 1 by addressing competing needs within your organization.
Review the national healthcare issue/stressor you examined in your Assignment for Module 1, and review the analysis of the healthcare issue/stressor you selected.
Identify and review two evidence-based scholarly resources that focus on proposed policies/practices to apply to your selected healthcare issue/stressor.
Reflect on the feedback you received from your colleagues on your Discussion post regarding competing needs.
The Assignment (4-5 pages):
Developing Organizational Policies and Practices
Add a section to the paper you submitted in Module 1. The new section should address the following:
Identify and describe at least two competing needs impacting your selected healthcare issue/stressor.
Describe a relevant policy or practice in your organization that may influence your selected healthcare issue/stressor.
Critique the policy for ethical considerations, and explain the policy’s strengths and challenges in promoting ethics.
Recommend one or more policy or practice changes designed to balance the competing needs of resources, workers, and patients, while addressing any ethical shortcomings of the existing policies. Be specific and provide examples.
Cite evidence that informs the healthcare issue/stressor and/or the policies, and provide two scholarly resources in support of your policy or practice recommendations.
Due to the nature of this assignment, your instructor may require more than 7 days to provide you with quality feedback.
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