Running head: MENTAL HEALTH CARE DELIVERY SYSTEM

Care Delivery Systems in Mental Health Settings

Halea Dardin and Anna Jarvis
Auburn University School of Nursing

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Abstract
Healthcare in the United States is known to be one of the most expensive and it is quickly
becoming unsustainable for hospitals to charge large sums for admission and treatment without
eventually being reimbursed. The care delivery system of Crossbridge Behavioral Health Center
in Montgomery, Alabama was assessed to determine overall cost and sustainability in the
delivery of psychiatric health care. A focused case study was implemented for a patient at
Crossbridge Behavioral Health Center to evaluate the patients care received throughout his
stay. This patient was receiving care for multiple mental health diagnoses including depression,
anxiety, and suicidal ideations. The care delivery system in place follows an integrated model of
care and covers a wide variety of services. By evaluating the care received and examining
interprofessional teamwork, medication administration, and therapy received, although costly,
the care delivery system at Crossbridge was shown to be effective in the care of this patient.
Keywords: care-delivery system, mental health, hospital expenses, interprofessional team

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Care Delivery Systems in Mental Health Settings

A critical component of achieving strong quality of care and positive patient experience is a care
delivery system that facilitates exemplary care. An integrated health care system addresses
multiple needs and services for patients and allows health-care providers to work together to
offer the best care for their patients. Oftentimes, however, exemplary care comes at a great cost
in order to ensure these quality services. The purpose of this paper is to examine and define the
current state of the care delivery system at Crossbridge Behavioral Health Center, to provide a
focused case study of a patient at Crossbridge, to evaluate the care received, and to describe the
cost of care for this specific care delivery system.
Care Delivery System Description
Current State of Care Delivery System
The current state of the mental health care delivery systems in the U.S. involves an
integrated behavioral health care system that covers a wide variety of services. An integrative
health care system focuses more on coordinated health care in which health care providers work
together to treat the whole patient. These mental health systems are usually delivered in
multidisciplinary teams within inpatient and outpatient settings (Carlyle, Crowe, & Deering,
2012).
Within mental health facilities, health care providers include physicians, registered
nurses, psychologists, psychiatrists, mental health therapists, social workers, recreational
therapists, counselors, and case managers, among others. According to Sundararaman (2009),
commonly used services range from family and marital counseling to treatment of severe mental
health conditions like bipolar disorder and Alzheimer's disease. In 2007, about 23.7 million
adults in the United States were affected by psychological distress, such as anxiety and mood

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disorders, which resulted in impairment of activities of daily living (Sundararaman,

2009). Mental health disorders are frequently caused and/or exacerbated by underlying health
conditions and patients are often affected by more than one mental illness at a time. Therefore,
the integrated system is beneficial in treating the medical diagnoses as well as the mental health
issues. It is the role of health care providers to work together in order to determine if the mental
illness is related to a coexisting medical problem and to create a plan of care specific to the
patients mental health.
Mental health diagnoses vary in the types of disorders and occur in men and women of all
ages. The most common disorders diagnosed in adults include substance abuse disorders,
anxiety disorders, depression, eating disorders, bipolar disorder, schizophrenia, and
posttraumatic stress disorder. Other types of disorders that may begin in childhood include
developmental disorders, such as autism spectrum disorder, attention deficit disorders, and
Tourettes disorder, and personality disorders such as borderline personality disorder or
obsessive-compulsive disorder. These disorders are treated using various methods including
medications, group therapies, individual therapies, cognitive therapies, etc.
Current Issues and Concerns of this Care Delivery System
In the United States, access to health care and inadequate allocation of resources
continues to be an issue, but improved telecommunication has increased availability to patients
in rural areas. Although literature has shown there are many benefits and effective outcomes
from delivering mental health care using technology such as videoconferencing, health care
providers must be aware of the safety concerns when using this technology (Kramer, Kinn, &
Mishkind, 2014). Tele-malpractice and proper licensing is a concern for patients and providers
alike.

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Quality of care can also be affected by underlying stigmas and discrimination among the
health care providers in regard to mental health. Many mental health disorders are not fully
understood by providers and this can result in inappropriate care delivery and treatment.
In addition to safety concerns and confidentiality, insurance coverage can become an
issue for patients seeking mental health services. Private insurance accounts for most mental
health services (Sundararaman, 2009), but often does not cover as generously as it does for
physical illnesses. Problems facing patients regarding insurance coverage includes non-coverage
of mental illnesses, higher co-pays, and lower treatment limits. Because many patients with
mental health disorders will require lifetime management of their disease, it becomes a major
issue for patients once their insurance expires. According to Sundararaman (2009), state and
local government funding for mental health care is second to federal funding, and state and
county-funded services are often a safety net for those who are unable to access or afford
private mental health services. The need for such varying health care services for mental health
can also create limitations for the quality of care. For example, the patient with schizophrenia
will need much different care and treatment than the patient with an eating disorder. The vast
range of disorders and mental illnesses makes it nearly impossible to have enough services to
address each persons illness, in addition to being accessible to all populations.
As stated earlier, integrative services are the most beneficial when addressing mental
health needs, but in many cases, individual services are the ones most easily accessed. Primary
care settings are most frequently used and case management is a significant resource that these
facilities can deliver. Case managers can assist patients to ensure they are receiving what they
need, and not receiving or paying for things that are not necessary for their mental
illness. Medicare programs use the Healthcare Effectiveness Data and Information Set (HEDIS)

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to measure mental health quality of care (Sundararaman, 2009). HEDIS measures factors such
as medication management for anti-depressants, follow-ups after hospitalization, and utilization
of health care services.
Provision of Care
As the mental health care delivery system is very broad and encompasses different
methods of treatment and care, nurses take on many roles. In a study by Carlyle et al. (2012),
nurses in outpatient settings were more likely to participate in interpersonal models of care,
which focus on the therapeutic nurse-patient relationships, while nurses in inpatient settings were
more likely to follow medical models. This study also found that nurses work involved
counseling, medication administration, patient education about their specific illness and needs,
family education, maintaining a safe environment, and assisting the psychiatrist or physician by
assembling clinical information and data.
The interdisciplinary team plays an important role when determining the plan of care for
mental health patients. The healthcare providers are responsible for different aspects of patients
care. As the nurse assists the physicians and psychiatrists, it may be the physicians job to
address coexisting medical issues while the social worker or psychiatrist addresses emotional and
mental status. The health care providers must then work together to diagnose, prescribe
medications, and create a plan of care of which all will work to implement with the patient. In
order to best treat the mental health patient, interprofessional teamwork is extremely
important. Interprofessional teamwork requires trust, respect, and good communication, and if
executed properly, will allow the team to properly diagnose and treat their patients with the best
possible patient outcomes.
Focused Case Study

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Overview of Patient Care

A case study for a male patient was implemented to analyze the care delivery system
received at Crossbridge Behavioral Health Center. The patient in this study was YT, a 29-yearold, African American male. The patient arrived at Baptist South Emergency Room via
ambulance on September 13, 2015 with suicidal ideations related to crack use, requesting
detox, and stated that he had been noncompliant with medications and drug abuse. The patient
was then transferred to Crossbridge Behavioral Health Center the following day. The patient
stated that he punched a window one week prior and lacerated a finger on his right hand. The
patient had a history of depression, anxiety, and irritability, and has had previous admissions
with similar presentations. On this admission, he presented with typical post cocaine dysphoria,
psychiatric problems and was threatening suicide while in the ER. He stated that the onset was
three days ago after losing his job as a factory worker and that his symptoms were
worsening. YT had a history of physical abuse from his mother, stating that she beat me
unnecessarily as a child, as well as a history of smoking, polysubstance abuse, and criminal
activity with pending charges for a string of burglaries to support himself. The patient had no
living will and family history of mental illness was unknown.
The medical diagnosis for patient YT included depression related to drug use, cocaine
dependence, cocaine induced dysphoria, and injury to right hand and fingers. There was no
evidence of drug induced psychosis, meningitis, encephalitis, sepsis, withdrawal symptoms,
electrolyte disturbances, CVA/TIA, seizure, traumatic brain injury, or hypoxemia. Associated
diagnoses included feeling suicidal, depression, drug abuse, and hand contusion. Labs were
drawn and results were as follows (abnormals only): positive for cocaine, Acetaminophen: < 2.0
ug/ml (L), Salicylate: < 1.7 mg/dl (L), Glucose: 127 mg/dl and Urobilinogen: 1.0 e.u/dl, with all

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other lab results within normal limits.

During this admission the treatment plan at Crossbridge was to administer Trazadone for
sleep, anticipate quick crisis intervention, and to follow up with CAPs, a long term care
facility. Long term goals for the patient included patient will verbalize understanding of
diagnosis, symptoms of relapse, and management of illness, patient has a safe living place to be
discharged, patient and significant people can utilize community mental health resources, patient
agrees to follow up care, and patient agrees to stay compliant with medications at
discharge. While at Crossbridge, YT was administered Trazadone, 100 mg once per evening
for sleep, Acetaminophen, 500 mg every six hours for mild to moderate pain, Maalox, 30 ml
every four hours for heartburn, Benzocaine (Orajel), every four hours for mouth sores, as well as
Chapstick, Benadryl, 500 mg, and Haldol, 5 mg as needed.
On the patients first day at Crossbridge, the patient sat in the day room with other
patients and reported auditory hallucinations. On his second day, YT sat in the day room,
interacted appropriately, and denied hallucinations or suicidal ideations. On day three, he sat in
the day room, was pleasant to speak with, denied suicidal ideations, but said he was hearing
voices again at this time. During his time at Crossbridge, YT attended community meetings,
nursing group, wrap-up group, and recreational group. However, he did not attend therapy
group. Health promotion and disease management teaching needs for YT included teaching him
the effects of drug abuse on his body and teaching him the dangerous adverse effects of drugs
such as cocaine. Other teaching should include the importance of medication compliance and
offering alternatives and help for substance abuse such as stress management techniques and
support groups such as Alcoholics Anonymous.
It was determined that stress played a big role in YTs life as he struggled with financial

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issues, the ability to parent, irritability, impulse control, and restlessness. Teaching topics for YT
included focusing on his strengths, using available personal support such as his mother,
girlfriend, church friends and family, continuing to support his 5 year old daughter, and
accessing support groups available in his area. An article by Pacic-Turk and Boskovic (2011)
addresses the role of health promotion and addiction prevention and supports the idea that
substance abuse health promotion should focus on activities aimed at increasing self respect and
positive self image development in addition to making good, drug free decisions. By changing
his personal attitude towards himself, YT can also change his attitude towards drugs. Patient and
family goals after discharge for YT were to get a job, to stop drug use and to detox, to remain
compliant with medications, and for the patient to be sent to a long term care facility for
continuing support and treatment.
Evaluation of Care
The care received by this patient as Crossbridge was typical, as it mainly involved
medication administration and group therapy. However, the health care providers did
communicate well as they worked as an interprofessional team in order to foster collaboration
and improve quality of care for the patients. The interprofessional team approach improves
clinical outcomes, health care processes, and patient satisfaction (Youngwerth & Twaddle,
2011). The interdisciplinary team at Crossbridge communicated well as they met and discussed
the patients while addressing various assessments, outcomes, and patient needs from their
perspectives. In the case of YT, the physician, RNs, therapists, and case manager each played a
big role. They collaborated while addressing medication needs and the best long-term care
options. In a study by Bajnok, Puddester, Macdonald, Archibald, and Kuhl (2012), health care
provider participants said they were able to offer better patient care as a result of their

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involvement in the project and were able to have a better understanding of everyones roles on
the team.
While medication administration was a major part of YTs treatment, the RNs also
addressed his personal concerns and desires for future treatment. A therapist also addressed
emotional issues in order to encourage health promotion and improve YTs overwhelming
feelings regarding his situation and his substance abuse. After being discharged from
Crossbridge, YT will need a strong support system as he has experienced similar circumstances
and events before and his previous treatment had not been successful. During this admission, he
stated that he wants to change and wants to detox, therefore it is likely that he will meet the
expected outcomes, as he is invested in making a change. Crossbridge was in contact with a
long-term facility, CAP, and he is planning to attend this facility. In the case of YT, this care
delivery system was effective in treating his acute illness and coordinating care for him in the
future in order to promote a healthy, drug free lifestyle.
Cost of Care
General Costs of Care
Where mental health may lack in accessibility and standardization of care, it is certainly
made up for in length of stay. One study showed that the typical number of days of
hospitalization for a psychiatric patient can range from 1 to 85 days, with a mean of 15 days and
median of 12 days. Primary reasons for hospitalization in the first week included potential risks
to self or others; in the second week: logistic reasons such as lack of social and family support,
lack of accommodation, negotiation with community team, and other practical difficulties
interfering with discharge were the reasons for continuation of hospitalization. Following the
fourth week, the main reason for continuation of inpatient treatment was compliance issues

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(Zhang, 2011).
Whether admitted for a few days or a few weeks, the cost of admission, labs,
medications, therapy, and room is extraordinary. According to a report by the Washington
Business Journal, the average cost of one nights hospital stay in the U.S. is $4,293 (Reed,
2014). Reinhardt, Hussey and Anderson (2004) from Health Affairs state that U.S. health
spending towers over that of other countries with much older populations and prominent
among the reasons are higher U.S. per capita gross domestic product as well as a highly complex
and fragmented payment system that weakens the demand side of the health sector and entails
high administrative costs.
Depending on an individuals current financial and insurance status, care is covered outof-pocket, through private insurance, Medicaid or Medicare. To qualify for Medicare, an
individual must be 65 or older, or disabled (Medicare, 2014). Medicaid provides health coverage
to children, pregnant women, parents, seniors and individuals with disabilities. Criteria for
eligibility are set by each state (Medicaid, 2014).
Despite nearly 90% of Americans being covered by some form of medical insurance,
there is still a large number, around 32 million people, who are uninsured. A report by the U.S.
Department of Health and Human Services concluded that on average, uninsured families can
only afford to pay in full for approximately 12% of hospital stays they may experience. Every
year, nearly two million uninsured Americans are hospitalized, and 58% of these hospital stays
result in bills more than $10,000 (Most Without Insurance Do Not Pay Hospital Bills: Federal
Report, 2011).
Hospitals typically only see approximately a ten percent reimbursement for their charges,
leading to the question what happens to the other 90% of the bill? Hospitals often end up

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auditing bills and absorbing the cost of visits that are not paid. In turn, when the hospital absorbs
these additional costs, they have to raise the prices of care for other patients to ensure that they
continue to stay in business. Higher prices for medical care then translate to higher insurance
costs for those who do have insurance.
The majority of costs in treating psychiatric patients in the inpatient setting include the
basic cost of a room, along with a sequence of psychiatric medications and therapy. As far as
medication is concerned, doctors often have to prescribe and evaluate multiple drugs to see what
will work best for a particular patient. This can include several different antidepressants,
antispychotics, mood stabilizers, analgesics and sleep aids. Dr. Eugene Rubin (2011) stated that
patients with psychiatric histories are typically on five or more psychiatric medications
alone. Patients without prior psychiatric history are often placed on a basic regimen of at least
three psychiatric medications when admitted in an acute setting.
Due to the trial-and-error nature of diagnosing mental health disorders, impatience in
allowing medications to take effect can lead to additional diagnoses tacked onto the original
diagnosis along with inappropriate medications being prescribed. In an effort to speed up the
improvement in the patient, several medications may be started at once to appease the patient,
family and even third party payers, disregarding the fact that more medications being added can
lead to vicious cycles. Beginning automatically with a particular cocktail can also cause the
adverse effects of one medication to mask the positive effects of another.
Specific Costs of Care
In the case of YT, who was admitted for nine days, his total bill came to
$12,143.54. These costs came from the cost of the room, medications, labs, x-rays, occupational
therapy, group therapy and the emergency department charge. According to Stensland, Watson

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and Grazier (2012), the average costs of psychiatric patients for similar lengths of stay were as
followed: schizophrenia treatment, $8,509 for 11.1 days and $5,707 for 7.4 days, respectively;
bipolar disorder treatment, $7,593 for 9.4 days and $4,356 for 5.5 days; depression treatment,
$6,990 for 8.4 days and $3,616 for 4.4 days; drug use disorder treatment, $4,591 for 5.2 days and
$3,422 for 3.7 days; and alcohol use disorder treatment, $5,908 for 6.2 days and $4,147 for 3.8
days. These values are all less than that of the bill of YT, who was admitted for drug use
disorder treatment and suicidal ideation.
The bill includes charges for many different aspects of the hospitalization with the cost of
the room being the most expensive factor in the total cost. The price of the room per night was
$588.00; it cost YT $5,292.00 for his nine-day stay. The second most expensive part of the bill
was occupational therapy with each 15-minute session costing between $63.00 and $75.00. For
all of the therapy that YT received, he was charged $4,664.00. Laboratory fees and x-rays cost
YT $1,227.00. Finally, drug therapy cost $749.08. YT was additionally charged $377.00 just to
visit the emergency department.
Since the patient presented to the emergency department, he was required to receive
standardized testing such as a drug test. This test was appropriate for YT since he did have
cocaine in his system, but because it is a standardized test, it must be paid for even if it does not
apply to a particular patient. As mentioned before, YT was placed on a sequence of psychiatric
medications that included anti-anxiety medications and selective serotonin reuptake inhibitors to
help induce sleep. These medications cost between $45.00 and $63.00 per dose and were taken
multiple times each day of the hospital stay. The patient was thus charged greatly for drugs that
were prescribed as a maintenance regimen.
Specific nursing care costs were not not explicitly stated in the bill but occupational and

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group therapies were charged and were a major source of expense for the total bill. If the patient
had not been required to attend therapies, the bill would have had a much lower total. However,
by mandating therapy, a patient may have better outcomes than if therapy was elective. If it
were voluntary, the majority of patients would be likely to not attend in order to save
money. Another extremely high cost for YT was the price of the room a price that cannot be
negotiated by the patient because the patient must pay for the room until discharged by a
physician unless he chose to sign an Against Medical Advice Form.
YTs care was covered by Medicare. Following discharge, the plan was for YT to attend
rehabilitation in a long-term care facility for three months. It was also planned for him to attend
multiple follow-up appointments along with being assigned a sponsor in order to track his
improvement. Medicare Part A covers care in a hospital rehab unit and may pay for rehab in a
skilled nursing facility in some cases. Following hospitalization for a minimum of three days,
Medicare will cover inpatient rehab for up to 100 days in a benefit period, which begins when
the patient is admitted to the hospital. The benefit period ends when a patient has not received
any hospital care or skilled nursing care for 60 days. Medicare pays for the first 20 days at
100%, and the next 80 days require a daily co-payment. Medicare will not pay for any rehab
following 100 days after the admission date (Summit Medical Group, 2015).
Conclusion
Although barriers arise in mental health care delivery systems such as access and
availability of mental health care, social stigmas related to mental health issues, and the great
cost for care to be received, overall, the integrated care delivery system at Crossbridge
Behavioral Health Center was effective for the treatment of YT. In looking at a specific patients
care, the effectiveness of an interprofessional team was able to be examined and was determined

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to be successful. However, the cost of using a wide variety of health care personnel within an
interprofessional team along with the cost of day-to-day care and treatment was found to be
excessive and unsustainable for patients, regardless of the method of payment.

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