Psychiatric Partial Hospitalization Programs: A Primer

Partial Hospitalization, sometimes referred to as “Day Hospital”, is neither an inpatient service nor a strict outpatient service, rather a mid-ground along the range of treatment intensity between the two traditional types of psychiatric services. Partial hospital programs (PHP) render acute care and intensive therapies as an alternative to inpatient hospitalization. They also provide transitional treatment between an inpatient episode and outpatient treatment in order to shorten inpatient length of stay and
enhance potential for renewed productivity of the individual. They also function as a supplement to traditional outpatient treatment. Although required to be a core component of the Community Mental Health Centers (CMHCs) by US Congress in the Community Mental Health Act of 1963, PHP did not become recognized and utilized in the continuum of psychiatric care until the Omnibus Budget Reconciliation Acts of 1987 and 1990 that authorized Medicare to pay for this service. By 2016, about one-third (39%) of all metropolitan hospitals in the US and 11% of rural hospitals provided PHP service, particularly for geriatric population. In an attempt to cut costs of inpatient care, private insurers have embraced PHPin recent years resulting in some growth of PHPs across the country but the PHP service is still under-utilized.

Medicare has been the primary driver in setting policies and standards for PHPs which have been widely adopted and further modified by private insurers and managed care companies to ration care and save costs. Medicare requires that the PHP treatment be active and structured to provide an individualized treatment plan that incorporates multidisciplinary team approach to patient care under the direction of a
physician; the treatment goals must be measurable, functional, time-framed, medically necessary and directly related to an acute Axis I mental disorder with severe impairments in multiple areas of functioning in daily life, and a “reasonable expectation” of patient’s mental disorder and functioning to improve as a result of the treatment.

Most PHPs for adults provide services 5 days per week and an average 5 hours of programming during the day that is mostly in group therapy format but individual therapy and medication monitoring are provided at least once a week. Family therapy is mandated for children and adolescents who attend PHPs either after school or during the day when some programs provide schooling as well. Most PHPs offer a step down Intensive Outpatient Program (IOP) 3 days per week at 3-4 hours per day as patients
improve with a goal to transition to work and independent living. The treatment duration 1 in PHP followed by IOP is generally 6 to 8 weeks that allows adequate time for symptom relief, then stability and mental clarity to be able to engage in and benefit from intense therapies, and learn, apply and reinforce various coping strategies for relapse prevention.

What are the advantages and disadvantages of PHP?

Neffinger, in a 1981 land mark review of the PHPs, outlined the following:
Advantages:

1. Discourages the excessive dependency and dehumanization that develops in the course of inpatient hospitalization.
2. Allows the client to maintain those independent activities of which he may be capable of despite mental illness.
3. Allows the client to remain with family if it is therapeutically desirable to do so.
4. Less social stigma.
5. Approximates the customary workweek, making the transition to full employment easier.
6. Makes possible part time jobs or schooling in the evenings and weekends.
7. Offers more active and varied therapeutic experience than most inpatient programs.
8. Costs substantially less than the inpatient services.

Disadvantage:

1. Does not remove the client totally from his environment, as may be
   desirable/necessary for some.
2. Not suitable for clients with assaultive or suicide potential.
3. May present problems of transportation and living arrangements.
4. May interfere with full-time employment or school.
5. Not suitable for clients with severe cognitive deficits.
6. More demanding and fatiguing for staff.
   Is PHP treatment effective?
7. Several studies indicate that PHP is at least as effective as inpatient service for all but the most acutely ill, and in most cases, superior in enhancing role functioning.
8. Studies also indicate that PHP is more effective than outpatient treatment in arresting, if not reversing to some extent, the deterioration in the function of the chronically mentally ill. 2
9. Russell, Busby, et al (1996) found that clinical outcomes were similar between inpatients and PHP patients but the gains made during treatment were better maintained in the PHP patients 3-6 months afterwards.
   

Is PHP cost effective?

1. Fink, Longabaugh et al (1978) found that even after correcting for the difference
   in the treatment days between inpatient and PHP services, there was significant
   financial advantage with PHP (1/3 less) primarily because of the lower cost per
   day.
2. Sledge, Tebes, et al (1996) found that PHP savings amounted to 20% and
   potential cost savings were higher for non-psychotic patients.
3. A Cigna Behavioral Health analysis found that IOP reduced recidivism by 53%
   while members without this treatment showed 11% increase in psychiatric
   admissions, and savings amounted to over $3000 per members treated in IOP
   vs. those not treated.
   

What are the therapeutic factors in PHP?

Michael Hogue and colleagues matched interview responses from patients and staff at Connecticut CMHC and found the following factors rated as the most therapeutic:

1. Structure (per 95% of patients and staff)
2. Interpersonal contact (95%)
3. Medication (85%)
4. Altruism (55%)
5. Catharsis (40%)
6. Learning (40%)
7. Mobilization of family support (40%)
8. Connection to community (40%)
9. Universality (35%)
10. Patient autonomy (30%)
11. Successful completion (25%)
12. Security (25%)
13. Feedback (20%)
    

What are the variables associated with a favorable outcome of PHP?

Some studies have revealed that successful outcomes are associated with:

• -Diagnosis of mood disorder rather than psychotic disorder
• -Higher functional status
• -Greater social support
• -Fewer stressful events during treatment
• -Longer duration of treatment

Case Example

Mr. X is a 43 year old attorney separated after last X-Mas from his wife and now living with his parents. He attempted suicide twice this year by drug overdose and presents with panic attacks, hopelessness and suicidal thoughts but has no intent or plan. He reveals sexual trauma during childhood by a neighbor and severe work stress. He admits to abusing alcohol to cope with his anxiety. He does not want hospitalization, and outpatient treatment has not been effective. He is admitted to the PHP and attends the program five hours per day five days per week and is put on medical leave and short term disability. He participates in intensive group and individual therapies targeting his loss of marriage, work stress, trauma and maladaptive coping. His medications are adjusted. He undergoes cognitive behavioral therapy, relational therapy, trauma recovery, stress management through meditative relaxation and yoga, and relapse prevention work. He improves gradually over six weeks and is stepped down to IOP three days per week for two more weeks. He is then transitioned to work three days per week for two weeks and is discharged well improved to full time work and outpatient office follow up by his psychiatrist and a therapist.

PHPs are effective, cost effective and available but why are they underutilized?

-Hospitals are biased toward high bed occupancy rate and third party reimbursement
greater for inpatient service, so low priority for PHP.
-Traditional conservatism and medicolegal risk avoidance among clinicians with a
bias toward 24-hour hospitalization in patients who are ill or deteriorating.
-Lack of knowledge or experience with PHP concept.
-Most psychiatric residency programs do not offer or require PHP training.

Key References:
Neffinger G.G. Partial Hospitalization: An overview. Journal of Community Psychology. 9: 262-269, 1981.
Fink, E., Longabaugh R., et al.

The Paradoxical Underutilization of Partial Hospitalization. American Journal of Psychiatry. 135: 713-716, 1978. Washburn S., Vanicelli M., et al.

A Controlled Comparison of Psychiatric Day Treatment and Inpatient Hospitalization. Journal of Consulting and Clinical Psychology. 44: 665-675, 1976. Russell V., Mai F., et al.

Acute Day Hospitalization as an Alternative to Inpatient Treatments. 41: 629-637, 1996. Plotkin D.A., Wells K.B.

Partial Hospitalization for Psychiatrically Ill Elderly Patients. 150: 266-271, 1993. Sledge W.H., Tebes J., et al.

Day Hospital/Crisis Respite Care Versus Inpatient Care, Part II: Service Utilization and Costs. 153: 1074-1083, 1996. Hoge M.A., Farrell S.P., et al.

Therapeutic Factors in Partial Hospitalization. 51: 199-210, 1988.

Psychiatric Program improves Outcomes, Reduces Costs. Employee Benefit News. June 2007. Leung M.H., Drozd E.M., et al.

Impacts Associated with the Medicare Psychiatric PPS: A Study of Partial Hospitalization Programs. A Project of the Centers for Medicare & Medicaid Services. February 2009. Williams T., Borders T., et al.

Partial Hospitalization Program Availability in Nonmetropolitan and Metropolitan Hospitals Nationally. Rural Health Gateway Publication. December 2019.

Author
Dr. Sudhakar Madakasira is a board certified psychiatrist in Flowood, MS, a Distinguished Life Fellow of the American Psychiatric Association and President and Chief Medical Director of Psycamore Psychiatric Programs.