WILTIMS #314: Exit plan

Something that has surprised me thus far in my time on this VA psych unit is how much energy is put towards placement compared with treatment. Placement is the process of finding somewhere for each veteran to go after discharge from our unit. "Why can't they just go home?" you might reasonably ask. Well, many veterans and many psych patients are homeless, so veterans with psych issues are especially prone to not having stable housing.

The places to which people are discharged vary from another floor in our building, to any of the many other units on the VA campus, other VA facilities all over the country, drug rehab facilities, nursing homes, medical foster homes, the patients' families, or ideally to their own homes. Social workers, the unsung heros of health care, have to work with the psychiatrists to assess how good the patient is at taking care of themself, to assess the risk of psychiatric or substance abuse relapse, to find out the patient's financial situation, and, what is often the hardest part, to convince the placement site to take a patient that is really a borderline fit.

Many of these patients have been through this system several times and have burned a lot of their bridges after past discharges. The conversation with the facilities that will even consider taking the patient turns into a negotiation for what the patient must commit to to be allowed to leave. Some conditions for discharge include reliably taking meds, quitting smoking, agreeing to attend support groups and consistently taking showers.

Some of the most difficult cases we've had recently involve people we just can't find a home for. They clearly are no longer a danger to themselves or others, which are the general problems that get them locked on an inpatient unit. But even though they're better than they were upon admission, they still can't really live on their own and are just too odd or difficult for a facility to take. If we can't find a place after a long enough time, the patient may end up on our chronic psychiatric floor, from which they may never leave. We work really, really hard to avoid that.

TIL: A patient who suffers from chronic alcohol abuse who also has a history of gastric bypass surgery is at very high risk of developing a thiamine (vitamin B1) deficiency, leading to Wernicke's encephalopathy and eventually Korsakoff syndrome. Alcoholics have increased use of the vitamin, decreased storage capabilities and poor transportation through the body's tissues. Meanwhile gastric bypass surgery bypasses the main areas of absorption in the duodenum and proximal jejunum of the small intestine. The symptoms of these conditions can present very similarly to the psychotic symptoms of schizophrenia, so you must be careful when teasing apart the mental and medical issues with these patients.