Patient acuity is rising. Approximately 21.2 million adults have a co-occurring mental illness and substance use disorder, according to the Substance Abuse and Mental Health Services Administration’s “2024 National Survey on Drug Use and Health.”
As whole-person care continues to be a focus for health systems, behavioral health leaders are redefining what it means to treat co-occurring mental health conditions.
Andrew Gerber, MD, medical director and CEO of New Canaan, Conn.-based Silver Hill Hospital, a nonprofit psychiatric hospital, told Becker’s the term “co-occurring” itself can be misleading. A patient with depression, a substance use disorder and anxiety is often described as having three separate conditions, he said, but he sees it differently.
“I see people as having one fundamental problem that we don’t currently have a way of describing with one term, so we label it by multiple words, because we want to capture different aspects of it,” Dr. Gerber said. “That’s where we are in psychiatry right now, where we describe things by the symptoms, rather than one word, because we don’t yet have a full understanding of the fundamental physiological cause.”
He compared it to appendicitis. If physicians did not have that single diagnostic term, he said, they would instead describe a patient as having abdominal pain, nausea and fever — three separate symptoms rather than one underlying cause.
Treatment has to address both the underlying problem and the individual symptoms at the same time, he said, the same way a physician treating appendicitis would not ignore a patient’s pain or fever while treating the underlying infection.
Assessment, treatment and continuity
Dr. Gerber described Silver Hill’s whole-person approach in three parts: assessment, treatment and continuity of care.
Assessment begins before a patient arrives, he said, often on the phone, by email or through the hospital’s website. When a patient arrives in person, a team in Silver Hill’s admissions department, consisting of a physician, a nurse and a social worker, completes a formal assessment that determines whether the patient needs inpatient, residential or outpatient care.
“That first stage can’t take multiple days, because we need to know where they can go — both from a safety perspective, but also where is the most effective treatment?” he said.
Once a patient is placed, a larger treatment team takes over for a more detailed assessment that can take anywhere from a few days to a few weeks, Dr. Gerber said. That team includes a psychiatrist, a social worker, a nurse and often a psychologist, along with psychiatric technicians, residential counselors, art therapists and recreational therapists.
Silver Hill also brings in outside medical specialists, such as surgeons, endocrinologists and cardiologists, when patients have co-occurring medical conditions, along with outside experts from academic partners including New Haven, Conn.-based Yale University, New York City-based NewYork-Presbyterian Hospital, Ithaca, N.Y.-based Cornell University and New York University.
Treatment combines medication, psychotherapy, community-based approaches and family involvement, delivered simultaneously rather than sequentially, Dr. Gerber said. Some patients also receive interventional psychiatry services, including transcranial magnetic stimulation, ketamine or electroconvulsive therapy.
“We’re constantly modifying. We’re constantly testing hypotheses and figuring out in a more specific way what’s wrong, and then applying modified treatments to that,” he said.
The final stage is continuity of care, which Dr. Gerber described using the metaphor of a relay race handoff.
“The most common place for patients to have negative outcomes or for treatments to fail is in the handoff, when they go from one kind of care to another,” he said. “We spend a lot of time and resources on making sure those communications happen well.”
Silver Hill said it offers inpatient, residential and outpatient care in-house, which Dr. Gerber said allows many of those handoffs to happen internally. “We’re one of the only facilities now that has all three levels of care,” he said.
The financial model behind whole-person care
Dr. Gerber said Silver Hill’s approach requires significant investment in the infrastructure that allows clinicians across departments to communicate, work that often falls outside standard reimbursement.
“There’s no reimbursement code for a lot of the things we do,” he said. “We’ve built an operational and financial system that allows us to invest in those things that are best for the patient, regardless of whether there happens to be a reimbursement for that particular service.”
That model predates Medicare and Medicaid, according to Dr. Gerber. Before those programs existed, Silver Hill relied on a cross-subsidization model in which patients who could pay for treatment, along with philanthropy, helped fund care for patients who could not. Silver Hill was also the site of the first community mental health clinic in Fairfield County, Conn., he said, predating the broader community mental health movement.
Today, Silver Hill takes commercial insurance and Medicare in-network for all inpatient services, some residential services and most outpatient services, Dr. Gerber said. For services that commercial insurance and Medicare do not reimburse, the hospital charges privately or covers the cost through what it calls patient financial aid, funded by philanthropy and other operational resources.
“We never let the funder drive the clinical,” Dr. Gerber said. “We always saw the clinical had to come first, and then we figured out a way to make the finances work.”
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