Perinatal depression impacts 10 to 15 percent of the general maternity population. While the vast majority of women with perinatal mood disorders can be well managed in the outpatient setting, five percent of those affected do require inpatient treatment. Clinical providers must ensure that an inpatient option is available to best meet the needs of high acuity patients.
Studies have shown that mothers housed in traditional psychiatric units have limited access to relevant programming, inadequate maternity-specific resources, and few opportunities to integrate their infant into the care plan.
University of North Carolina (UNC) Health Care System has established the first perinatal psychiatry inpatient unit in the US. The unit provides a dedicated space and integrated behavioral health care programming to meet the unique needs of pregnant and postpartum patients. Through the program, UNC is able to provide a safe and secure clinical care site for mothers and visiting babies, resources tailored to maternal needs, and programs that encourage healthy mother-baby and family relationships.
Hospitals with general psychiatry inpatient units seeking to improve clinical effectiveness, efficiency, and care quality provided to at-risk maternity patients should consider how a perinatal psychiatry inpatient program can help achieve those goals.
The Advisory Board disscussed the development of the program with Dr. Samantha Meltzer-Brody MD, MPH, psychiatrist and director of the UNC Perinatal Psychiatry Program.
Could you give us a brief history of the UNC Perinatal Psychiatry Inpatient Unit?
Dr. Meltzer-Brody: We started an outpatient perinatal psychiatry program at UNC in 2004. By 2005, all of our obstetricians were performing universal screening at the routine six-week postpartum visits, and identifying perinatal psychiatric disorders in 10-15 percent or more of patients. The larger our patient volumes grew, the more people we identified that needed inpatient psychiatric hospitalization.
Although we had a specialized perinatal psychiatry outpatient program, we could not provide the same specialized level of care in our general psychiatric inpatient unit for a few reasons. First, general psychiatric inpatient units have a wide variety of patients, many with serious and persistent mental illness or psychotic disorders. Therefore it’s not a place that women feel comfortable bringing babies. Furthermore, the programming is not tailored to the mother-infant dyad, so patients feel that their needs are not being met.
To solve this issue, we looked at the broader context of the perinatal period. For example, when patients are admitted during the perinatal period for a medical condition, they don’t go to the general medical unit, but rather into an obstetrical or antenatal unit where their specific clinical needs can be met.
We felt that a specialized model made a lot of sense for psychiatry as well, especially for a condition that is the most common complication of pregnancy. Perinatal psychiatry inpatient units have existed all over Europe and the rest of the world for more than 50 years—the US has just been slow to adopt the model.
Could you describe how the unit operates?
Dr. Meltzer-Brody: In 2008, we took two beds (a shared room) at one end of our geropsychiatry unit and designated them for perinatal patients—those currently pregnant or up to one year postpartum. Between 2008-2010 we demonstrated to the hospital that we had a robust enough patient flow to sustain the beds, and that the care we were delivering was effective in terms of clinical improvements and patient satisfaction.
After the pilot period, we renovated adjacent office space to create a freestanding unit with three more beds. The five bed unit operates on a swing door system, so if the perinatal unit is not full, the beds can be reconnected with the geropsychiatry unit. Being able to swing the beds for either service is ideal because it enables the unit to be as financially viable as possible.
In terms of payer mix, the perinatal unit is no different from the regular inpatient psychiatric unit. UNC is committed to providing inpatient psychiatric care, so the beds were going to be filled regardless, whether with perinatal or geropsychiatric patients. A key decision in developing the unit was that we were not adding more beds; we were just designating existing beds for this patient population and tailoring programs to their needs.
The unit opened in August 2011 and was completely full. Volumes have since settled down a bit. We have had patients come from all over North Carolina, the Southeast, and even from the Midwest to access care, because we are the only inpatient unit like this in the country.
Can you describe the unique programming for patients in the unit?
Dr. Meltzer-Brody: We developed specialty programming tailored to the perinatal population, informed by research literature and 50 years of European standard of care data. Our program includes comprehensive assessment and treatment including psychopharmacology, mother-infant attachment groups, partner assistance groups which focus on couple and family issues, spirituality groups, occupational therapy (coping strategies, mindfulness, stress and biofeedback measures), and perinatal yoga. We give our patients a follow-up plan and tools to use at home, giving them a skill set they would not have otherwise had.
In terms of provider follow-up, we work very hard to get absolutely everyone set up with an outpatient mental health provider and connected with available resources such as therapy and support groups.
What are some specific challenges unique to Medicaid patients?
Dr. Meltzer-Brody: Women with low socioeconomic status have a higher risk for mood disorders due to chronic poverty, frequency of co-morbid substance abuse, histories of trauma and abuse, and PTSD. Unfortunately, mothers that qualify for Medicaid during their pregnancy usually lose coverage three months postpartum, leaving them vulnerable at a critical time. These women often suffer in silence until their behavioral health condition reaches the point where they present to the emergency department.
We have been very effective in engaging our indigent patients in self-care and stress reduction. We also work with social services to identify resources available for additional support, such as state-subsidized childcare for at-risk mothers. The social worker on our team is very passionate about these issues and extremely knowledgeable about available resources. She has done an excellent job of tailoring offerings to each individual patient’s needs.
What are the next steps for the program?
Dr. Meltzer-Brody: Our goal is to demonstrate both the fiscal viability and clinical effectiveness of the program. We feel that this model is very exportable to many hospitals, particularly those that accept patients covered by all insurance types.
Hospitals that serve a primarily commercial payer mix may have to modify the program offerings to account for lower volumes, for example by turning services on or off. But we feel that providers can adjust the program to meet their unique needs.
This type of treatment program really changes the paradigm for the type of behavioral health care we provide to pregnant and postpartum women. The outpouring of letters and support we have received from both patients and advocates really speaks to the need to offer this type of specialty care. Our program feels a sense of responsibility to communicate our positive outcomes and to extend this model beyond North Carolina.