Alternative to Hospitalization — Is There Such a Thing?

by Tony Salvatore, M. A.

Over the years (decades actually), I have often heard the phrase “alternative to hospitalization” used in conversations about the suitability and capability of some community-based mental health services to serve as a substitute for inpatient psychiatric care. The implication being that use of these alternatives would be less expensive, less restrictive, less stigmatizing, and less traumatizing than hospitalization while being equally effective. This phrase and the promise that it bespeaks is always taken as a valid assertion and never (in my experience) challenged by users, advocates, or providers of mental health services.

My intuition told me that there was something illogical about this phrase, but I never spoke up because I always assumed that the service in question was being presented as a means of deterring admissions involving individuals who could be safely and effectively treated in community settings. I was wrong. I have discovered that many people strongly believe that the need for inpatient psychiatric care can be met outside of a freestanding psychiatric hospital or a psychiatric unit of a community hospital. Moreover most of those espousing this view also seem to believe that inpatient psychiatric care is over-utilized because adequate substitutes are or could be available.

There are a number of misconceptions about psychiatric hospitalization. One is that it should be up to the patient who, after all, would seem to be in the best position to know if inpatient care is needed. Another is that hospitalization should follow from a determination by an outpatient provider, in the form of a referral, that this level of care is needed. Still another is that admission is solely at the discretion of the psychiatrist covering intake at the hospital. Of these, only the last has any degree of validity. A psychiatrist does indeed order an admission, but it is not based on her or his decision alone.

What is often not understood is that there are explicit criteria for an inpatient psychiatric admission that must be met. These criteria have been established by the various parties regulating, offering, or paying for inpatient psychiatric care. They are based on clinical need and appropriateness for this level of care. Satisfaction of these criteria are the primary purpose of the psychiatric evaluation that must precede any inpatient admission. The criteria of medical necessity for inpatient psychiatric care are basically clear. The individual must:

  1. Have a primary psychiatric diagnosis, excluding intellectual disability, substance abuse, or dementia, unless these conditions co-occur and are secondary to the presence of a diagnosed psychiatric disorder. (NB: Psychiatric diagnosis by itself does not equate to need for hospitalization.)
  2. Require ongoing 24-hour clinical management, monitoring, supervision, and assessment by psychiatry and nursing to develop, implement, and modify the treatment plan, which cannot be done in a less controlled care environment.
  3. Be at significant risk of harm to herself/himself or to others because of an imminent risk of suicide, assaultive behavior, or homicide, represent a risk to self because of psychosis, or demonstrate a serious inability to care for one’s self.

These criteria clearly indicate that, when strictly and correctly applied, there is, in fact, no alternative to, or substitute for, inpatient psychiatric care when that is what an individual needs. There is no single community-based program or any combination of such programs that can deliver the degree of safety, supervision, or service intensity that can be provided in an inpatient psychiatric setting. Put more plainly, someone either needs hospitalization or someone does not, yes or no.

Here is a suggestion: Use an “alternative to inappropriate hospitalization” instead of improperly using hospitalization. Inpatient care should be turned to when it is the only option capable of meeting the individual’s needs. Any other use is unnecessary, wasteful of a limited resource, and potentially harmful. Inpatient psychiatric care is not a “Plan B” for problems that cannot be otherwise resolved. It is not a stand-in for shelters or rehabs that have no beds. It is not a respite for frustrated family members or providers. It is not an alternative to incarceration when the offense is unrelated to any underlying serious mental illness.

There is no alternative to psychiatric hospitalization and psychiatric hospitalization is not an alternative to any other service.