Psychotic, Homeless, Black and Breast Cancer: The value of a unique role for the C-L Psychiatrist in the care of disenfranchised populations in “Value Based” health care delivery systems.

Abstract:

Background: There is increasing awareness within medicine of the importance of “value” (Teisberg, 2020) in designing health care delivery systems and the discrepancy in the outcomes for disenfranchised minorities. This case will highlight the intersection of these imperatives and the critical contribution of the C-L psychiatrist to the areas of health care delivery, beyond the conventional role of the inpatient consultant.

Case: We present the case of a 45 year old black female diagnosed with a “treatable” stage of breast cancer at the age of 41 at a well-regarded health care system who managed to resist and avoid cancer treatment for several years prior to admission and C-L intervention. The lack of care for her breast cancer occurred despite going to the ED over 200 times (sometimes 2-3 times/day) in 2021, leading up to an admission in December 2021and the involvement of the C-L service. At each ED visit she had seemingly “appropriate” care where her immediate medical and/or psychiatric complaints were managed, with minimal attention to her life-threatening cancer. She came to the attention of the C-L service through during an admission where she was identified through a “value based”, “high utilizer” registry. We will describe the role of C-L that led to appropriate, life sustaining care.

Discussion: The case illustrates the potential value to disenfranchised and diverse patient populations (that lack advocates) of organizational efforts to track and intervene in their service utilization and the role of the C-L psychiatrist to look beyond the “blinders” of medical disciplines, to identify system dysfunction and to advocate for the care of the whole patient.
We will describe an expanded role that the C-L psychiatrist (beyond the traditional role of diagnosis and acute management) can play in the morass of the myopic/traditional role of medical specialists within health care delivery. (Goldman, 2018) We will review the following topics: 1) the value of “value based” tracking of disenfranchised patients; 2) the importance of the psychiatrist to look beyond the immediate medical and psychiatric needs with consideration of the context of chronic medical conditions in the acute care setting; 3) the importance of the C-L. psychiatrist to engage and coordinate the care of specialists in the service of caring for disenfranchised populations; and 4) the need for an “aggressive” interpretation of commitment regulations for the psychotic patient with chronic, life-threatening illness.

Conclusion:
This case describes the value of an unconventional approach of the C-L psychiatrist utilizing a value based data set, specialty coordination and community outreach in the care of a marginalized (psychotic, black, homeless) female with cancer.