What is the appropriate course of action when a patient at high risk for suicide is denied inpatient admission by their health insurance provider, which instead recommends outpatient management?

From the Guidelines

When a patient at high risk for suicide is denied inpatient admission by their health insurance provider, which instead recommends outpatient management, the most appropriate course of action is to contact hospital risk management to navigate the situation and potentially facilitate admission despite insurance denial, as patient safety must take priority over financial considerations. This approach is supported by the need to prioritize patient safety and the clinical necessity of admission for a suicidal patient, as highlighted in the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1.

The guidelines emphasize the importance of assessing suicide risk and providing appropriate care, including inpatient admission when necessary. While the guidelines do not specifically address the issue of insurance denial, they do emphasize the need for clinicians to use caution in assessing suicide risk and not rely exclusively on any one tool 1.

In this situation, contacting hospital risk management can help ensure that the patient receives the necessary care while also addressing the practical realities of healthcare systems. This approach is consistent with the principles of prioritizing patient safety and providing high-quality care, as emphasized in the guidelines.

Some may argue that outpatient management is sufficient, but the guidelines suggest that inpatient admission may be necessary for patients at high risk for suicide, particularly if they have a recent history of self-directed violence or other risk factors 1.

Key considerations in this situation include:

• The patient's level of suicide risk, as assessed using a comprehensive evaluation, including self-reported measures and clinical interviews 1
• The availability of alternative funding sources or emergency appeals to the insurance company
• The potential benefits of inpatient admission, including intensive multidisciplinary treatments and skilled observation and support, as highlighted in the practice parameter for the assessment and treatment of children and adolescents with suicidal behavior 1
• The need for clinicians to use caution in assessing suicide risk and not rely exclusively on any one tool, as emphasized in the guidelines 1.

Ultimately, the decision to contact hospital risk management and pursue inpatient admission despite insurance denial should be based on a careful assessment of the patient's individual needs and circumstances, with a focus on prioritizing patient safety and providing high-quality care.

From the Research

Appropriate Course of Action

When a patient at high risk for suicide is denied inpatient admission by their health insurance provider, which instead recommends outpatient management, the following steps can be considered:

• Ensure that the patient's suicide risk is thoroughly assessed using evidence-based methods, such as the Collaborative Assessment and Management of Suicidality 2.
• Develop a comprehensive treatment plan that incorporates psychological interventions, such as cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT), which have been shown to be effective in reducing suicide risk 2.
• Consider the use of pharmacological treatments, such as lithium, clozapine, ketamine, and esketamine, which have been shown to be effective in reducing suicide risk 2.
• Implement a care coordination approach, such as Linking Individuals Needing Care (LINC), which has been shown to be effective in increasing service utilization and decreasing suicide risk among youth discharged from inpatient psychiatric hospitalization 3.
• Ensure that the patient has a safe environment and access to crisis services, such as emergency departments or crisis hotlines, in case of a suicidal crisis.

Risk Factors and Protective Factors

It is essential to identify risk factors and protective factors associated with suicide risk, including:

• Recent adverse life events, which have been shown to be associated with an increased risk of suicide 4.
• Short final admission, which has been shown to be associated with an increased risk of suicide 4.
• Older age and comorbid psychiatric disorders, which have been shown to be associated with an increased risk of suicide 4.
• Receiving enhanced aftercare, such as the Care Programme Approach, which has been shown to be protective of suicide 4.

Outpatient Management

Outpatient management should prioritize patient engagement, suicide risk assessment and management, safety planning, community networking, referral/linkage monitoring, coping and motivational strategies, and linguistic/culturally responsive practices to meet the service and support needs of high-risk suicidal patients 3. Regular follow-up appointments and access to crisis services should be ensured to prevent suicide risk 4.