The value of consultation-liaison interventions to the general hospital

An Economic Evaluation of a Proactive Consultation-Liaison Psychiatry Pilot as Compared to Usual Psychiatric Consultation On-Demand for Hospital Medicine

BACKGROUND

A growing literature demonstrates the value of the Proactive Consultation-Liaison (C-L) Psychiatry model for healthcare systems through reductions in hospital length of stay (LOS). Few studies include financial outcomes. We evaluated the return on investment (ROI) of a one-year Proactive C-L Psychiatry pilot on a hospital medicine unit.

METHODS

We used a pre-post method with an active comparison of three hospital medicine units with regular psychiatric consultation on-demand. We staffed the Pilot unit with one full-time psychiatrist who focused on early case finding, close communication with unit staff, frequent follow-up visits, and proactive discharge planning. We assessed the one-year change in mean LOS for all patients receiving psychiatric consultation, from which we estimated the direct contribution margin (DCM) from bed backfills and the program's return on investment (ROI).

RESULTS

On the Pilot unit, the percent of discharges that received psychiatric consultation increased from 7.34% to 13.79%, and the LOS for patients consulted on declined by a mean of 1.82 days (P<0.05), as compared to an increase of 0.15 days (P>0.05) on the usual care units. The Pilot unit reduction in LOS saved 451.71 days total, allowing for 73.81 bed-backfills, a DCM of $419,343 (95% confidence interval, $50,754 to $787,933), a net DCM of $298,245 (-$70,344 to $666,835) and ROI of 132% (-31% to 295%).

CONCLUSION

This study strengthens existing evidence for the relative cost-effectiveness of Proactive Consultation-Liaison (C-L) Psychiatry for hospital medicine compared to usual psychiatric consultation on-demand.

Addressing mental health stigma: A pilot educational video intervention for caregivers to facilitate psychiatric consultation in inpatient pediatric care settings

Mental health stigma continues to be a significant barrier for psychiatric care in youth. Parental misperceptions regarding mental health may interfere with their child's care and negatively influence their child's view of mental health. For some children, their first experience with psychiatry occurs during medical hospitalization when they are seen by the Pediatric Consultation-Liaison (C/L) Psychiatry Service. Despite this unique role, there is sparse research on how to address mental health stigma with patients and families within the context of Pediatric C/L Psychiatry. This study explores the use of a brief educational video with messages from the Pediatric C/L Psychiatry team, families who have accessed mental health consultation in the hospital, and brief video interactions between family and the C/L team, to address mental health stigma. Common misconceptions are addressed during the video with the intent of reducing negative parental perceptions relating to mental health care. Families are given a survey highlighting these concerns, prior to and after watching the video. Pre- and post-intervention responses were compared using paired sample's t-tests. Results indicated that the video did positively change parent's confidence that psychiatry can be helpful, reduced their preconceived stigma regarding confidentiality, while alleviating concerns regarding psychotropic medication use in youth. Use of an educational video may be feasible, time efficient, and effective at reducing parental mental health stigma.

Towards the development of a reciprocal liaison service

Aims and Method

The aim of this survey was to determine attitudes among consultants in different specialities towards the development of a reciprocal liaison service providing access for psychiatric patients to medical and surgical liaison services equal to the access of medical and surgical patients to psychiatric liaison services. All medical, surgical and psychiatric consultants in a district health service were surveyed, with a total response rate of 48%.

Results

The mean number of medical and surgical patients requiring a psychiatric liaison service was 6%. The mean number of psychiatric patients requiring medical and surgical liaison services was 11%. Ratings overall for various components of the two types of liaison service were generally similar, with acute assessments and follow-up being given a high priority for both types.

Clinical Implications

As liaison services are developed, the notion of equity of access for all patients is paramount. Commissioning of such services should thereby specify the reciprocal nature of development. This survey shows that generally there is a positive attitude to the development of such a service.

Intelligent outcome measures in liaison psychiatry: essential even if not desirable: Commentary on … a multidimensional Framework for Routine Outcome Measurement in Liaison Psychiatry (FROM-LP)

Service development is guided by outcome measures that inform service commissioners and providers. Those in liaison psychiatry should be encouraged to develop a positive approach that integrates the collection of outcome measures into everyday clinical practice. The Framework for Routine Outcome Measurement in Liaison Psychiatry (FROM-LP) is a very useful tool to measure service quality and clinical effectiveness, using a combination of clinician-rated and patient-rated outcome measures and patient-rated experience measures. However, it does not include measures of cost-effectiveness or training activities. The FROM-LP is a significant step towards developing nationally unified outcome measures.

Effect of timing of psychiatry consultation on length of pediatric hospitalization and hospital charges

OBJECTIVES

The purpose of this study was to evaluate the impact of timing of a psychiatry consultation during pediatric hospitalization on length of hospital stay and total hospitalization charges.

METHODS

The charts of 279 pediatric patients (totaling 308 consultations) referred to the psychiatry consultation liaison service at a freestanding tertiary pediatric hospital between January 1, 2010, and June 30, 2010 were retrospectively analyzed. The variables analyzed included the following: patient demographic characteristics; dates of admission, psychiatric consultation, and discharge; psychiatric diagnoses based on the psychiatric diagnostic evaluation; psychiatric treatment disposition; and illness severity and total charges associated with the medical stay.

RESULTS

Earlier psychiatry consultation was associated with shorter length of stay and lower hospitalization charges after adjusting for psychiatric functioning, physical illness severity, and psychiatric disposition. Poorer psychiatric functioning and milder physical illness were associated with shorter referral time.

CONCLUSIONS

Timely involvement of psychiatry consultation services during a medical or surgical hospitalization was associated with reductions in length of stay and total hospital charges in pediatric settings. These findings have important effects on quality of care via decreasing burden on the patient and family and on the medical system resources. Educating pediatric health care providers about the importance of early psychiatry consultation regardless of physical illness severity or psychiatric acuity will likely improve resource management for patients and hospitals.

Psychiatrists for medically complex patients: bringing value at the physical health and mental health/substance-use disorder interface

BACKGROUND

In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use.

METHOD

The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties.

CONCLUSION

Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.

Audit of an inpatient liaison psychiatry consultation service

PURPOSE

The purpose of this paper is to examine an audit that was performed of all patients referred to a liaison psychiatry inpatient consultation service which sought to establish a baseline for demographics, type of referral, and management of referrals, with a view to introducing improved evidence-based treatments. It also aims to examine timeliness of response to referrals benchmarked against published standards.

DESIGN/METHODOLOGY/APPROACH

All inpatient referrals to a liaison psychiatry service were recorded over a six-month period, including demographics, diagnosis, management and timeliness of response to referrals. The data were retrospectively analysed and compared against international standards.

FINDINGS

A total of 172 referrals were received in the six months. Commonest referral reasons included assessments regarding depressive disorders (23.8 per cent), delirium/other cognitive disorders (19.2 per cent), alcohol-related disorders (18.6 per cent), anxiety disorders (14.5 per cent), and risk management (12.2 per cent). Evidence-based practices were not utilised effectively for a number of different types of presentations. A total of 40.1 per cent of referrals were seen on the same day, 75.4 per cent by the end of the next day, and 93.4 per cent by the end of the following day.

PRACTICAL IMPLICATIONS

Use of a hospital protocol for management of delirium may improve outcomes for these patients. Evidence-based techniques, such as brief intervention therapies, may be beneficial for referrals involving alcohol dependence. Referrals were seen reasonably quickly, but there is room for improvement when compared with published standards.

ORIGINALITY/VALUE

This paper provides valuable information for those involved in management of liaison psychiatry consultation services, providing ideas for development and implementation of evidence based practices.

The Cornell Psychiatric Screen: a brief psychiatric scale for hospitalized medical patients

Psychiatric comorbidity among medicine inpatients is prevalent, yet no reliable screen for identifying need for psychiatric referrals exists. The Cornell Psychiatric Screen was developed as a brief, reliable, and valid screening tool. The items on the Cornell Psychiatric Screen assess a range of psychiatric conditions, including cognition and behavior, depressive symptoms, anxiety, drug and alcohol history, and the patient's desire to see a psychiatrist. Of the patients whose Cornell Psychiatric Screen results indicated possible psychopathology, 89% had documented psychiatric comorbidity according to DSM-IV criteria. On the basis of preliminary validation, the Cornell Psychiatric Screen appears to be a useful tool for identifying patients who require a psychiatric evaluation.

When consultants write orders: physicians' attitudes, beliefs, and practices

The process by which a consultation is performed may significantly impact the extent to which the content of the consultation contributes positively to patient care. The practice of consultants writing orders independent of the explicit permission of the consultation requester is a common event. A survey of 211 multispecialty physicians on the medical staff of a large, urban, Northeastern, teaching hospital about their attitudes, beliefs, and practices regarding consultation on the inpatient service reveal that the majority of respondents in all specialties were unaware of departmental or hospital policy regarding the practice of consultant order writing. Significant differences between specialties existed in the perception of the impact of consultant order writing on patient outcomes, in the practice of discussion with the primary attending prior to order writing, and in the documentation practices. The authors discuss such results and their policy implications in light of important medico-legal and ethical principles, and best practice standards.

Funding for consultation-liaison services in public sector-managed care plans. The experience of the Consultation-Liaison Association of Philadelphia

Recently, the Commonwealth of Pennsylvania initiated plans to implement a mandated behavioral health carve-out program for Medicaid-eligible persons. The Consultation-Liaison Association of Philadelphia (CLAP) discovered that there was no provision for the coverage of psychiatric services for patients with concomitant medical illness. As a result, the authors responded by initiating a series of actions aimed at ensuring inclusion of such services as part of mental health services to be delivered. CLAP developed a brief position paper that includes a description of the need for such services, the types of services typically delivered, the impact of psychiatric input in the medical setting on costs and other outcomes, and a specific set of recommendations. These efforts have lead to the inclusion of consultation-liaison services in the new plan. A description of recent changes in Medicaid, including expansion of managed care plans, the status of mental health carve outs, and the possibility for inclusion of psychiatric consultations for the medically ill within these plans, is detailed.