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

Patient and Medical Unit Staff Experiences of Proactive and Integrated Consultation-Liaison Psychiatry in The HOME Study: A Qualitative Investigation

BACKGROUND

Consultation-liaison (C-L) psychiatry services aim to help general hospital staff provide better care for their patients. Recently, many inpatient C-L psychiatry services have adopted proactive and integrated approaches to achieve this aim. Despite these developments, there have been no interview-based studies of patients' and staff members' experiences of the new approaches.

OBJECTIVE

To gain an in-depth understanding of patients' and medical unit staff members' experiences of a proactive and integrated C-L psychiatry service for older medical inpatients (Proactive Integrated C-L Psychiatry [PICLP]).

METHODS

We conducted an interview-based qualitative study with thematic analysis. The participants were patients and staff who had experienced PICLP during The HOME Study, a randomized trial that evaluated PICLP in 24 medical units of three UK general hospitals.

RESULTS

We conducted 97 interviews: 43 with patients or their proxies (family members who were interviewed on behalf of patients with significant cognitive impairment) and 54 with staff members of all relevant disciplines. Patients and staff both described how PICLP was a helpful addition to medical care and discharge planning. It enhanced the medical unit team's ability to address psychological, psychiatric, and social needs and provide patient-centered care. They welcomed proactive biopsychosocial assessments and the broader perspective that these offered on patients' complex problems. They also valued the integration of C-L psychiatrists into the unit teams and their daily contact with them. For patients, it fostered a therapeutic relationship and helped them to be more engaged in decisions about their medical care and discharge planning. For staff, it enabled ready access to psychiatric expertise and training opportunities. The few reported experiences of PICLP being unhelpful were mainly about the greater number of clinicians involved in patients' care and a lack of clarity about professional roles in the integrated team.

CONCLUSIONS

We found that older inpatients and medical unit staff experienced PICLP as both acceptable and generally helpful. Our findings add to the existing evidence for the benefits of proactive and integrated C-L psychiatry services.

Defining Vision and Mission of a Medical Psychiatry Unit (MPU) for Older Adults: A Focus Group Study

This study aims to determine the vision and mission of an academic hospital's medical psychiatry unit (MPU) that exclusively treats geriatric patients. All healthcare providers working at an academic hospital's geriatric MPU were invited to reflect on formulate the vision and mission of this ward. Twenty-two of them took part in the focus group interviews. The interviews focused on defining the MPU's functioning, its objectives, how it will reach these objectives, and where the MPU aspires to go. The interviews were transcribed verbatim and analyzed according to the QUAGOL guide. The themes from the analysis emerged from these group discussions. The participants defined the MPU's vision as to excel in integrated mental and physical geriatric inpatient healthcare, inspiring others to shed the stigma related to this vulnerable patient population. The mission that emerged from the focus group discussions is to provide patient-centered, integrated healthcare for older adults with combined mental and physical disorders. To achieve this, involving the patient's network, interdisciplinarity, shared decision-making, clear communication between all stakeholders, and reintegration of patients into their communities emerged as important themes. This study provides a vision and mission of a geriatric MPU in an academic psychiatric hospital. Since there is no consensus in the literature about the characteristics of MPUs despite the international call for integrated care for older persons with combined mental and physical disorders, these vision and mission statements can feed the discussion on how to install excellent healthcare for this vulnerable patient population.

Proactive and integrated consultation-liaison psychiatry for older medical inpatients: A mixed methods description of training, care provided and clinician experience in the HOME study

OBJECTIVES

To describe the practical experience of delivering a proactive and integrated consultation-liaison (C-L) psychiatry service model (PICLP). PICLP is designed for older medical inpatients and is explicitly biopsychosocial and discharge-focused. In this paper we report: (a) observations on the training of 15 clinicians (seven senior C-L psychiatrists and eight assisting clinicians) to deliver PICLP; (b) the care they provided to 1359 patients; (c) their experiences of working in this new way.

METHOD

A mixed methods observational study using quantitative and qualitative data, collected prospectively over two years as part of The HOME Study (a randomized trial comparing PICLP with usual care).

RESULTS

The clinicians were successfully trained to deliver PICLP according to the service manual. They proactively assessed all patients and found that most had multiple biopsychosocial problems impeding their timely discharge from hospital. They integrated with ward teams to provide a range of interventions aimed at addressing these problems. Delivering PICLP took a modest amount of clinical time, and the clinicians experienced it as both clinically valuable and professionally rewarding.

CONCLUSION

The experience of delivering PICLP highlights the special role that C-L psychiatry clinicians, working in a proactive and integrated way, can play in medical care.

A Cross-Sectional, Retrospective, and Comparative Study between Delirium and Non-Delirium Psychiatric Disorders in a Psychogeriatric Inpatient Population Referred to Consultation-Liaison Psychiatry Unit

Background and objectives: Delirium is the most prevalent psychiatric disorder in inpatient older people. Its presence is associated with higher rates of institutionalization, functional disability and mortality. This study aims to evaluate delirium in a hospitalized psychogeriatric population, focusing on which factors predict the appearance of delirium, the impact it generates and the diagnostic concordance between non-psychiatric physicians and psychiatrists. Material and methods: This is an observational, cross-sectional, retrospective, and comparative study. We obtained data from a sample of 1017 patients (≥65 years) admitted to general hospital and referred from different services to the consultation-liaison psychiatry (CLP) unit. Logistic regression was performed using delirium as the dependent variable. To estimate the concordance of the diagnoses, the Kappa coefficient was used. To assess the impact of delirium, an ordinal regression, Wilcoxon median test and Fisher’s test were performed. Results: Delirium is associated with a higher number of visits, OR 3.04 (95% CI 2.38–3.88), longer length of stay and mortality, OR 2.07 (95% CI, 1.05 to 4.10). The model to predict delirium shows that being >75 years old has an OR of 2.1 (95% CI, 1.59–2.79), physical disability has an OR of 1.66 (95% CI, 1.25–2.20), history of delirium has an OR of 10.56 (95% CI, 5.26–21.18) and no use of benzodiazepines has an OR of 4.24 (95% CI, 2.92–6.14). The concordance between the referring physician’s psychiatric diagnosis and the psychiatrist CLP unit showed a kappa of 0.30. When analysing depression and delirium, the concordance showed Kappa = 0.46. Conclusions: Delirium is a highly prevalent psychiatric disorder, but it is still underdiagnosed, with low diagnostic concordance between non-psychiatric doctors and psychiatrists from CLP units. There are multiple risk factors associated with the appearance of delirium, which must be managed to reduce its appearance.

A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews

BACKGROUND

There is pressing need to improve hospital-based addiction care. Various models for integrating substance use disorder care into hospital settings exist, but there is no framework for describing, selecting, or comparing models. We sought to fill that gap by constructing a taxonomy of hospital-based addiction care models based on scoping literature review and key informant interviews.

METHODS

Methods included a scoping review of the literature on US hospital-based addiction care models and interventions for adults, published between January 2000 and July 2021. We conducted semi-structured interviews with 15 key informants experienced in leading, implementing, evaluating, andpracticing hospital-based addiction care to explore model characteristics, including their perceived strengths, limitations, and implementation considerations. We synthesized findings from the literature review and interviews to construct a taxonomy of model types.

RESULTS

Searches identified 2,849 unique abstracts. Of these, we reviewed 280 full text articles, of which 76 were included in the final review. We added 8 references from reference lists and informant interviews, and 4 gray literature sources. We identified six distinct hospital-based addiction care models. Those classified as addiction consult models include (1) interprofessional addiction consult services, (2) psychiatry consult liaison services, and (3) individual consultant models. Those classified as practice-based models, wherein general hospital staff integrate addiction care into usual practice, include (4) hospital-based opioid treatment and (5) hospital-based alcohol treatment. The final type was (6) community-based in-reach, wherein community providers deliver care. Models vary in their target patient population, staffing, and core clinical and systems change activities. Limitations include that some models have overlapping characteristics and variable ways of delivering core components.

DISCUSSION

A taxonomy provides hospital clinicians and administrators, researchers, and policy-makers with a framework to describe, compare, and select models for implementing hospital-based addiction care and measure outcomes.

Specialized Biopsychosocial Care in Inpatient Somatic Medicine Units-A Pilot Study

Introduction

Specialized biopsychosocial care concepts are necessary to overcome the dualism between physical and psychosocial treatment in acute care hospitals. For patients with complex and chronic comorbid physical and mental health problems, neither standardized psychiatric/psychosomatic nor somatic care units alone are appropriate to their needs. The “Nuremberg Integrated Psychosomatic Acute Unit” (NIPA) has been developed to integrate treatment of both, psychosocial and physical impairments, in an acute somatic care setting.

Method

NIPA has been established in inpatient internal medical wards for respiratory medicine, oncology and gastroenterology. One to two patients per ward are regularly enrolled in the NIPA treatment while remaining in the same inpatient bed after completion of the somatic care. In a naturalistic study design, we evaluated treatment effects by assessment of symptom load at admission and at discharge using the Patient Health Questionnaire (PHQ) and the Generalized Anxiety Disorder Scale-7 (GAD-7). Furthermore, we assessed the severity of morbidity using diagnosis data during treatment. At discharge, we measured satisfaction with treatment through the Patient Satisfaction Questionnaire (ZUF-8).

Results

Data from 41 NIPA patients were analyzed (18–87 years, 76% female). Seventy-eight percent suffered from at least moderate depression and 49% from anxiety disorders. Other diagnoses were somatoform pain disorder, somatoform autonomic dysfunction, eating disorder and posttraumatic stress disorder. Hypertension, chronic lung diseases and musculoskeletal disorders as well as chronic oncological and cardiac diseases were the most common somatic comorbidities. Treatment resulted in a significant reduction of depressive mood (admission: M = 10.9, SD = 6.1, discharge: M = 7.6, SD = 5.3, d = 0.58, p = 0.001), anxiety (admission: M = 10.6, SD = 4.9, discharge: M = 7.3, SD = 4.1, d = 0.65, p< 0.001) and stress (admission: M = 6.0, SD = 3.6, discharge: M = 4.1, SD = 2.5, d = 0.70, p< 0.001). Somatic symptom burden was reduced by NIPA treatment (admission: M = 10.9, SD = 5.8, discharge: M = 9.6, SD = 5.5, d = 0.30), albeit not statistically significant (p = 0.073) ZUF-8 revealed that 89% reported large or full satisfaction and 11% partial dissatisfaction with treatment.

Discussion

NIPA acute care is bridging the gap for patients in need of psychosocial treatment with complex somatic comorbidity. Further long-term evaluation will show whether psychosocial NIPA care is able to reduce the course of physical illness and hospital costs by preventing hospitalization and short-term inpatient re-admissions.

Moving Beyond the Status Quo of Integrated Inpatient Medical and Psychiatric Care Units: The Path to Real-World Evaluation

Integrated inpatient medical and psychiatric care units (IMPUs) are hospital wards that care for inpatients with both acute general medical and psychiatric disorders. IMPU development has stalled, and wide variation in IMPU designs may reflect the fact that IMPUs are still in an early evolutionary stage. High-quality evidence concerning the costs and effectiveness of IMPUs is sparse, because IMPUs do not lend themselves well to traditional evidence-based medicine methods. As a result, most studies of IMPUs have been only observational. Therefore, it is time for a different approach, in which goals for IMPUs are explicitly formulated and IMPU research is incorporated into evidence-based practice (EBP) instead of evidence-based medicine. EBP can be viewed as integrating best available evidence into organizational practices by using four pillars of evidence: organizational, experiential, stakeholder, and scientific. Such types of evidence require an investment in describing the field more precisely. When pragmatic reasoning, where clinical expertise and organizational needs determine IMPU designs, is replaced with EBP, researchers can more effectively perform studies that may convince health care policy makers that IMPUs represent a cost-effective way to improve patients' health and that they increase the well-being of both patients and hospital staff.

Specialty Psychiatric Services in US Emergency Departments and General Hospitals: Results From a Nationwide Survey

OBJECTIVE

To explore the handling of psychiatric patients in medical hospitals and emergency departments (EDs) as well as hospital characteristics associated with the availability of psychiatric services in these settings.

METHODS

From October 1, 2017, to April 1, 2018, a telephone survey regarding the presence and nature of psychiatric services was attempted among all US registered Medicare hospitals.

RESULTS

Of the included 4812 US hospitals, 2394 (50%) were surveyed. Of these hospitals, 1108 (46%) have some psychiatric services available, either in medical EDs or through psychiatric consultation on general medical inpatient wards. If medical ED patients with active psychiatric issues need admission, 59% of hospitals transfer the patient to a different hospital and 28% admit the patient to a medical ward. Exploration by logistic regression analysis of the association of selected variables and available psychiatric expertise suggested that larger hospitals, nonprofit services, or hospitals in urban settings were more likely to have psychiatrists on staff or available for consultation.

CONCLUSION

Despite the growing number of psychiatric patients seeking help in medical EDs and general hospitals, more than 50% of the EDs and general hospitals lack psychiatric services. These results suggest that accessibility to psychiatric care in medical settings requires improvement.

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.

Organization and Outcomes of Integrated Inpatient Medical and Psychiatric Care Units: A Systematic Review

OBJECTIVE

The goal of this review was to assess the relationships among aims, designs, and outcomes of integrated inpatient medical and psychiatric care units (IMPUs) and gather the evidence base on the effectiveness of these units.

METHODS

Using online searches of Embase, Medline, Web of Science, PsycINFO, Scopus, CINAHL, Cochrane, and Google Scholar, the authors identified and reviewed literature describing the aims and outcomes of specific IMPU designs.

RESULTS

The search yielded 55 studies, in which the authors identified 39 IMPUs that focused on patients with mood, psychotic, somatic symptom, substance use, organic, and personality disorders and a broad array of medical diagnoses. Most units were psychiatric-medical units and had medium medical and psychiatric acuity capabilities. The studies reviewed provided little information on the cost-effectiveness of various IMPU designs. Although some comparative studies indicated reductions in hospital length of stay (LOS), these studies were generally of low quality and rarely reported other intended outcomes.

CONCLUSIONS

IMPUs may help shorten LOS. IMPUs should focus care on patients with complex conditions and high acuity to maximize health system value. Implementing compulsory admission facilities; qualified psychiatric, medical, and nursing staff involvement; and cross-disciplinary training may improve IMPUs' capacity to treat high-acuity patients. Future research should relate IMPU designs to intended outcomes.

Proactive Integration of Mental Health Care in Hospital Medicine: PRIME Medicine

BACKGROUND

Proactive consultation-liaison (C-L) psychiatry has been shown to reduce hospital length of stay (LOS), increase psychiatric C-L consult rate, and improve hospital staff satisfaction. Nursing attrition has not been studied in relation to proactive C-L.

OBJECTIVE

Our primary aim in evaluating the proactive C-L service called Proactive Integration of Mental Health Care in Medicine (PRIME Medicine) is to analyze change in LOS over 10 months using historical and contemporary comparison cohorts. As secondary aims, we assess change in psychiatric consultation rate, time to consultation, and change in nurse attrition.

METHODS

PRIME Medicine was implemented in 3 hospital medicine units as a quality-improvement project. Team members systematically screened patients arriving to assigned units for psychiatric comorbidity. Identified patients were reviewed with hospitalist teams and nurses with the goal of early intervention.

RESULTS

Including historical and contemporary comparison cohorts, the mean sample age was 62.4 years (n = 8884). Absolute LOS was unchanged, but difference-in-difference analysis trended toward reduced LOS by 0.16 day (P = 0.08). Consultation rate increased from 1.6% (40 consults) to 7.4% (176 consults). Time to consultation was unchanged (4.0-3.8 d). Annual per-unit nursing turnover increased from 4.7 to 5.7 in PRIME units but from 8.5 to 12.0 in comparison units. Nurses citing "population" as the reason for leaving decreased from 2.7 to 1.7 in PRIME units but increased from 1.5 to 4.5 in comparison units. PRIME Medicine led to increased consultation rate, and our unit-wide outcomes provide a conservative estimate of effect. Factors that may have influenced effect size include our cohort's advanced age, considerable emergency department boarding times, increasing proportion of patients discharged to skilled nursing facilities, and concurrent LOS-reduction initiatives on all units. The favorable trends in nursing attrition on PRIME units may be explained in part by our prior finding that PRIME Medicine was associated with enhanced nursing satisfaction.

CONCLUSIONS

While PRIME Medicine had no more than a modest effect on LOS, it was associated with a markedly increased psychiatric consult rate and favorable trends in nursing retention. This analysis highlights important factors that should be considered when implementing and determining value metrics for a proactive C-L service.

Screening for more with less: Validation of the Global Appraisal of Individual Needs Quick v3 (GAIN-Q3) screeners

Multi-morbidity is the norm among adolescents and adults with substance use and other mental disorders and warrants a multi-pronged screening approach. However, the time constraints on assessment inherent in clinical practice often temper the desire for a full understanding of multi-morbidity problems. The 15- to 25-minute Global Appraisal of Individual Needs Quick version 3 (GAIN-Q3) includes screeners for 9 common clinical problems that are short (4 to 10 items) and provide dimensional measures of problem severity in each area that are also categorized to guide clinical decision making. The screeners are summed into a total score that represents a 10th screener for multi-morbidity. This paper provides background on the development of the GAIN-Q3 screeners, their psychometric behaviors, efficiency, and predictive power relative to the 1-2 h full GAIN-I. Based on literature showing differential item and scale functioning by age, analyses were conducted separately using data from 10,625 adolescent and 10,167 adult treatment clients. Despite the condensed lengths of the screening measures compared with their longer versions, the reliability estimates are within the good to excellent range (0.7 to 0.9) in terms of internal consistency for 6 of the 10 screeners for adolescents and 7 of the 10 screeners for adults. In addition, the part to whole correlation for all 10 comparisons for both adolescents and adults are excellent (0.82 to 0.96). Moreover, there is strong evidence for the measures' convergent and discriminant validity and efficiency (i.e., maximum information gathered in as few items possible) relative to the full-length scales as well as relative to other scales in the full GAIN-I. Analyses of the interpretive cut-scores provide accurate identification of cases with high sensitivity and specificity, thus supporting the screeners' capacity to triage. PUBLIC SIGNIFICANCE STATEMENT: This study reports on the ability (GAIN-Q3) to efficiently screen for multiple co-occurring substance use, mental health, and associated problems. Multi-problem presentation in the social service sector is the normal expectation, yet time constraints prevent broad assessment of potentially many problematic areas. The GAIN-Q3 showed convergent and discriminant validity relative to the full-length scales as well as other scales assessed in the GAIN-I. The GAIN-Q3 achieves the desired balance between broad coverage and measurement efficiency to provide ample information to identify the best course of action for an individual.

Diagnostic Agreement between Physicians and a Consultation-Liaison Psychiatry Team at a General Hospital: An Exploratory Study across 20 Years of Referrals

Consultation-liaison psychiatry (CLP) manages psychiatric care for patients admitted to a general hospital (GH) for somatic reasons. We evaluated patterns in psychiatric morbidity, reasons for referral and diagnostic concordance between referring doctors and CL psychiatrists. Referrals over the course of 20 years (2000-2019) made by the CLP Service at Modena GH (Italy) were retrospectively analyzed. Cohen's kappa statistics were used to estimate the agreement between the diagnoses made by CL psychiatrist and the diagnoses considered by the referring doctors. The analyses covered 18,888 referrals. The most common referral reason was suspicion of depression (n = 4937; 32.3%), followed by agitation (n = 1534; 10.0%). Psychiatric diagnoses were established for 13,883 (73.8%) referrals. Fair agreement was found for depressive disorders (kappa = 0.281) and for delirium (kappa = 0.342), which increased for anxiety comorbid depression (kappa = 0.305) and hyperkinetic delirium (kappa = 0.504). Moderate agreement was found for alcohol or substance abuse (kappa = 0.574). Referring doctors correctly recognized psychiatric conditions due to their exogenous etiology or clear clinical signs; in addition, the presence of positive symptoms (such as panic or agitation) increased diagnostic concordance. Close daily collaboration between CL psychiatrists and GH doctors lead to improvements in the ability to properly detect comorbid psychiatric conditions.

Intoxicated persons showing challenging behavior demand complexity interventions: a pilot study at the interface of the ER and the complexity intervention unit

Intoxicated persons showing challenging behavior (IPCBs) under influence of alcohol and/or drugs frequently have trouble finding appropriate acute care. Often IPCBs are stigmatized being unwilling or unable to accept help. Separated physical and mental healthcare systems hamper integrated acute care for IPCBs. This pilot aimed to substantiate the physical, psychiatric, and social health needs of IPCBs visiting the emergency room (ER) during a 3-month period. All ER visits were screened. After triage by the ER physician, indicated IPCBs were additionally assessed by the consultation-liaison-psychiatry physician. If needed, IPCBs were admitted to a complexity intervention unit for further examinations to provide integrated treatments and appropriate follow-up care. The INTERMED and Health of the Nation Outcome Scale (HoNOS) questionnaires were used to substantiate the complexity and needs. Field-relevant stakeholders were interviewed about this approach for acute integrated care. Alongside substance abuse, almost half of identified IPCBs suffered from comorbid psychiatric disturbances and one third showed substantial physical conditions requiring immediate medical intervention. Almost all IPCBs (96%) accepted the acute medical care voluntarily. IPCBs showed high mean initial scores of INTERMED (27.8 ± 10.0) and HoNOS (20.8 ± 6.9). At discharge from the complexity intervention unit, the mean HoNOS score decreased significantly (13.4 ± 8.6; P < 0.001). Field-relevant stakeholders strongly supported the interdisciplinary approach and ER-facility for IPCBs and acknowledged their unmet health needs. A biopsychosocial assessment at the ER, followed by a short admission if necessary, is effective in IPCBs. This approach helps to merge separated healthcare systems and may reduce stigmatization of IPCBs needing help.

Proactive Integrated Consultation-Liaison Psychiatry: A new service model for the psychiatric care of general hospital inpatients

OBJECTIVE

To describe a new service model for the psychiatric care of general hospital inpatients, called Proactive Integrated Consultation-Liaison Psychiatry ('Proactive Integrated Psychological Medicine' in the UK).

METHOD

The new service model was developed especially for general hospital inpatient populations with multimorbidity, such as older medical inpatients. Its design was informed by the published literature and the clinical experience of C-L psychiatrists. It was operationalized by a process of iterative piloting.

RESULTS

The rationale for the new model and the principles underpinning it are outlined. Details of how to implement it, including a service manual and associated workbook, are provided. The training of clinicians to deliver it is described. The effectiveness and cost-effectiveness of this new service model is being evaluated. Whilst we have found it feasible to deliver and well-accepted by ward teams, potential challenges to its wider implementation are discussed.

CONCLUSION

Proactive Integrated Consultation-Liaison Psychiatry (PICLP) is a fusion of proactive consultation and integrated care, operationalized in a field-tested service manual. Initial experience indicates that it is feasible to deliver. Its effectiveness and cost effectiveness for older patients on acute medical wards is currently being evaluated in a large multicentre randomized controlled trial (The HOME Study).

Proactive Psychiatry Intervention Using a Nurse-Led Behavioral Response Model for Hospitalized Patients With Behavioral Disturbances

BACKGROUND

The health care sector has one of the highest rates of workplace violence, putting staff at risk and impeding care. To deliver quality health care, staff need targeted resources. This article describes a program to improve staff safety and reduce barriers to care for patients with behavioral disturbances.

PROGRAM DESCRIPTION

A nurse-led behavioral response team was created to identify high-risk patients and offer prompt targeted interventions. The Behavioral Optimization and Outcomes Support Team (BOOST) was implemented in November 2012, in conjunction with a proactive model of care, enabling psychiatric intervention. Advanced practice nurses in psychiatry respond to requests from staff on medical/surgical units to assist with management of behavioral disturbances.

METHODS

Consultation and intervention data were reviewed, and staff satisfaction surveys were completed to evaluate the program.

RESULTS

The program has contributed to staff feeling more supported and safer at work. There has also been a reduction in staff's experience of perceived burden in the care of patients with behavioral disturbances although they are caring for more of these patients.

CONCLUSIONS

Although violence risk in health care continues to be a significant issue, programs to intervene early can be effective in supporting staff to minimize these risks.

Integration of a proactive, multidisciplinary mental health team on hospital medicine improves provider and nursing satisfaction

OBJECTIVE

Psychiatric comorbidity among hospital medicine patients is common and often complicates care delivery and compromises outcomes. Team-based, proactive consultation-liaison (CL) psychiatry has been shown to reduce hospital length of stay (LOS) and care costs, but staff satisfaction with this model has not been explored in detail. Here we evaluate its impact on hospital medicine provider and nurse satisfaction.

METHODS

We implemented a team-based proactive CL service that reviews all admitted hospital medicine patients across 3 units for psychiatric comorbidity and provides unit-wide integrated mental health care. Hospital medicine staff completed surveys before and after a 6-month pilot phase: 10-item provider surveys covered resource adequacy, safety, time for healthcare improvements, and burnout; 26-item nurse surveys included the same 10 items plus 8 on behavioral health assessment competency and 8 on intervention competency. Additionally, we characterized psychiatric comorbidity, calculated consultation latency and volume and also average LOS during these 6 months.

RESULTS

The provider response rate was 57% (20/35 before; 21/37 after) and roughly a third for nurses (32/~90 and 31/~90, respectively). Providers rated 9 of 10 items as improved, including one on burnout. Nursing satisfaction improved similarly but with lower effect sizes. During the pilot (n = 1590), 71% had chart-identified psychiatric comorbidity. Consultation latency decreased by 0.86 days; consultation rate increased nearly 3-fold; and average LOS decreased by 0.33 days.

CONCLUSIONS

Team-based proactive CL psychiatry enhances provider and nurse satisfaction and may even reduce provider burnout. We also confirmed that this model is associated with reduced average LOS.

Experience Of Resident Presentations In Consultation-Liaison Psychiatry Grand Rounds: Increase Value For Clinical Education

BACKGROUND

Grand rounds is a formal meeting at which physicians and trainees discuss excellence in medical care. Residents should participate in scholarly activity per Accreditation Council for Graduate Medical Education (ACGME). Consultation-Liaison (CL) psychiatry focuses on caring for patients presenting with psychiatric complications in general hospital. Post-residency subspecialty CL fellowship training plays a big role in creating future leaders in CL. Our program decided to conduct annual CL grand rounds fully allotted to discuss complex CL psychiatry cases in medical setting.

METHODS

We conducted a retrospective review of resident's interest in pursuing CL fellowship. We compared the number of residents pursuing CL fellowship after the CL grand rounds to the previous years starting 2005 when CL was recognized as an ACGME approved subspecialty. We also compared our program residents pursuing CL psychiatry fellowship to national trend obtained from National Residency Matching Program (NRMP).

RESULTS

From 2013 to 2018, CL grand rounds n=8, Number of residents graduated from 2013 to 2018 n=26. Number of residents pursued CL fellowship from 2013 to 2018 n=3 (11.5%) compared to no residents pursuing CL fellowship before 2013. Fisher's exact test to compare and examine the data from the residents pursuing CL fellowship after implementation of the CL grand rounds is 0.0668 (p value < 0.10). When combining all the available NRMP match results for CL from 2015 to 2019, a total of 531 positions were offered and 359 positions were filled (fill rate of 67.6%). In our program, after we implemented the annual CL grand rounds, 11.5% of the residents from 2013 to 2018 pursued CL fellowship, which is higher than the likely national average of 5.7%.

CONCLUSION

Our residency program grand rounds educational module appears to nurture and sustain interest in CL subspecialty compared to previous years. Prospective studies are required.

Factors influencing the admission decision for Medical Psychiatry Units: A concept mapping approach

OBJECTIVE

Medical Psychiatry Units (MPUs), also known as Complexity Intervention Units (CIUs), provide care for complex patients suffering from both psychiatric and physical disorders. Because there is no consensus on the indications for admission to an MPU, daily practice and effectiveness research are hampered. This study therefore used a concept mapping approach to investigate which organizational and medical factors determine the decision to admit a patient to an MPU.

METHODS

The first step of the concept mapping approach was to create a list of factors determining MPU admission from literature. Secondly, clinical experts sorted and ranked these factors. The sorted and ranked data were then analyzed, and a draft conceptual framework was created. A final conceptual MPU admission framework was then drawn during an expert consensus meeting and recommendations for implementation were suggested.

RESULTS

Thirteen clinical experts defined 90 factors from literature, which were sorted and ranked by 40 experts from 21 Dutch hospitals. This concept mapping approach resulted in a five-cluster solution for an MPU admission framework based on: 1. Staff competencies and organizational pre-requisites; 2. Patient context; 3. Patient characteristics; 4. Medical needs and capabilities; and 5. Psychiatric symptoms and behavioral problems. Furthermore, three inclusion and two exclusion criteria were formulated to help the clinicians decide whether or not to admit patients to an MPU. These criteria can be implemented in daily practice.

CONCLUSION

Implementing the five criteria derived from this conceptual framework will help make the admission decision for complex patients with psychiatric and physical disorders to an MPU more correct, consistent, and transparent.

Need analysis for a new high acuity medical psychiatry unit: which patients are considered for admission?

BACKGROUND

The study aims were: to estimate the proportion of patients with an indication for admission to a new high acuity Medical Psychiatric Unit (MPU), to explore the reasons for MPU-admission according to different health disciplines, and to check for differences in patient characteristics. The results of this study are to be utilized in the proposed establishment of a high-acuity MPU in a University Medical Center. Such a unit currently does not exist at Erasmus MC.

METHODS

Hospital in-patients were included if they received psychiatric consultation from the Psychiatric Consultative Service (PCS). As part of the study protocol, psychiatrists, other medical specialists, and nurses determined the need for admission to the proposed MPU. Patient groups were compared with respect to diagnoses, socio-demographic characteristics and patient routing.

RESULTS

One hundred and fifty-one patients were included, 43% had an indication for MPU-admission, for the other patients PCS involvement was sufficient. There was agreement on suicide attempts as a reason for MPU-admission. For psychiatrists, the need for further diagnostic evaluation was a common reason for MPU admission, while other medical specialists more often emphasized the need for safety measures. Patients with an unplanned hospital admission had a higher chance of MPU eligibility (OR = 2.72, 95% CI 1.10-6.70). The main psychiatric diagnoses of MPU-eligible patients were organic disorders (including delirium), mood disorders, and disorders related to substance abuse. The most common diagnoses found were similar to those in previous research on MPU populations.

CONCLUSION

Different medical disciplines have different views on the advantages of MPUs, while all see the need for such facilities. The proposed MPU should be able to accommodate patients directly from the Emergency Unit, and the MPU should provide specialized diagnostic care in an extra safe environment.

Towards integrated medical and mental healthcare in the inpatient setting: what is the role of psychology?

Integrated medical and psychiatric hospital units hold great promise for improving the value and quality of care for patients with severe mental illness and concomitant acute medical needs. It is important to explore the utility of providing a range of multidisciplinary inpatient services to meet patients' complex needs. Within this context, services typically provided by psychologists have received little research attention. To address this gap in the literature, this study assessed inpatient clinicians' perceptions of the need for specific behavioural services on a medical psychiatric unit, exploring their overlap with established psychological services. Results indicate the potential utility of specific psychological services, including psychological assessments, direct psychosocial interventions, and psychoeducational training. While reimbursement and billing barriers still exist for psychologists to be routinely incorporated into hospital settings, the movement towards value-based care could provide the opportunity to think about the value added. Embedding evidence-based psychological services has the potential to promote high quality, well-rounded care that aligns with the established mission of multidisciplinary teamwork on integrated medical and psychiatric inpatient units.

Development of an operational manual for a consultation-liaison psychiatry service

OBJECTIVES

Consultation-liaison psychiatry (CLP) services sit between mental health and the general hospital, and risk being poorly understood by both systems. The aim of this study was to develop an operational manual for a CLP service, which defined functions and governance.

METHODS

The CLP literature was reviewed with a focus on descriptions of CLP roles, organisational processes, quality measures and service development. The CLP team held service planning meetings and met with members of the mental health and hospital executives. Site visits and collaboration with other CLP services occurred in defining the roles of the CLP service and organisational governance.

RESULTS

A CLP operational document was developed, including a description of the service, its functions, staff roles and governance. Procedural information such as the CLP timetable, referral process, triage and assessment, documentation, activity recording, quality assurance and relevant policies were outlined.

CONCLUSIONS

The development of a dedicated operational manual for CLP clarified the roles, functions and governance of CLP within the general hospital and mental health systems. The development process facilitated the engagement of key clinicians and administrators of these systems, the determination of quality improvement targets and greater transparency and accountability.

Psychiatric consultation requests by inpatient medical teams: an observational study

Background

We describe the way psychiatric issues are addressed by inpatient medical teams through analysis of discussions of patients with behavioral health concerns and examination of teams’ subsequent consultation practices.

Methods

We observed morning rounds for nine inpatient medical teams for approximately month-long periods, for a total of 1941 observations. We compared discussions of patients admitted for behavioral health related medical conditions between those who did and did not receive a psychiatric consultation, developing categories to describe factors influencing consultation or other management.

Results

Out of 536 patients, 40 (7.5%) received a psychiatry consult. Evaluation of a known concern (i.e., substance use, affective disorder, or suicidal ideation) was the most common reason for referral (41.7%). Requests for medication review were second (30.6%). Thirty patients with concomitant behavioral and medical health issues did not receive a psychiatry consult. Cirrhosis with active substance use was the most common medical diagnosis (15), followed by alcohol withdrawal (9).

Conclusions

Four primary themes emerged from our data: positive identification of behavioral health issues by physicians, medication management as a primary reason for referral, patient preference in physician decision-making, and poor management of substance abuse. Our results identify two potential areas where skills-building for inpatient physicians could have a positive impact: management of medication and of substance abuse management.

Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care

Mental disorders account for 25% of all health-related disability worldwide. More patients receive treatment for mental disorders in the primary care sector than in the mental health specialty setting. However, brief visits, inadequate reimbursement, deficits in primary care provider (PCP) training, and competing demands often limit the capacity of the PCP to produce optimal outcomes in patients with common mental disorders. More than 80 randomized trials have shown the benefits of collaborative care (CC) models for improving outcomes of patients with depression and anxiety. Six key components of CC include a population-based approach, measurement-based care, treatment to target strategy, care management, supervision by a mental health professional (MHP), and brief psychological therapies. Multiple trials have also shown that CC for depression is equally or more cost-effective than many of the current treatments for medical disorders. Factors that may facilitate the implementation of CC include a more favorable alignment of medical and mental health services in accountable care organizations and patient-centered medical homes; greater use of telecare as well as automated outcome monitoring; identification of patients who might benefit most from CC; and systematic training of both PCPs and MHPs in integrated team-based care.

Psychosomatic problems among medical students: a myth or reality?

Background

Medical students are exposed to stress and this can predispose them to psychological and behavioral consequences.

Methods

Psychosomatic disorders were investigated among 385 medical students from two teaching hospitals using a stratified random sampling. The Enugu somatization Scale (ESS) was used to evaluate for presence of somatization in the participants. Statistical analysis was done with the Statistical Package for Social Sciences (SPPS) version 19 (Chicago IL).

Results

A total of 385 medical students with a calculated mean age of 23.55 ± 3.33 years were recruited in this study. The prevalence of psychosomatic disorder was 55 (14.3%) with prevalence among males 33 (14.2%) and among females 22 (14.4%). Based on features, 44 (11.4%) had head features while 30 (7.8%) had body features of psychosomatic disorder respectively. Similar proportion of both males and females (about 14% each) had psychosomatic disorder. There was no statistically significant difference (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\chi^{2}$$\end{document}χ2 = 0.002, p = 0.966). Students aged 24 years and below had similar proportion of psychosomatic disorder 38 (14.3%) with those aged over 24 years 17 (14.2%). The difference was not statistically significant (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\chi^{2}$$\end{document}χ2 = 0.002, p = 0.964). Students from lower social class had lower proportion of psychosomatic disorder (10.6%) when compared to middle (17.2%) and upper (15.2%). The difference was equally not statistically significant (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\chi^{2}$$\end{document}χ2 = 1.759, p = 0.415). Male students had similar likelihood of psychosomatic disorder with females (OR 1.01, 95% CI 0.56−1.82). Those had belong to middle socio-economic class were about 1.2 times (AOR 1.15, 95% CI 0.54−2.45) and lower socio-economic class about 0.6 times (AOR 0.66, 95% CI 0.31−1.37) likely to have psychosomatic disorder than those from upper socio-economic class.

Conclusions

Psychosomatic disorders constitute an emerging mental health problem among medical students in Nigerian Universities. This can pose a major mental health problem if neglected.

Electronic supplementary material

The online version of this article (doi:10.1186/s13033-016-0105-3) contains supplementary material, which is available to authorized users.

Journeying with HIV patients across the health care spectrum - an examination of a seamless model of HIV Psychiatry of a large urban general hospital

OBJECTIVE

To describe a model of HIV psychiatry used in an urban hospital in Toronto and examine it against current literature.

METHOD

Using a narrative method, we elaborate on how this model delivers care across many different settings and the integral roles that the HIV psychiatrist plays in each of these settings. This is articulated against a backdrop of existing literature regarding models of HIV care.

RESULTS

This model is an example of an integrated model as opposed to a traditional consultation-liaison model and is able to deliver seamless care while remaining focused on patient-centric care.

CONCLUSION

An HIV psychiatrist delivers seamless and patient-centric care by journeying with patients across the healthcare spectrum and playing different roles in different care settings.

[Geropsychiatric consultation-liaison services. An answer to the challenges of dementia?]

BACKGROUND

The care for people suffering from dementia is difficult, independent from the setting they live in or are cared for (at home, in nursing homes, or in general hospitals).This study looks at the possibility to achieve sustained quality improvement as well as cost-offset effects by the implementation of psychogeriatric consultation-liaison services in these settings.

METHODS

We compare effects of psychogeriatric consultation-liaison services in primary care patients, nursing homes, and general hospital inpatients. We re-analyze longitudinal data drawn from our own studies conducted in the respective settings.

RESULTS

Our comparison shows that many patients in all settings show benefits with regard to several measures following the consultation-liaison interventions. Patient-specific improvement in delivery of services can be seen in primary care, while in both nursing homes as well as in general hospitals, we found improvement in staff competency with regard to the improvement in knowledge and expertise in dementia care practice. Cost-offset effects can be observed in all three settings.

CONCLUSION

For consultation-liaison services to reach their optimum in efficiency in Germany, the transgression of sector boundaries (e.g., between primary care and general hospitals) must be addressed and improved by specific integrated service delivery contracts that help all participants to achieve a solid legal basis.

[Economic impact of consultation-liaison psychiatry in a French University Hospital Centre]

BACKGROUND

In times of fiscal restraint for health structures, apart from the clinical input, it seems important to discuss the economic impact of liaison psychiatry. There are only a few studies on the economic added value provided by a liaison psychiatry team. In addition to this, only a few psychiatric pathologies are coded as they should be, hence we make the assumption of an additional development provided by a specialised team.

METHODS

Over a short period of 4months, in three departments of the Toulouse University Hospital Centre, the added value to the general pricing system of liaison psychiatry was studied. The population was represented by all the consecutive requests for consultations from patients over 18years old, men and women, hospitalised at that time. These three departments frequently request consultations with the psychiatry liaison team. They set a diagnostic, and if this is associated with a higher Homogeneous Group of Patients (HGP), it provides added value.

RESULTS

Fifty-two patients benefited from a psychiatric consultation over 4months. The results highlight a development of € 8630.43 for the traumatology department, € 3325.03 for the internal medicine department, and € 513.61 for the haematology department over the study period. The overall development over this period was € 12,469.07.

CONCLUSION

To our knowledge, this approach is one of the first in France to highlight an economic impact of the intervention of liaison psychiatry in the claiming departments.

What is integrated care?

Increasing awareness of mental illness's impact on medical and psychiatric health has accelerated global efforts to integrate medical and behavioural health services. As the field of integration has advanced, numerous integrated programmes have been implemented. In examining the impact of these programmes, it is important to maintain a standardized vocabulary to describe the various components of their integration. Additionally important is examination of how these programmes impact elements of patient care and the healthcare system. Specifically, what value do they bring? This article will discuss the importance of carefully assessing the value integrated services bring to patients, and questioning whether they do so in ways in which today's segregated world of medical and behavioural health cannot. This article will also explore the various settings in which medical and behavioural integration can bring added value.

Société de psychologie médicale et de psychiatrie de liaison (avec le soutien de la FTLSU) – Le malade complexe en psychiatrie de liaison : évaluation, stratégies thérapeutiques et aspects médico-économiques

La Société de psychologie médicale et de psychiatrie de liaison de langue française souhaite consacrer un symposium à la place grandissante des « malades complexes » en psychiatrie de liaison, situations exigeant plus que toute autre, une intervention multidisciplinaire coordonnée, basée sur des expertises complémentaires, telles qu’elles sont réunies tout particulièrement dans les Centres Hospitalo-Universitaires. Ces situations sont également exemplaires pour aborder les aspects médico-économiques et proposer des pistes pour une valorisation des activités de psychiatrie de liaison. La complexité bio-psycho-sociale des cas rencontrés sera déclinée et approchée :

– à l’aide d’outils évaluatifs, comme INTERMED, en cours de validation dans différents pays européens sous sa forme d’auto-questionnaire ;

– au travers d’exemples de patients pris en charge dans des secteurs d’excellence comme la chirurgie bariatrique, les greffes cardiaques ou le cœur artificiel, à l’Assistance Publique–Hôpitaux de Paris ou dans d’autres Centres Hospitalo-Universitaires, comme le CHU d’Angers ;

– en précisant les rôles respectifs des psychiatres, psychologues, infirmiers de liaison ;

– en brossant la diversité des approches thérapeutiques initiées ou envisagées ;

– enfin en réfléchissant à l’impact médico-économique de la complexité et des interventions menées pour rendre plus efficient le parcours de soins de ces patients et mieux préserver leur qualité de vie.

Biopsychosocial aspects and the complexity of care of hospitalized elderly

Objective To investigate the biopsychosocial aspects and aspects of the health system of hospitalized elderly and to classify their degree of care complexity. Methods This was a quantitative study whose convenience sample consisted of 279 elderly. The Interdisciplinary Medicine Instrument (INTERMED) method was used, a tool that identified biopsychosocial aspects and conditions of the health system and classified the complexity of the patient. The data were submitted to descriptive analysis. Results The prevailing profile was of elderly women, retired, white, with low educational levels, married and satisfied with their life conditions. The mean age was 72.3 years. The biological domain was the most compromised. As for the complexity of care, 34.8% of the patients required multiprofessional care. Conclusion The elderly had high care complexity, with the biological and health system domains being the most compromised.

Value-based financially sustainable behavioral health components in patient-centered medical homes

Because a high percentage of primary care patients have behavioral problems, patient-centered medical homes (PCMHs) that wish to attain true comprehensive whole-person care will find ways to integrate behavioral health services into their structure. Yet in today's health care environment, the incorporation of behavioral services into primary care is exceptional rather than usual practice. In this article, we discuss the components considered necessary to provide sustainable, value-added integrated behavioral health care in the PCMH. These components are to: (1) combine medical and behavioral benefits into one payment pool; (2) target complex patients for priority behavioral health care; (3) use proactive onsite behavioral "teams;" (4) match behavioral professional expertise to the need for treatment escalation inherent in stepped care; (5) define, measure, and systematically pursue desired outcomes; (6) apply evidence-based behavioral treatments; and (7) use cross-disciplinary care managers in assisting the most complicated and vulnerable. By adopting these 7 components, PCHMs will augment their ability to achieve improved health in their patients at lower cost in a setting that enhances ease of access to commonly needed services.

Direct and indirect costs in persons with chronic back pain and comorbid mental disorders--a systematic review

OBJECTIVE

Direct inpatient and outpatient healthcare costs as well as indirect costs (e.g. productivity losses) are hypothesized to be increased in chronic back pain (CBP) patients with mental disorders. The aim of this systematic review is to examine this hypothesis by comparing costs in CBP patients with and without mental disorders.

METHODS

A comprehensive literature search (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS) was conducted. All studies were included which allowed for a comparison of direct and indirect costs between CBP patients with and without mental disorders.

RESULTS

Of 2283 potentially relevant articles, 10 studies fulfilled the inclusion criteria. Total healthcare costs (SMD=0.16 [SE=0.06]; n=1), CBP-related healthcare costs (SMD=0.21 [0.06]; n=1), CBP-related primary care visits (OR=1.6 [95%-CI:1.2-2.3]; n=1), CBP-related specialty care visits (OR=1.4 [1.0-2.0];n=1), CBP-related radiologic procedures (OR=1.6 [1.0-2.5]; n=1) and mental health visits (OR=8.1 [7.3-9.1]; n=2) were increased in CBP patients with depression. The incidence of new surgeries was increased in CBP patients with PTSD (OR=4.2 [1.6-10.8]; n=1). Pain-related healthcare use (n=1) in CBP patients with both depression and anxiety and CBP-related hospital admissions (n=1) in CBP patients with depression were not increased. Regarding indirect costs results were inconsistent for both return to work rates (n=3) and work absence (n=2).

CONCLUSION

The results indicate increased direct but not indirect costs in CBP patients with mental disorders. However, the evidence is limited due to the low number of studies per outcome. This is all the more problematic, since the adequate allocation of healthcare resources will become a major topic of health care policy due to limited resources.

Practice and career outcomes of double-boarded psychiatrists

BACKGROUND

The practice patterns and career paths of physicians who are double-boarded in medicine, family practice, or neurology and psychiatry are not well understood. Given increased attention to integrated medical and psychiatric care, these individuals may play an important role.

OBJECTIVE

To compare the practice patterns and career paths of physicians who are double-boarded in medicine, family practice, or neurology and psychiatry with physicians who are boarded in general psychiatry, and among double-boarded physicians with various training sequences and specialty types.

METHOD

A survey was distributed to all physicians identified by the American Board of Medical Specialties (ABMS) as double-boarded in medicine, family practice, or neurology and psychiatry, and an equal number of physicians who are boarded in general psychiatry.

RESULTS

Compared with psychiatrists who are not double-boarded, double-boarded psychiatrists are significantly more likely to be older, more likely to be male, to practice in consultation-liaison or inpatient settings, and to assume positions of leadership in departments of psychiatry or in general health care organizations. Among the various groups of double-boarded physicians, 39% continue to practice their medical specialty in addition to their psychiatry practice, although this varies by medical specialty, sequence or type of program, and motivation for double-board training.

CONCLUSION

Double-boarded physicians appear to be a distinct group within psychiatry and may serve as an important bridge to the general medical environment because of their leadership roles and medical psychiatric practice patterns. Further understanding of their career development and roles is warranted.

Tiered Frameworks for Planning Substance Use Service Delivery Systems: Origins and Key Principles

It is well known that only a relatively small proportion of people in the community who experience substance use problems seek assistance from the specialized sector of services that have been commissioned to provide treatment and support for these problems. Going back to seminal reports from the early 1990s there has been a call for a systems approach to “broaden the base of treatment” in order to achieve wider coverage and yield positive outcomes at a population level. In some jurisdictions conceptual models referred to as “tiered models” have been advanced to support planning, system design and performance monitoring. This paper traces the evolution of such tiered models for substance use services and describes a recent model advanced in Ontario Canada for design of an integrated system of mental health, substance use and problem gambling services and supports. The paper concludes by highlighting key features and principles of the tiered approach that are critical for its actual operationalization. Some challenges operationalizing such a comprehensive system design framework are also noted.