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Sharpe M, Walker J, van Niekerk M, Toynbee M, Magill N, Frost C, White IR, Walker S, Duarte A, Owens C, Dickens C, Price A. Proactive integrated consultation-liaison psychiatry and time spent in hospital by older medical inpatients in England (The HOME Study): a multicentre, parallel-group, randomised controlled trial. Lancet Psychiatry 2024; 11:684-695. [PMID: 39137790 DOI: 10.1016/s2215-0366(24)00188-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/02/2024] [Accepted: 06/04/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Older people admitted to hospital in an emergency often have prolonged inpatient stays that worsen their outcomes, increase health-care costs, and reduce bed availability. Growing evidence suggests that the biopsychosocial complexity of their problems, which include cognitive impairment, depression, anxiety, multiple medical illnesses, and care needs resulting from functional dependency, prolongs hospital stays by making medical treatment less efficient and the planning of post-discharge care more difficult. We aimed to assess the effects of enhancing older inpatients' care with Proactive Integrated Consultation-Liaison Psychiatry (PICLP) in The HOME Study. We have previously described the benefits of PICLP reported by patients and clinicians. In this Article, we report the effectiveness and cost-effectiveness of PICLP-enhanced care, compared with usual care alone, in reducing time in hospital. METHODS We did a parallel-group, multicentre, randomised controlled trial in 24 medical wards of three English acute general hospitals. Patients were eligible to take part if they were 65 years or older, had been admitted in an emergency, and were expected to remain in hospital for at least 2 days from the time of enrolment. Participants were randomly allocated to PICLP or usual care in a 1:1 ratio by a database software algorithm that used stratification by hospital, sex, and age, and randomly selected block sizes to ensure allocation concealment. PICLP clinicians (consultation-liaison psychiatrists supported by assisting clinicians) made proactive biopsychosocial assessments of patients' problems, then delivered discharge-focused care as integrated members of ward teams. The primary outcome was time spent as an inpatient (during the index admission and any emergency readmissions) in the 30 days post-randomisation. Secondary outcomes were the rate of discharge from hospital for the total length of the index admission; discharge destination; the length of the index admission after random allocation truncated at 30 days; the number of emergency readmissions to hospital, the number of days spent as an inpatient in an acute general hospital, and the rate of death in the year after random allocation; the patient's experience of the hospital stay; their view on the length of the hospital stay; anxiety (Generalized Anxiety Disorder-2); depression (Patient Health Questionnaire-2); cognitive function (Montreal Cognitive Assessment-Telephone version); independent functioning (Barthel Index of Activities of Daily Living); health-related quality of life (five-level EuroQol five-dimension questionnaire); and overall quality of life. Statisticians and data collectors were masked to treatment allocation; participants and ward staff could not be. Analyses were intention-to-treat. The trial had a patient and public involvement panel and was registered with ISRTCN (ISRCTN86120296). FINDINGS 2744 participants (1399 [51·0%] male and 1345 [49·0%] female) were enrolled between May 2, 2018, and March 5, 2020; 1373 were allocated to PICLP and 1371 to usual care. Participants' mean age was 82·3 years (SD 8·2) and 2565 (93·5%) participants were White. The mean time spent in hospital in the 30 days post-randomisation (analysed for 2710 [98·8%] participants) was 11·37 days (SD 8·74) with PICLP and 11·85 days (SD 9·00) with usual care; adjusted mean difference -0·45 (95% CI -1·11 to 0·21; p=0·18). The only statistically and clinically significant difference in secondary outcomes was the rate of discharge, which was 8.5% higher (rate ratio 1·09 [95% CI 1·00 to 1·17]; p=0·042) with PICLP-a difference most apparent in patients who stayed for more than 2 weeks. Compared with usual care, PICLP was estimated to be modestly cost-saving and cost-effective over 1 and 3, but not 12, months. No intervention-related serious adverse events occurred. INTERPRETATION This is the first randomised controlled trial of PICLP. PICLP is experienced by older medical inpatients and ward staff as enhancing medical care. It is also likely to be cost-saving in the short-term. Although the trial does not provide strong evidence that PICLP reduces time in hospital, it does support and inform its future development and evaluation. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- Michael Sharpe
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK.
| | - Jane Walker
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Maike van Niekerk
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Mark Toynbee
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Nicholas Magill
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Frost
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Ana Duarte
- Centre for Health Economics, University of York, York, UK
| | - Colm Owens
- NHS Devon Mental Health, Learning Disability and Neurodiversity Provider Collaborative, Devon, UK
| | - Chris Dickens
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Annabel Price
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
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Sharpe M, Toynbee M, van Niekerk M, Solomons L, Owens C, Price A, Yousif M, Palmer A, Clay F, Berk G, Burns J, Hill L, Harris J, Bajorek T, Sirois-Giguere G, Magill N, Aitken P, Dickens C, Walker J. 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. Gen Hosp Psychiatry 2024; 86:108-117. [PMID: 38185070 DOI: 10.1016/j.genhosppsych.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/09/2024]
Abstract
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.
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Affiliation(s)
- Michael Sharpe
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK.
| | - Mark Toynbee
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Maike van Niekerk
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Luke Solomons
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Colm Owens
- NHS Devon Mental Health, Learning Disability and Neurodiversity Provider Collaborative, Devon, UK
| | - Annabel Price
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | | | - Aelfrida Palmer
- NHS Devon Mental Health, Learning Disability and Neurodiversity Provider Collaborative, Devon, UK
| | - Felix Clay
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Gunes Berk
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Jonathan Burns
- NHS Devon Mental Health, Learning Disability and Neurodiversity Provider Collaborative, Devon, UK
| | - Laura Hill
- NHS Devon Mental Health, Learning Disability and Neurodiversity Provider Collaborative, Devon, UK
| | - Jessica Harris
- Gloucestershire Health and Care NHS Foundation Trust, Gloucester, UK
| | - Tomasz Bajorek
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Nicholas Magill
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Aitken
- Sussex Partnership Foundation Trust, Worthing, UK
| | | | - Jane Walker
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
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Pinto C, Fabbricotti IN, van Wijngaarden J, Hoogendijk WJG, Alsma J, van Busschbach JJ, van Schijndel MA. Moving Beyond the Status Quo of Integrated Inpatient Medical and Psychiatric Care Units: The Path to Real-World Evaluation. Psychiatr Serv 2022; 73:555-560. [PMID: 34704774 DOI: 10.1176/appi.ps.202000811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- C Pinto
- Department of Psychiatry (Pinto, Hoogendijk), Department of Internal Medicine (Alsma), and Department of Medical Psychology (van Busschbach), Erasmus University Medical Centre, Rotterdam, the Netherlands; Erasmus School of Health Policy and Management,Erasmus University Rotterdam, Rotterdam, the Netherlands (Fabbricotti, Wijngaarden, van Schijndel)
| | - I N Fabbricotti
- Department of Psychiatry (Pinto, Hoogendijk), Department of Internal Medicine (Alsma), and Department of Medical Psychology (van Busschbach), Erasmus University Medical Centre, Rotterdam, the Netherlands; Erasmus School of Health Policy and Management,Erasmus University Rotterdam, Rotterdam, the Netherlands (Fabbricotti, Wijngaarden, van Schijndel)
| | - J van Wijngaarden
- Department of Psychiatry (Pinto, Hoogendijk), Department of Internal Medicine (Alsma), and Department of Medical Psychology (van Busschbach), Erasmus University Medical Centre, Rotterdam, the Netherlands; Erasmus School of Health Policy and Management,Erasmus University Rotterdam, Rotterdam, the Netherlands (Fabbricotti, Wijngaarden, van Schijndel)
| | - W J G Hoogendijk
- Department of Psychiatry (Pinto, Hoogendijk), Department of Internal Medicine (Alsma), and Department of Medical Psychology (van Busschbach), Erasmus University Medical Centre, Rotterdam, the Netherlands; Erasmus School of Health Policy and Management,Erasmus University Rotterdam, Rotterdam, the Netherlands (Fabbricotti, Wijngaarden, van Schijndel)
| | - J Alsma
- Department of Psychiatry (Pinto, Hoogendijk), Department of Internal Medicine (Alsma), and Department of Medical Psychology (van Busschbach), Erasmus University Medical Centre, Rotterdam, the Netherlands; Erasmus School of Health Policy and Management,Erasmus University Rotterdam, Rotterdam, the Netherlands (Fabbricotti, Wijngaarden, van Schijndel)
| | - J J van Busschbach
- Department of Psychiatry (Pinto, Hoogendijk), Department of Internal Medicine (Alsma), and Department of Medical Psychology (van Busschbach), Erasmus University Medical Centre, Rotterdam, the Netherlands; Erasmus School of Health Policy and Management,Erasmus University Rotterdam, Rotterdam, the Netherlands (Fabbricotti, Wijngaarden, van Schijndel)
| | - M A van Schijndel
- Department of Psychiatry (Pinto, Hoogendijk), Department of Internal Medicine (Alsma), and Department of Medical Psychology (van Busschbach), Erasmus University Medical Centre, Rotterdam, the Netherlands; Erasmus School of Health Policy and Management,Erasmus University Rotterdam, Rotterdam, the Netherlands (Fabbricotti, Wijngaarden, van Schijndel)
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van Schijndel MA, van Wijngaarden JDH, van de Klundert JJ. Organization and Outcomes of Integrated Inpatient Medical and Psychiatric Care Units: A Systematic Review. Psychiatr Serv 2022; 73:64-76. [PMID: 34407632 DOI: 10.1176/appi.ps.202000416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Maarten A van Schijndel
- Rijnstate Hospital, Arnhem, the Netherlands (van Schijndel); Erasmus MC, University Medical Center, Rotterdam, the Netherlands (van Schijndel); Erasmus School of Health Policy and Management, Rotterdam, the Netherlands (van Wijngaarden, van de Klundert); Prince Mohammed Bin Salman College of Business and Entrepreneurship, King Abdullah Economic City, Saudi Arabia (van de Klundert)
| | - Jeroen D H van Wijngaarden
- Rijnstate Hospital, Arnhem, the Netherlands (van Schijndel); Erasmus MC, University Medical Center, Rotterdam, the Netherlands (van Schijndel); Erasmus School of Health Policy and Management, Rotterdam, the Netherlands (van Wijngaarden, van de Klundert); Prince Mohammed Bin Salman College of Business and Entrepreneurship, King Abdullah Economic City, Saudi Arabia (van de Klundert)
| | - Joris J van de Klundert
- Rijnstate Hospital, Arnhem, the Netherlands (van Schijndel); Erasmus MC, University Medical Center, Rotterdam, the Netherlands (van Schijndel); Erasmus School of Health Policy and Management, Rotterdam, the Netherlands (van Wijngaarden, van de Klundert); Prince Mohammed Bin Salman College of Business and Entrepreneurship, King Abdullah Economic City, Saudi Arabia (van de Klundert)
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Azraai M, Pham JH, Looi WF, Wirth D, Ng ASL, Babu U, Saluja B, Lim AKH. Observational cohort study of the triggers, diagnoses and outcomes of the medical emergency team (MET) response in adult psychiatry inpatients colocated with acute medical services in Australia. BMJ Open 2021; 11:e046110. [PMID: 34620654 PMCID: PMC8499333 DOI: 10.1136/bmjopen-2020-046110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Medical emergencies in psychiatric inpatients are challenging due to the model of care and limited medical resources. The study aims were to determine the triggers and outcomes of a medical emergency team (MET) call in psychiatric wards, and the risk factors for MET activation and mortality. DESIGN Retrospective multisite cohort study. SETTING Psychiatry units colocated with acute medical services at three major metropolitan hospitals in Melbourne, Australia. PARTICIPANTS We studied 487 adult inpatients who experienced a total of 721 MET calls between January 2015 and January 2020. Patients were relatively young (mean age, 45 years) and had few medical comorbidities, but a high prevalence of smoking, excessive alcohol intake and illicit drug use. OUTCOME MEASURES We performed a descriptive analysis of the triggers and outcomes (transfer rates, investigations, final diagnosis) of MET calls. We used logistic regression to determine the factors associated with the primary outcome of inpatient mortality, and the secondary outcome of the need for specific medical treatment compared with simple observation. RESULTS The most common MET triggers were a reduced Glasgow Coma Scale, tachycardia and hypotension, and 49% of patients required transfer. The most frequent diagnosis was a drug adverse effect or toxidrome, followed by infection and dehydration. There was a strong association between a leave of absence and MET calls, tachycardia and the final diagnosis of drug adverse effects. Mortality occurred in 3% after MET calls. Several baseline and MET clinical variables were associated with mortality but a model with age (per 10 years, OR 1.61, 95% CI 1.29 to 2.01) and hypoxia (OR 3.59, 95% CI 1.43 to 9.04) independently predicted mortality. CONCLUSION Vigilance is required in patients returning from day leave, and drug adverse effects remain a challenging problem in psychiatric units. Hypoxic older patients with cardiovascular comorbidity have a higher risk of death.
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Affiliation(s)
- Meor Azraai
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Jeanette H Pham
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Wenye F Looi
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Daniel Wirth
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Ashley S L Ng
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Umesh Babu
- Department of Psychiatry, Monash Health, Clayton, Victoria, Australia
| | - Bharat Saluja
- Department of Psychiatry, Monash Health, Clayton, Victoria, Australia
| | - Andy K H Lim
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
- Department of Medicine, Monash University School of Clinical Sciences at Monash Health, Clayton, Victoria, Australia
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Wittink MN, Cross W, Goodman J, Jackson H, Lee HB, Olivares T, Maeng DD, Caine ED. Taking the Long View in an Inpatient Medical Unit: A Person-Centered, Integrated Team Approach for Patients With Severe Mental Illnesses. Psychiatr Serv 2020; 71:885-892. [PMID: 32362225 DOI: 10.1176/appi.ps.201900385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Patients with severe mental illnesses and related conditions, such as substance misuse and suicide attempts, are among the highest utilizers of acute inpatient medical services. The objective of this study was to assess the impact of a specialized medical unit that uses a comprehensive biopsychosocial model to care for patients with severe mental illnesses. METHODS The study used administrative data to compare patients with severe mental illnesses admitted to a specialized unit with patients admitted to medically similar acute (non-intensive care) medical units in a tertiary academic medical center. With controls for sociodemographic variables, illness severity, and medical complexity, multivariate regression analyses compared utilization outcomes for patients from the specialized unit with outcomes from comparison units. RESULTS Patients on the specialized unit (N=2,077) were younger, had more mental disorder diagnoses, and were more likely to have less severe general medical illness and less medical complexity than patients from comparison units (N=12,824). Analyses of a subsample of patients with complex behavioral health diagnoses indicated that those on the specialized unit had a shorter average stay, higher odds of discharge to home, and lower odds of 30-day readmission, compared with those on comparison units. CONCLUSIONS Specialized units targeted to the needs of patients with serious mental illnesses can provide a moment of engagement when vulnerable patients are likely to benefit from more coordinated care. Findings suggest that a specialized unit that capitalizes on this moment of engagement and uses a biopsychosocial model of care can improve utilization outcomes.
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Affiliation(s)
- Marsha N Wittink
- Department of Psychiatry (Wittink, Cross, Jackson, Lee, Olivares, Maeng, Caine), Department of Family Medicine (Wittink), Department of Pediatrics (Cross), and Department of Medicine (Olivares), University of Rochester Medical Center (Goodman), Rochester, New York
| | - Wendi Cross
- Department of Psychiatry (Wittink, Cross, Jackson, Lee, Olivares, Maeng, Caine), Department of Family Medicine (Wittink), Department of Pediatrics (Cross), and Department of Medicine (Olivares), University of Rochester Medical Center (Goodman), Rochester, New York
| | - Jacqueline Goodman
- Department of Psychiatry (Wittink, Cross, Jackson, Lee, Olivares, Maeng, Caine), Department of Family Medicine (Wittink), Department of Pediatrics (Cross), and Department of Medicine (Olivares), University of Rochester Medical Center (Goodman), Rochester, New York
| | - Heather Jackson
- Department of Psychiatry (Wittink, Cross, Jackson, Lee, Olivares, Maeng, Caine), Department of Family Medicine (Wittink), Department of Pediatrics (Cross), and Department of Medicine (Olivares), University of Rochester Medical Center (Goodman), Rochester, New York
| | - Hochang B Lee
- Department of Psychiatry (Wittink, Cross, Jackson, Lee, Olivares, Maeng, Caine), Department of Family Medicine (Wittink), Department of Pediatrics (Cross), and Department of Medicine (Olivares), University of Rochester Medical Center (Goodman), Rochester, New York
| | - Telva Olivares
- Department of Psychiatry (Wittink, Cross, Jackson, Lee, Olivares, Maeng, Caine), Department of Family Medicine (Wittink), Department of Pediatrics (Cross), and Department of Medicine (Olivares), University of Rochester Medical Center (Goodman), Rochester, New York
| | - Daniel D Maeng
- Department of Psychiatry (Wittink, Cross, Jackson, Lee, Olivares, Maeng, Caine), Department of Family Medicine (Wittink), Department of Pediatrics (Cross), and Department of Medicine (Olivares), University of Rochester Medical Center (Goodman), Rochester, New York
| | - Eric D Caine
- Department of Psychiatry (Wittink, Cross, Jackson, Lee, Olivares, Maeng, Caine), Department of Family Medicine (Wittink), Department of Pediatrics (Cross), and Department of Medicine (Olivares), University of Rochester Medical Center (Goodman), Rochester, New York
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Sharpe M, Toynbee M, Walker J. Proactive Integrated Consultation-Liaison Psychiatry: A new service model for the psychiatric care of general hospital inpatients. Gen Hosp Psychiatry 2020; 66:9-15. [PMID: 32592995 DOI: 10.1016/j.genhosppsych.2020.06.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 01/08/2023]
Abstract
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).
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Affiliation(s)
- Michael Sharpe
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK.
| | - Mark Toynbee
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Jane Walker
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
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- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
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Jansen L, Hunnik F, Busschbach JJV, Lijmer JG. Measuring outcomes on a Medical Psychiatric Unit: HoNOS,, CANSAS and costs. Psychiatry Res 2019; 280:112526. [PMID: 31445422 DOI: 10.1016/j.psychres.2019.112526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/16/2019] [Accepted: 08/17/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To study the course of the functional status and healthcare needs of patients on a Medical Psychiatric Unit (MPU). METHODS In a single-centre observational prospective design the Health of the Nation Outcome Scales (HoNOS) and Camberwell Assessment of Needs Short Appraisal Schedule (CANSAS) instruments were administered at admission and discharge. Functional status and healthcare needs were assessed utilizing the HoNOS and CANSAS respectively. The total costs of healthcare claims related to the admission were calculated based on claims data. RESULTS In total 50 patients were included with a mean improvement of 4.6 on the HoNOS and an effect size of 0.6.The total number of unmet needs fell from 208 to 115. The median costs per decreased HoNOS point were €2.842 and €6.880 per unmet need. DISCUSSION Many patients improved, but due to a large standard deviation at baseline and a low Cronbach's alpha, only 4 patients showed a reliable improvement on functional status. That substantial remission was achieved was shown by the decrease in unmet needs of 93 (44.7%) for the whole group. These observations support the implementation of MPUs, although more research is warranted to ensure cost-effectiveness.
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Affiliation(s)
- L Jansen
- Erasmus MC - Deparment of Psychiatry, University Hospital located in Rotterdam, the Netherlands; DC Klinieken - Chain of Private Clinics, staff is situated in Almere, the Netherlands.
| | - F Hunnik
- OLVG - Large Teaching Hospital located in Amsterdam, the Netherlands
| | - J J V Busschbach
- Erasmus MC - Deparment of Psychiatry, University Hospital located in Rotterdam, the Netherlands
| | - J G Lijmer
- OLVG - Large Teaching Hospital located in Amsterdam, the Netherlands
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Pudalov LR, Swogger MT, Wittink M. Towards integrated medical and mental healthcare in the inpatient setting: what is the role of psychology? Int Rev Psychiatry 2018; 30:210-223. [PMID: 30821187 DOI: 10.1080/09540261.2018.1552125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Lauren R Pudalov
- a Chronic Pain Rehabilitation Program and Bariatric & Metabolic Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Marc T Swogger
- b Department of Psychiatry, University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Marsha Wittink
- c Departments of Family Medicine and Psychiatry, University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
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