“C-L Psychiatry’s reactive service model is in need of refinement,” say co-chairs of ACLP’s newest SIG
“We need an urgent capacity evaluation. He wants to leave AMA. He just hit the nurse, and security’s here on the floor.”
A week into a patient’s hospitalization you’re consulted on a patient whose outpatient antipsychotic had been held on admission and has not yet been restarted. “We have a patient for you. He has schizophrenia, and he’s floridly psychotic.”
“New consult here: the patient’s med seeking. She’s been getting alprazolam since she first came in, and now she makes threats when we talk about stopping it.”
Late Friday afternoon the dreaded request comes in: “We have this patient we need you to see. It’s discharge-dependent.”
“Could you assess our patient’s capacity? He’s making poor decisions.”
“Please evaluate and treat.”
“Could you see our patient? I want to make sure his psych meds are right.”
“We’d like you to see our patient. They’re leaving this evening, but we thought they might benefit from something for depression and maybe a referral.”
Every C-L psychiatrist knows the feeling: the sense that if we had been here just a couple of days earlier, we might have avoided this crisis.
If we could have been there from the beginning, perhaps the course of care would have been altered, providers and nurses would have made different decisions, and the outcomes might have been better for everyone, especially the patient. Yet, the arrow of time has only one direction.
The examples above constitute a significant portion of the work of C-L Psychiatry, variations on a theme of crisis. There’s the patient who has been escalating for days, but the psychiatric consultation was delayed until frank agitation emerged, or a critical decision had to be made.
There’s the patient with schizophrenia whose medication was held on admission for any number of reasons and never re-started—for example, a result of imperfect hand-offs between providers as teams rotated—whose subsequent psychiatric crisis alerts everyone to the oversight.
Similar are the instances where psychotropics are inadvertently discontinued causing withdrawal or rebound syndromes and then re-started at full-dose, only to be met with new side-effects. Well-meaning providers start opioids or benzodiazepines, leading to physiological dependence and pseudo-addiction. And what C-L psychiatrist has not known the heart-sink of the “discharge-dependent” consult late Friday afternoon?
Then, there are the consults that are ill-defined or feel inconsequential. For instance, many consults lack a clear question: “Capacity for what decision in particular?” “Evaluate and treat for what?” we might ask. “What concerns do you have about the patient’s medications?”
Consult questions for issues where we might have little to offer, or that we think don’t rise to the level of a “full consult” can introduce thorns in the relationship: “Psych doesn’t want to see our patient.” Yes, if it weren’t a busy day, or if we had a chance to start a medication a few days earlier and monitor tolerability, or perhaps even if the patient had a stable clinical relationship with an outpatient provider who could oversee dose titration… Often, our consultations feel unsatisfying because we feel helpless: we might have little to offer this patient, at this time, in this setting. And feeling helpless is unsettling.
The limitations are real, though. Staff availability, consult volume, institutional priorities, and academic obligations like teaching and administrative duties often conspire together to prevent further expansion or development of our services, or of meeting many of the mental health needs in the general hospital.
Regardless of how we parcel out the clinical and staffing issues, the fact of need among our patients and in our hospitals remains. Traditional C-L Psychiatry services see only a fraction of general hospital patients who have clinically actionable mental health concerns, and the limitations inherent in our current systems of care mean that C-L Psychiatry providers end up prioritizing the most acute psychiatric crises first and address the others only when, or if, we have time.
We would all like to do more and to do better for our patients, for the providers requesting consultation, and for the nurses and other hospital staff who work hand-in-hand with our patients. But, as hospital systems shift increasingly toward value-based care, our C-L Psychiatry programs run the risk of being outdated and stale—maintaining an old-fashioned “wait and react” approach—while the health care environment around us is fast evolving.
Our conventional C-L Psychiatry model was first formally implemented by Billings during the 1930s when average lengths of stay were measured in weeks, not in days. We have overwhelming evidence of unmet mental health needs undetected, neglected, or turfed to the next care settings. The key question for us is this: Shouldn’t C-L Psychiatry services also evolve to meet the changing demands of our health care environment?
Team-based proactive psychiatry
Enter team-based Proactive C-L Psychiatry, which we believe offers new perspectives on common issues within changing systems of care.
From its inception, C-L Psychiatry has been an invaluable asset to hospital care, but our conventional, reactive C-L Psychiatry service model is in need of refinement and adaptation in view of the modern health care environment.
We would identify four tenets of team-based Proactive C-L Psychiatry: it represents an interdisciplinary model of inpatient C-L Psychiatry that incorporates systematic screening for mental health concerns, early clinical intervention and clinical integration with primary teams. Its goal is to enhance the value that C-L Psychiatry provides to patients, clinicians, and health care systems by facilitating efficient care and improving outcomes.
Two aspects of Proactive C-L Psychiatry deserve emphasis:
First, it’s not a one-size-fits-all approach. Rather, it’s a flexible model of care that can be adapted to specific settings, patient populations and hospital systems. Although commonly comprising psychiatrists, psychiatric nurse practitioners, and psychiatric social workers as the core team members, new Proactive C-L Psychiatry services continue to explore unique team compositions, workflows, screening processes and interventions.
Secondly, it’s not new. Each of its four tenets has been explored in various ways for decades, but their combination within this model offers more value than the sum of its parts. Team-based Proactive C-L Psychiatry takes a systems-level approach to mental health care in the general hospital, serving as an inpatient corollary to integrated care models in outpatient settings that have become an alternative to the historical “silos of care.”
Proactive C-L Psychiatry is an attempt to leverage the clinical expertise of mental health clinicians to provide more care, more efficiently, and with greater impact. For primary teams, knowing the expertise of a C-L Psychiatry service meaningfully informs their decisions just as much as it informs the C-L Psychiatry services’ decisions to know a given team’s personal savvy with certain clinical scenarios.
This model, however, does not obviate the system of consultation but provides meaningful gradations of interventions, titrated to clinical need and acuity. Nor should one be under the illusion that proactivity prevents all crises, but when they do occur this model often enhances the ability of the entire team—both primary and consultative services together—to address them far more efficiently and with a greater degree of mutual goodwill.
From our experience, both within this model and within the traditional model of C-L Psychiatry, which responds to consultation requests as they are ordered, we find the relationships with primary services among the most gratifying aspect of the work. In a way, this model of care represents the realization of our liaison role, as one team to another. It allows for close education, support, and mental health engagement. We are able to advocate for our patients better—for instance, recommending certain work-ups, care allowances, and other considerations within collegial relationships.
We propose team-based Proactive C-L Psychiatry as a meaningful alternative to traditional models of care that deserves further exploration and development. In short, it is our suggested answer to the question: How might we enhance the value of C-L Psychiatry? As we launch the new Proactive C-L Psychiatry SIG, we invite you to explore the resources we’ve assembled on our webpage and engage with us in the discussion on our Listserv.
University of Rochester Medical Center
Co-chairs of the Proactive C-L Psychiatry SIG
See: New SIG for a New Model of C-L Psychiatry, this issue.
Read about hospitals where they’ve introduced Proactive C-L Psychiatry here.