Mark Oldham, MD, chair of the Proactive Psychiatry SIG, discusses aspects of the Proactive C-L Psychiatry Model
Under the proactive model, regular patient reviews ensure that planned actions are implemented consistently and progress in addressing the patient’s condition is monitored closely. This systematic approach to care is said to differ from the typically ad hoc nature of the traditional C-L Psychiatry service. Do you agree?
“Regular patient reviews and frequent follow-up are among the defining characteristics of Proactive C-L Psychiatry. In combination, though, they also allude to an aspect of Proactive C-L that has received relatively less attention: the greater availability of mental health clinicians to patients and primary teams. The team-based approach of Proactive C-L represents a more intensive level of care enabled by more staff, but it involves more than simply increasing the staffing ratio. It also involves a strategic plan where each team member has defined roles that complement one another. Therefore, close monitoring is not only a by-product of this model but rather one of its clinical emphases, and this is further enhanced by the intensive approach to relationship-building with primary teams, nurses, and other hospital staff.
“Such a comment in favor of Proactive C-L, though, does not imply a mark against traditional C-L services in this regard. In fact, there is a great deal of diversity across ‘traditional C-L’ service models. In some settings where traditional C-L is practiced, close psychiatric follow-up is the norm, and the liaison relationship between the psychiatric consultant and consultee involves a high degree of mutual trust. However, in the traditional practice of C-L, it is common for a given psychiatrist to provide consultation to multiple floors, interact with a variety of clinical specialties, and communicate with an array of different providers—all of which limits the degree of engagement with specific patients. Even the geographic dispersion itself introduces relational distance with consultees, such that most interactions are telephonic or digital rather than face-to-face. It’s safe to say that within most traditional C-L services, close follow-up is not the norm, especially where a given hospital culture does not value the integration of mental health services and where a systematic approach to care is not an intentional part of service delivery.”
The traditional C-L Psychiatry service model is also said to be limited by reliance on ward teams referring patients to Psychiatry, resulting in a very small proportion being referred. In medical services, is it true that many patients with complex needs who could benefit from psychiatric care are not seen by psychiatrists?
“There is no question that only a portion of patients in most hospital settings who would likely benefit from a psychiatric consultation receive it. Psychiatric consultants regularly overhear conversations among ward hospital staff about active behavioral or psychological concerns where the psychiatrist is not even so much as curb-sided for advice. As in my prior response, though, there are hospitals where medical and surgical teams have a high degree of mental health awareness and are more apt to consult Psychiatry for a broader range of clinical presentations. Even still, consultations in these settings are limited by C-L staff availability, and traditional C-L services are simply not designed to meet population-level mental health needs in hospital settings.”
Because referrals to Psychiatry are commonly made late in the patient’s hospital stay, the opportunity to make a difference to outcomes is limited. Is that fair?
“Yes, this is generally correct because (1) later consultations mean that there is less time available to make a difference and (2) prevention is superior to management. Proactive C-L addresses each of these. First, the goal in Proactive C-L is to identify patients at the earliest possible point in their course of care with the goal of early engagement. The second is by embracing a prevention mindset. It has been said that ‘an ounce of prevention is worth a pound of cure,’ but this is true only when proper cure is available. However, there is no substitute to preventing many foreseeable consequences, such as due to ill-advised medication adjustments (e.g., ‘holding clozapine’ for several days).”
Traditional C-L Psychiatry services are said typically to delegate implementation of their management recommendations to the ward teams. However, such recommendations are frequently not implemented, especially if they require changes in the patient’s overall care plan, as is often the case for patients with multimorbidity. Would Proactive C-L Psychiatry resolve this issue?
“Proactive C-L would not claim to resolve this issue, but it often enhances the likelihood of recommendations being implemented. There are several reasons for this. First, it is standard within Proactive C-L for the C-L psychiatrist or nurse practitioner to review the request directly with the consultee to develop a better understanding of the medical presentation. Second, the C-L psychiatrist routinely reviews recommendations with the consultee in person after performing the consultation so that the recommendations are tailored to the clinical presentation and are consistent with current care goals. Third, as the relationship between consultees and the Proactive C-L team grows, both parties learn one another’s clinical approach and personal sense of comfort, thereby building mutual trust. All this leads to a greater likelihood that specific recommendations are implemented, both by the primary medical or surgical teams and also by other clinicians such as nurses and therapists. Routine conversations between primary and mental health teams also stand to de-stigmatize mental illness and may reduce a variety of personal biases that primary teams might hold that represent barriers to specific recommendations.”
From the budget holder’s perspective, is it correct to say a major goal of Proactive Psychiatry is to avoid patients spending more time in hospital than they need to—to benefit the patient and avoid unnecessary resource use?
“Financial considerations play an essential role in the viability of any hospital initiative—Proactive C-L included. Delivering cost-effective care is part of the Institute for Healthcare Improvement’s Triple Aim. For hospitals, this means optimizing resource utilization and avoiding unnecessary costs: reducing the hospital length of stay is a key way to achieve these ends. Also, where bed occupancy in a hospital is greater than 100%, reducing length of stay means that beds become available sooner for additional patients, thereby increasing the number of patients who receive care over a set period of time.
“Reducing hospital length of stay also needs to be balanced with reducing readmissions. Patients can be discharged sooner, but if they remain medically or psychiatrically unwell they are at a higher risk of readmission. This is just one reason why the role of the psychiatric social worker in Proactive C-L to arrange appropriate psychiatric aftercare is so important.”
If that’s the case, clinicians will therefore prioritize those problems that are most likely either to impede the patient’s discharge, or to lead to early readmission and address them in inpatient action plans (differing from traditional C-L Psychiatry, which typically focuses inpatient care on addressing questions posed by the referring clinicians). Is that how you foresee it?
“Aside from islands of single-payer systems across levels of care in the US (e.g., Veterans Administration), most care is delivered by independent health care organizations. As such, most hospitals have financial incentives to reduce costs to their institution alone. Hospitals typically have little to no incentive to address more than acute concerns that increase institutional costs. Therefore, addressing acute/active issues are the primary objective of such settings. However, provided that Proactive C-L services continue to prove cost-effective, there’s a public health case to be made that they might screen for and make referrals for chronic mental health conditions as well, such as major depression or generalized anxiety disorder, especially since hospitalizations provide unique opportunity to expand the reach of mental health services across the hospital population.”
The proactive model of care is described as doing more than consultations, including curb-sides, real-time recommendations, and general advice. It seems like the idea of “consultation” is being de-emphasized in favor of the “liaison” role. Is this right?
“This is a nice way to think about it: the ethos of Proactive C-L is to create a healthy balance between the consultation and liaison roles of the C-L psychiatrist. Words matter. It’s common to hear specialists in C-L Psychiatry described as ‘consult psychiatrists’ though I can’t recall ever hearing them described simply as ‘liaison psychiatrists.’ There are several reasons for this, not least of which is that within the medical model formal consultations are billable services and parallel care provided by other specialist consultants. However, this is rather limiting for the C-L psychiatrist, especially given the global impact of mental health on a patient’s overall wellness, their engagement with health care, and on health care delivery. Proactive C-L honors the ‘C-L psychiatrist’ who lives in both worlds of consultation and liaison simultaneously and appreciates the complementarity of these two roles. When properly understood and practiced, both of these roles of the C-L psychiatrist reinforce one another. A good consultant should have a healthy relationship with the consultee, and a good liaison offers expert consultation on complex situations tailored to the patient and clinical context.”
What practical resources are available for clinical colleagues looking to learn more about this model of care?
“In addition to the recent publication on Proactive Integrated Consultation-Liaison Psychiatry, I would refer your readers to the Proactive Psychiatry SIG resource page where we have posted a guide on launching a Proactive C-L service, a variety of materials to get people started, and a regularly updated bibliography. The new Collaborative Care Resources ACLP Toolkit on Proactive C-L will be included here shortly as well as a link to the forthcoming APA Resource Document on Proactive C-L.”