Transforming the Landscape
By Melissa Bui, MD, Virginia Commonwealth University, and Nicolás Zamorano, MSc, MD, Hospital de La Serena, Chile.
Psychiatry is facing a shortage of providers: the number of psychiatrists per 100,000 people is set to decrease over the coming decades. 1 Integrated models of mental health care, which expand the scope of patients receiving care, provide a potential solution.
These models reimagine the historical approach to care delivery, with an emphasis on treating populations rather than individual patients, providing early clinical intervention, and utilizing a team-based approach with members from both behavioral health and medical specialties.
Collaborative care has proven to be one such successful model within primary care and has demonstrated the Institute of Healthcare Improvement’s ‘quadruple aim’ of desirable outcomes: patient experience, patient outcomes, cost of care, and staff experience. 2, 3 Utilizing similar principles, team-based Proactive C-L Psychiatry has begun to demonstrate success as well, with a broad range of potential applications. 4,5
Here we discuss the application of Proactive C-L Psychiatry in the two ends of the acute hospital care spectrum: the intensive care unit (ICU) and the community hospital setting. These examples underscore how Proactive C-L Psychiatry can be adapted to such vastly different care environments to provide early mental health intervention to large or high-acuity patient populations, at times using little more than the resources already in place.
Intensive Care Units
Whereas the high number of intubated, sedated patients might suggest the ICU would be an unfavorable climate for C-L Psychiatry, the opposite is true. With or without the help of psychiatrists, critical care teams routinely use benzodiazepines, antipsychotics, and other agents familiar to psychiatrists.
Universal deep sedation is increasingly being replaced with an environment of mechanically ventilated patients who are awake and calm, and consequently better able to participate in care. C-L psychiatrists can be a valuable resource in achieving such a desirable level of sedation, providing tailored regimens that reflect our psychopharmacological familiarity and expertise.
Add to that the high incidence of pre-existing and emergent psychopathology found in the critical care setting, and the ICU becomes rife with opportunity for C-L psychiatrists.
Furthermore, given the high cost of care associated with the ICU, efforts to improve outcomes and shorten the length of stay demonstrate a remarkably high return on investment (ROI), cementing this partnership as one with enormous potential value for patients, providers, trainees, and the health care system as a whole.
A pilot study examining the impact of proactive psychiatric consultation in the Medical ICU (MICU) when compared with usual care demonstrated shorter hospital length of stay among patients with respiratory failure, shorter consult latency, higher consult frequency, and improved staff satisfaction. 6, 7
An internal financial analysis performed as part of that study suggested an ROI ranging from 26 to 31, suggesting this strategy has enormous potential for future expansion and development. Qualitative surveys of nursing and house staff reflected strongly positive opinions of the model, suggesting MICU providers felt delirium and other psychiatric conditions were better managed with the presence of a proactive psychiatric consultant than without. 7
A follow-up pilot is currently being conducted in the Medical Respiratory ICU at Virginia Commonwealth University, examining clinical, safety, and financial outcomes among critically ill patients receiving proactive psychiatric consultation when compared with usual care.
Community Hospital Settings
Whereas most C-L psychiatrists complete their medical training in academic health care settings, rather than in community settings, roughly 80% of the US population will receive medical treatment in community hospitals, making this care environment a critical target for optimizing mental health care delivery. 8
Between 20 and 40% of hospitalized patients have a comorbid psychiatric disorder or substance use disorder, which has each independently been demonstrated to prolong the length of stay, resulting in greater costs, and to increase the likelihood of preventable medical complications. 8
Integrated models of care where psychiatric and medical providers had joint responsibility for medical inpatients with psychiatric disorders have demonstrated improved outcomes9, yet the community medical setting is unlikely to implement sufficient mental health resources to sustain such models of medical and psychiatric co-management, even though it may be cost effective. 10
Proactive psychiatric consultation, however, with its emphasis on systematic screening, early intervention, and integration with primary teams, provides a comprehensive and feasible model of mental health treatment that can be achieved across a broad range of settings, including the community hospital. 8,11
A 2020 pilot study by Kugler and colleagues demonstrated just that, showing that proactive psychiatric C-L in a 32-bed acute care medical-surgical unit resulted in reduced length of stay, increased psychiatric consultation rate, and decreased consult latency. 8
In addition, proactive models of psychiatric C-L are highly complementary with other models of psychiatric care delivery, ranging from historical reactive models of consultation to co-management models,9 and with different models of payment, such as capitation systems or pay for outcomes.
Proactive models routinely use interdisciplinary teams of providers, including physicians, advanced-practice providers, nurses, social workers, and case managers, further extending the potential reach of this model into additional populations within the hospital.
Furthermore, the systematic screening and population-based focus of proactive consultation allow for better detection of psychiatric disorders, resulting not only in earlier treatment but may also increase outpatient referrals to ambulatory follow-up and improve continuity of care.
By embracing proactive psychiatry, community-based C-L psychiatrists can champion a successful application of integrated care delivery into a caring environment where most patients receive medical treatment. In doing so, our field can continue to embody the 2013 World Health Organization’s powerful mantra: There is no health without mental health. 12
Proactive C-L Psychiatry reiterates the strengths seen in other models of integrated care, including reaching a broad patient population at an earlier point in each patient’s trajectory than that which would be captured in a reactive model of psychiatric consultation. While there are up-front costs associated with the model, such as establishing an interdisciplinary team and securing administrative support, these costs are relatively small in comparison to the demonstrated savings.
Combined efforts from ACLP and APA have led to a published list of resources 13 available to help guide interested individuals in the development of their own such programs. While still in its early stages, Proactive C-L Psychiatry has already been established as a promising model that can operate alongside traditional approaches to C-L Psychiatry.
Whether in highly specialized care environments such as the ICU, wide-reaching community hospital settings, or in between, this is a paradigm which deserves consideration as the pressures of cost-effective, population-based behavioral health delivery continue to transform the landscape of our field.