General hospital psychiatry from the perspective of medical economics

The purpose of this study was to investigate the efficacy of consultation-liaison (C-L) psychiatry from the perspective of medical economics, by comparing a part-time and full-time psychiatric department. One full-time (5 days per week) psychiatrist began work at a general hospital (GH-A), and one part-time (once per week) psychiatrist had been working at another general hospital (GH-B). Both general hospitals are teaching hospitals of the same size. The number of patients and the medical reimbursements were investigated each month and compared. This study demonstrated that the establishment of C-L psychiatry was economically profitable in contrast with what was the common belief among general hospital administrators. Also, the differences in the total number of patients (GH-A: GH-B = 500:35-50 patients/month) and the total reimbursement (GH-A: GH-B = 3 million: 2-300000 yen/month) was not explained by the number of working days (GH-A: GH-B = 5:1 day/week). The full-time model of C-L psychiatry has also indirect effects (i.e. educational and relieving effects) on the hospital staff. Promoting the establishment of C-L psychiatry requires many evidence-based studies that demonstrate the necessity for C-L psychiatry and can directly persuade hospital directors.     

Referral pattern of neurological patients to psychiatric Consultation-Liaison Services in 33 European hospitals.

The referral pattern of neurological patients to 33 European psychiatric consultation-liaison (C-L) services in the general hospital was examined. Analyses were conducted on the ECLW CS data set, which consists of 14,717 psychiatric C-L referrals made in 56 European hospitals during 1991. Psychiatric referrals of patients admitted to neurological wards were compared to referrals from other wards. Information was obtained from 33 neurological wards, consisting of 34,506 neurological admissions. Of these admissions, 839 were referred to C-L psychiatry. The median consult rate among the hospitals was 1.8%. Compared to other hospital wards, patients referred from neurology were more frequently diagnosed as suffering from somatoform (P<.01) and dissociative disorders (P<.01), and less from substance abuse (P<.01) and delirium (P<.01). Referral to C-L psychiatry from neurological wards is characterized by an underestimation of psychiatric co-morbidity and a late detection, comparable to other medical specialties. An appeal is made for a standardized referral procedure including admission screening method, detecting patients at risk for nonstandard care during their hospital admission.     

Current status of general hospital psychiatry in Japan.

The current status of general hospital psychiatry was overviewed to clarify the progress and the stagnation. To facilitate well-organized community psychiatric care, general hospital psychiatry should play a central role in psychiatry. The policy makers of the Japanese mental health system should place a special emphasis on general hospital psychiatric beds to further process of shifting from a hospital based to a community based psychiatry system. It is also necessary that general hospital psychiatry should become more aggressively involved in community psychiatry, e.g. emergency psychiatry. Consultation-liaison (C-L) psychiatry has been quickly developed and become one of the main psychiatric fields. For further development, a multidisciplinary team approach with co-medical staffs is necessary to supply efficient and effective care to medically ill patients. A proactive model of C-L care rather than a doctors' needs model should also be considered. Well designed research evaluating the efficiency and effectiveness of C-L activities in medical settings needs to be done to increase funding to general hospital psychiatry. This research evidence would also lead to a more fully integrated general hospital psychiatry into the practice of medicine and catch up with the ongoing medical reform in Japan.     

Consultation-liaison psychiatry in Brazil. Psychiatric residency training.

A mailing survey assessed consultation-liaison (C-L) service delivery and training among all 23 approved psychiatric residency training programs throughout the country. Twenty questionnaires were returned. Outpatient, inpatient, emergency, and consultation services were present together in 35% of the academic hospitals where residency training took place. Consultation service was provided by 18 (90%) responding programs. Eleven of those reported C-L training as part of their general psychiatry rotation. Nevertheless, educational objectives, weekly case conferences, and didactic seminars were provided by only five of them. The training time varied from 40 to 560 hours, 190 hours on average. The same five programs offered an elective third-year residency training, including liaison with specific units. The results illustrate the migration of academic psychiatric departments from the psychiatric hospital to the general hospital as well as the beginning of C-L training programs in Brazil.     

Satisfaction with community and hospital-based emergency services amongst severely mentally ill service users

Objective This study compares the satisfaction with emergency interventions among severely mentally ill (SMI) service users of a community-based and a hospital-based mental health service (South-Verona, Italy and Nunhead, South-London, UK). Methods A measurement of the satisfaction with psychiatric emergency services was conducted among all those users in the two catchment areas who, in a 1-year period: (1) had at least two contacts with the service; (2) had a diagnosis of psychosis according to ICD10; (3) had not been living in hospital or sheltered apartment for most of the time. These users completed seven items belonging to the Verona Service Satisfaction Scale (VSSS) regarding their satisfaction with crisis response during and out of office hours and their satisfaction with the different interventions, which may be provided during emergencies, such as consultation for the user, consultation for the relative, day-centre attendance, informal and compulsory admission. Results Users in South-Verona were generally more satisfied with emergency interventions. The main differences between the two samples were due to contacts outside the hospital setting, whilst satisfaction scores for informal admission were similar. The number of users who did not receive, but would have liked, different types of emergency intervention was smaller in South-Verona than in Nunhead. In South-Verona, users wishes mainly concerned consultation for the relatives during emergencies; in the Nunhead sample, the most requested types of intervention were consultation for the user and the possibility of day-centre attendance during crisis. Conclusions The findings suggest that users of a service with a well developed community-oriented approach and with crisis intervention outside the hospital setting are more satisfied of the emergency interventions than users of a mental health service relying mostly on hospital facilities during emergencies.     

Crisis work challenged in emergencies]

This paper present a statistical study on the population of 775 psychiatric emergencies that arrived at the emergency service of Saint-Luc Hospital in Brussels (Belgium), between September 1, 1986 and December 31, 1986. The first request of the patient is medical, whereas his relatives expect that the abnormal and disturbing aspects of the patient's behaviour be taken in charge. From the point of view of diagnosis, two populations are clearly identified: psychiatric disorders (or psychiatry in emergency) and couple or family crisis situations, these representing the most specific aspect of psychiatric emergencies. The model of crisis interaction-intervention developed to address these emergencies is presented.     

European guidelines for training in consultation-liaison psychiatry and psychosomatics: report of the EACLPP Workgroup on Training in Consultation-Liaison Psychiatry and Psychosomatics

Objective

The European Association of Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) has organized a workgroup to establish consensus on the contents and organization of training in consultation-liaison (C-L) for psychiatric and psychosomatic residents.

Methods

Initially, a survey among experts has been conducted to assess the status quo of training in C-L in different European countries. In several consensus meetings, the workgroup discussed aims, core contents, and organizational issues of standards of training in C-L. Twenty C-L specialists in 14 European countries participated in a Delphi procedure answering a detailed consensus checklist, which included different topics under discussion.

Results

Consensus on the following issues has been obtained: (1) all residents in psychiatry or psychosomatics should be exposed to C-L work as part of their clinical experience; (2) a minimum of 6 months of full-time (or equivalent part-time) rotation to a C-L department should take place on the second part of residency; (3) advanced training should last for at least 12 months; (4) supervision of trainees should be clearly defined and organized; and (5) trainees should acquire knowledge and skills on the following: (a) assessment and management of psychiatric and psychosomatic disorders or situations (e.g., suicide/self-harm, somatization, chronic pain and psychiatric disorders, and abnormal illness behavior in somatically ill patients); (b) crisis intervention and psychotherapy methods appropriate for medically ill patients; (c) psychopharmacology in physically ill patients; (d) communication with severely ill patients and dying patients, as well as with medical staff; (e) promotion of coordination of care for complex patients across several disciplines; and (f) organization of C-L service in relation to general hospital and/or primary care.In addition, the workgroup elaborated recommendations on the form of training and on assessment of competency.

Conclusion

This document is a first step towards establishing recognized training in C-L psychiatry and psychosomatics across the European Union.     

European Consultation-Liaison Psychiatric Services: the ECLW Collaborative Study

OBJECTIVE: To describe the patterns of organization of consultation-liaison (C-L) services in 11 European countries in relation to hospital characteristics and national approaches to C-L psychiatry. METHOD: Cross-sectional survey. RESULTS: Services can best be described in terms of their size and seniority of their staff and whether or not they are multidisciplinary. Single-discipline services are based upon the standard medical consultant model, whereas those with multidisciplinary teams work in a way that is comparable with community mental health teams. German psychosomatic C-L services belonged to either model. National differences were found. CONCLUSION: This first international study provides empirical evidence for the wide variation in the organization of C-L services. In view of the increasing numbers of patients with psychiatric disorder who are being treated in general hospitals and the changing patterns of medical care there are important implications for clarification and improvement of the role of C-L services.     

Place des unités de soins intensifs psychiatriques (USIP) dans le dispositif de soins

Psychiatric Intensive Care Units (PICU) are a recent creation in France. These facilities propose a secure setting for patients with acute behavioural disturbances difficult to manage in psychiatric general wards. Physical violence against other patients or hospital staff, substance abuse, non-compliance with care and treatment, intensity of symptoms or absconding are common motives for admission. Patients are admitted from psychiatric facilities of a health-care area or by agreement between hospitals. Care and treatment must be centred on the patient, be multidisciplinary, intensive, and comprehensive with an immediacy of response to critical situations. Interface and liaison with original services of patients are important issues as the length of stay should not exceed two months. In France, PICU exist at Cadillac, Lyon, Paris, Montpellier, Nice, Pau, Prémontré and Eygurande. They are a missing link between psychiatric general wards and maximum security hospitals in the mental health care system. The report emphasizes the creation of an association, foreign experience and existence of national minimum standards.     

Development of consultation-liaison psychiatry in The Netherlands. Its social psychiatric heritage

Dutch consultation-liaison psychiatry (C-L psychiatry) has followed a developmental line separate from the American system. First, C-L psychiatry in the Netherlands has been less influenced by psychosomatic medicine than by social psychiatry. Second, the presence of psychiatric units in general hospitals that appear to be correlated with the growth of C-L psychiatry in the United States occurred later in the Netherlands. Third, little government support for clinical care, research, and especially for training has been available to Dutch psychiatry. Consequently, there has been little recent financial pressure on C-L psychiatry from reduced government support, as occurred in the United States. Finally, the relationship between primary and secondary health care in the Netherlands allows C-L psychiatry to have a direct impact on several inpatient and ambulatory levels in the health care chain. A nationally accepted database form for the computerized registration of the Psychiatric Consultations at the eight university hospitals and ten other general hospitals is currently in use. To facilitate standardization and recording the psychiatric consultation process, the Netherlands Consortium for C-L psychiatry (NCCP) was formed.     

Unwelcome guests: bugbears of the emergency room physician

In a prospective study on psychiatric emergencies in the setting of a general hospital, the phenomenon of repeat-visits was studied. Results confirm that repeaters represent a sizeable load on emergency services--about 18% of all psychiatric emergencies. Females and neurotics are over-represented among the repeaters. Chronic repeaters tend to evoke strong feelings among the emergency physicians thereby decreasing their chances of referral to the psychiatry resident on call.     

Consultation-liaison psychiatry in Korea.

The Korean Psychosomatic Society, our national organization for consultation-liaison (C-L) psychiatry was formed within the Korean Neuropsychiatric Association (KNPA) in 1992. Since then, there has been increasing interest in C-L activities in general hospitals. All psychiatry departments in university teaching hospitals offer C-L experiences as part of the rotation for residents. Recently, there have been increasing research activities in C-L psychiatry. However, there are some current obstacles to further development of C-L psychiatry. No reimbursement for C-L activities is one of the most pressing problems facing C-L psychiatrists. Insufficient staffing at C-L services and stigmatization of mental illness are also problems to be dealt with. In order to resolve those issues, a more organized approach to demonstrate the usefulness of psychiatric C-L activities will be needed.     

中国老年精神科服务现状调查

目的:调查全国精神科机构老年精神科服务现状。方法:采用问卷调查的方法,了解全国省/地市级精神专科机构老年精神科室设置,老年精神科的服务现状。结果:全国260家省/地市级精神专科机构中,136家有反馈,其中有66所机构设老年精神科,有83所设老年精神科病房,有54所设老年科门诊,43所未设科亦无专科病房/门诊。共有老年专科病床3799张,老年专科医师383名,护士952名。结论:我国各地区老年精神卫生的服务不平衡,差异显著。老年精神科的床位设置与人员配置与老年人口的绝对数不成比例,需求大于供给,专科的发展空间很大。     

A new tool for consultation-liaison funding: modified DRGs to reflect psychiatric comorbidity.

Funding for consultation-liaison (C-L) psychiatry remains an overriding obstacle to its implementation and practice. Several methods have been described to access funds for this subspecialty of psychiatry, but none has been enacted as a policy by third party payers to reimburse adequately for the service. In addition, although the consultation portion of the effort can be reimbursed in part in some cases through fee for services, the liaison portion is dependent on the donation of psychiatry time or the largesse of the host department. The efforts at Stanford to capitalize on the findings that psychiatric and medical comorbidity results in prolonged length of hospital stay and increased health resource utilization suggest that specific DRGs would be important patient groups to screen and charge for psychiatric services. Furthermore, DRGs that are accompanied by a high frequency of psychiatric comorbidity are a "target" for an additional funding aliquot to assess and manage the patient's psychiatric status.     

Evaluation of a mobile crisis program: effectiveness, efficiency, and consumer satisfaction

OBJECTIVE: The effectiveness and efficiency of a mobile crisis program in handling 911 calls identified as psychiatric emergencies were evaluated, and the satisfaction of consumers and police officers with the program was rated. METHODS: The study retrospectively examined differences in subjects' demographic characteristics, hospitalization and arrest rates, and costs for 73 psychiatric emergency situations handled by a mobile crisis team and 58 psychiatric emergency situations handled by regular police intervention during three months in 1995. Consumers' and police officers' satisfaction with the mobile crisis program was evaluated through Likert-type scales. RESULTS: Fifty-five percent of the emergencies handled by the mobile crisis team were managed without psychiatric hospitalization of the person in crisis, compared with 28 percent of the emergencies handled by regular police intervention, a statistically significant difference. The difference in arrest rates for persons handled by the two groups was not statistically significant. The average cost per case was 23 percent less for persons served by the mobile crisis team. Both consumers and police officers gave positive ratings to the mobile crisis program. CONCLUSIONS: Mobile crisis programs can decrease hospitalization rates for persons in crisis and can provide cost-effective psychiatric emergency services that are favorably perceived by consumers and police officers.     

A multicenter investigation of consultation-liaison psychiatry in Italy. Italian C-L Group.

In order to evaluate the extent and quality of consultation-liaison (C-L) activity in Italy, a multicenter investigation was conducted in 17 general hospitals. All of the hospitalized patients referred to C-L psychiatry during a 1-year period were assessed by means of a specific instrument (Patient Registration Form, PRF-SF). Of 518,212 patients, 4182 were referred to C-L services (referral rate = 0.72%). Typical consultations were for female patients (60.1%), admitted to medical wards (71.5%), aged 55-75 years. Most interventions were carried out within 2 days; a minority (22%) were urgent requests. Gastrointestinal and cardiovascular disorders, and unexplained medical symptoms were the most frequent ICD-9 somatic diagnoses at admission. One-third of the patients were not informed of having been referred to C-L and half of them had a lifetime history of psychiatric disturbances. Most frequent ICD-10 psychiatric diagnoses were neurotic, stress-related, and somatoform syndromes (33.1%), affective syndromes (19.4%), and organic mental syndromes (10.7%). Two-thirds of the patients were given only one consultation whereas the reminder received two to four follow-up visits. The rate of transfer to psychiatric wards was low (2.1%). Psychopharmacological treatment was suggested in 65% of cases, and 75.5% of the patients were referred to community psychiatric care at discharge. The implications of the findings are discussed.     

A UK survey of psychiatric services for older people in general hospitals

BACKGROUND: Psychiatric illness is common in older people in general hospitals, but little is known of the service models operating in the UK, or of the views of old age psychiatrists regarding service provision in this area. We set out to determine the range of UK old age psychiatry service models for older people in general hospital wards, and the opinions of clinicians on future service priorities and development. METHOD: A postal questionnaire survey of old age psychiatrists providing psychiatric services to older people in general hospital wards. RESULTS: 73% of services were provided through a generic, sector-based, consultation psychiatry model. The remaining 27% employed a range of general hospital-based liaison psychiatry services for older people, involved in proactively seeking referrals and educating general hospital staff. Those providing a generic sector-based model were significantly slower at responding to referrals. 89% of respondents were unhappy with their service to older people in general hospital wards, with only 11% preferring the generic sector-based model. Organisational barriers to change identified included the management of mental health care and physical care by different organisations. Training, both of psychiatric staff in this specialist area, and of general hospital staff in the detection and basic management of common psychiatric conditions in the general hospital setting, was felt to be necessary. CONCLUSIONS: The management of co-morbid psychiatric and physical illness in older people is an important issue for health services. Old age psychiatrists are unhappy with the prevalent, reactive, consultation-based model, preferring a range of liaison psychiatry models based in the general hospital. The most important barriers to service development in this area were the separate managerial arrangements for psychiatric and physical care services, and a lack of evidence for effective old age psychiatry services in this setting.     

The changing pattern of referrals for psychogeriatric consultation in the general hospital: An eight-year study

An eight-year retrospective evaluation of referrals to a psychogeriatric consultation service demonstrated a highly significant linear increase of total referrals with a selective change of case mix that included more depressions and fewer cases of acute confusion or referrals with no psychiatric disorder. This did not occur with referrals from general practice, where case mix remained stable though total referrals also increased. It is suggested that this selective change relates to an educational influence of the specialist consultation service operating within the hospital and represents a desirable change of referral behaviour. The degree of psychiatric morbidity on general hospital wards far exceeds the capacity of a consultationservice whose primary objective must be education to enable non-psychiatrists to detect and manage the majority of these disorders without recourse to specialist referral. Research that will further define the elements of the educational process that have greatest impactis needed and offers a new research direction for liaison psychiatry of old age.     

Prises en charge de situations psycho-légales complexes aux urgences psychiatriques

During a significant and clinically-varied influx of patients arriving at emergency psychiatry units, for some of these people the problem with regard to forensic psychology arises of rapid resolutions to complex situations. These situations are alluded to in this presentation: treatments in danger of non-completion when close relations refuse to sign a third-party agreement; psychiatric expertise in emergency departments; the evaluation of patients in administrative or police border control retention centers; refusal of somatic care; unclassifiable situations.