- Email: [email protected]
Consultation-liaison psychiatry
Consultation-Liaison
Psychiatry
Possibilities for the 1990s James J. Strain, M.D., Leslie H. Gise, M.D., and George Fulop, M.D.
Abstract: In order for consultation-liaison (C/L) psychiatry to enhance its acceptance and funding, carefully designed outcome studies that will demonstrate its clinical effectiveness to other disciplines in medicine, departments of psychiatry, hospital administration, third-party payors, and patients are required. The development of alternative methods of funding CIL services is described: (1) high-risk screening, renal transplant, geriatric units (Medicarc); (2) sala y stipends from collaborating disciplines, e.g., medicine, EAT, neoplastics; (3) consultation fees; (4) ambulatory GIL clinics (Medicaid); and (5) grants from collaborative research. With a change in structure when it can be employed (from consultation to the screen methodology), the development of scientijically derived outcome data of C/L psychiatry interventions, adequate documentation of the evaluation and treatment by CIL psychiatry, and the new fools biological psychiatry and psychopharmacology will provide, the 2990s could and should be an exciting time for this subspecialty of psychiatry.
Proposal by Weiner et al. from the University of Texas Southwestern Medical Center at Dallas is an important and timely commentary and perspective on the prospects for consultationliaison (C/L) psychiatry in the 1990s [l]. The authors capture the concern, disappointment, and exasperation of workers in C/L psychiatry and suggest that the “wagons be drawn” to encompass a lesser sphere of influence and espouse more modest goals. The authors state that the primary reasons for the failure of C/L psychiatry to play a more significant role for “all medical/surgical patients in large A Very Modest
From the Division of Behavioral Medicine and Consultation Psychiatry, Mount Sinai Hospital, New York, New York. Address reprint requests to: James J. Strain, MD, Professor/ Director, Division of Behavioral Medicine and Consultation Psychiatry, Box 1229, The Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029.
General Hospital Psychiatry 11, 235-240, 1989 8 1989 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
hospitals . . . is that no adequate funding mechanism has ever been found to support such a large endeavor. The economic climate as we enter the 1990s makes such funding even less likely” [l]. Based on a lo-year experience at the Southwestern Medical Center, the authors suggest that C/L psychiatry accept a lesser role, largely confined to teaching hospitals, and focus on teaching medical students, residents, and postgraduate physicians rotating through psychiatry, offering innovative dispositions for medically ill psychiatric patients, and engaging in interdisciplinary research. In essence, this article presents a case study of one service and attempts to generalize from that experience to the prospects for the discipline of C/L psychiatry in the next decade. And the authors underscore from their experience that the lack of funding appears to be the major impediment confronting the potential breadth and scope of C/L psychiatry. However, other issues that will be important in the 1990s have even more relevance for teaching, future research, patient care, subspecialization, fellowship training, research into the mechanism of transduction, psychotropic pharmacokinetics, stress and the immune response, and determinants of noncompliance. As is so often the case, money appears to be’ the bottom line. Yet are there other issues, such as organizational structures, research findings, outcome data, communication with other disciplines, and the like, that would permit C/L psychiatry to not only let the wagons keep rolling but even impressively progress? C/L psychiatry faces a major dilemma in its breadth and lack of focus. It does not deal with a particular age group (children or the aged), a particular disease (schizophrenia, asthma or cancer), a specific issue (forensic), a des-
235 ISSN 0163-8343/89/!$3.50
J. J.
Strain et al.
ignated approach (pharmacology), or a specific research agenda (biologic, neuroscience, molecular, genetic). Consequently, it has all the problems of a generalist with the lack of concentrated effort and alliances that emanate from a sufficiently narrowed field so that it can be meaningfully tilled, fertilized, and harvested. C/L psychiatry runs the gamut of general psychiatry with the imposed confounds from the comorbidity of medical illness that does not encourage it to have a sufficiently focused constituency to prosper. It is the erroneous impression that anyone can do it and that it only requires the core skills and competence of general psychiatry. The American Cancer Society, The American Heart Foundation, The Tourettes Society, The Pain Society-all have a specified agenda that permits them to combine their efforts. The larger question remains how an appropriate focus can be articulated for C/L psychiatry so that the 1990s will offer unprecedented opportunities. The 1990s are likely to be a heady time for psychiatry, with exciting research, new discoveries, and improved treatments. Why shouldn’t C/L psychiatry be a part of this? Even if it is difficult, C/L psychiatry is obliged to try to implement knowledge about the psychology of medical illness. Furthermore, increasingly sophisticated medical care places additional personal burdens on patients who must make choices, actively participate in their own care, and comply with complicated regimens. These stresses intensify psychologic reactions and often require treatment. In addition, neglect of the psychosocial aspects of medical care decreases efficiency and increases costs. These and other factors make C/L psychiatry timely in the 1990s. In order to address these issues, this article examines the importance of psychiatric and medical comorbidity, traditional consultation versus screen strategies, and alternative methods of funding that could be employed in university or community hospitals. Rather than suggesting a period of retrenchment, the following research agendas and alternative health care delivery systems may provide a template for continued growth for the field.
Psychiatric and Medical Comorbidity Background Recent studies report psychiatric disorders in one of every five Americans in a 6-month period, of whom 62% are seen exclusively in the general medical setting [2]. Among medical and surgical in236
patients, as many as 30%-50% manifest concurrent psychiatric morbidity [3,4], although less than 1% are referred for psychiatric consultation [5]. Similar to the outpatient primary medical setting, medical/ surgical units in general hospitals function as de facto mental health delivery networks [6]. Relatively few patients receive specialized mental health care. Fulop and colleagues have reported that patients with concurrent medical and psychiatric morbidity remain in the general hospital twice as long as patients with medical illness alone [7,8]. Furthermore, Lyons et al. observed that the earlier during the hospitalization that the psychiatric consultation occurred, the earlier the patient was discharged [9]. Consequently, there is no dearth of patients requiring C/L psychiatry services: they consume enormous hospital resources, and this may be altered by early psychiatric intervention. As said before, however, few inpatients with medical and psychiatric comorbidity are referred for psychiatric consultation by physicians, nurses, or social workers. Furthermore, other medical and surgical departments are reluctant to reimburse psychiatrists for routine consultations, as that is a traditionally offered medical service either paid for by consultation fees from third-party payors or included in the per diem charges that support house officer stipends to render patient care. Fulop et al. have also identified the medical/surgical conditions most likely to be associated with psychiatric morbidity that may serve as a focus for C/L psychiatry interventions [8].
Alternative
Methods of Funding
Indeed, we can use The Mount Sinai Hospital as another case example of successful alternative strategies to permit C/L psychiatry service delivery in more settings. Although The Mount Sinai Hospital’s contribution to the Division of Behavioral Medicine and Consultation and its secretarial staff is minimal ($34,000 per year)‘, it has been possible to support six full-time lines for C/L psychiatry functions by five alternative routes to funding. First, this has been partly achieved by organizing the structure of the service so that it is primarily staffed by attendings. Psychiatric residents and medical students see consultations, but they do not direct any services or teams. Second, psychiatric ‘Faculty practice earnings from staff members contributed to the Medical Center exceeded the $34,000 from the Medical Center.
C/L Psychiatry: Possibilities for the 1990s
screening has been ferred consultations Third, grants and other medical and the trustees of the
implemented in contrast to reon certain high-risk services. gifts have been obtained from surgical departments and from Mount Sinai Hospital.
Inpatient Services By utilizing attendings to deliver psychiatric consultations these physicians are able to bill for services rendered. For example, all patients in the hemodialysis/renal transplant program are evaluated by a psychiatrist and offered treatment as indicated. As the majority of these patients are on Medicare, funds generated support a half-time psychiatrist [lo]. Similarly, because of the high prevalence of psychiatric comorbidity among geriatric inpatients, they are all screened and (if necessary) treated on the inpatient service Department of Geriatrics. As the majority have Medicare, a full-time attending is funded. The Department of Geriatrics provides a separate teaching supplement [ll]. One half-line is supported by the Department of Neoplastic Diseases and AIDS-related work. The orthopedic department funds a one quarter-line for an attending psychiatrist to screen all elderly patients admitted for hip fracture. The modal reimbursed fee for psychiatric service is $80 for each patient visit [12]. An otolaryngology department annual stipend provides the majority of one halfline for an attending to screen head and neck patients and conduct weekly ENT-psychiatry rounds [ 11,131. The remainder of this half-line comes from the same attending coordinating the psychiatric consultation service and his or her direct evaluation and treatment of consultation patients with the psychiatric resident observing.
The Consultation Service Between $15,000 and $20,000 is generated annually from the consultation service where patients are evaluated and treated by an attending psychiatrist.
Ambulatory Services With Medicaid reimbursement ($72.79 per patient visit) for outpatient psychiatric care, it has been possible to maintain a full psychiatric attending line in collaboration with the Department of Obstetrics, Gynecology, and Reproductive Science [14]. This service also includes the only premenstrual syndrome program for the indigent in New York City
[14]. Space, secretarial support, and travel to professional meetings are provided for the C/L psychiatry attending by the Department of Obstetrics, Gynecology, and Reproductive Science. Using a similar format, the Division of General Medicine funds one attending half-line in the general internal medicine ambulatory clinic. The attending consults on patients to offset his salary. Support is offered from the Division of General Internal Medicine to attend the weekly team teaching conference and participate in collaborative research. It is planned to reinstitute the behavioral medicine clinic, which will offer a variety of treatments: psychotherapy, cognitive therapy, relaxation treatment, biofeedback, hypnosis, and psychotherapy [15]. This clinic will provide follow-up for all appropriate service cases seen on the inpatient consultation service and for medical/surgical clinic patients requiring psychiatric treatment. It is anticipated that this clinic will generate sufficient revenues from Medicaid reimbursement to support one full-time attending C/L psychiatrist and, more importantly, offer essential services heretofore unavailable at The Mount Sinai Hospital. Treatment time is usually not available for consultation patients with psychiatric and medical comorbidity in either the general psychiatry outpatient department or in sufficient numbers in the general medical clinic.
Funding from Other Disciplines The Department of Social Work Services supports 25 hours of psychiatric attending services per week: 5 for obstetrics/gynecology, 5 for the general internal medicine clinic, and 15 for the other 150 outpatient medical and surgical clinics. An attending psychiatrist reviews cases with social workers, discusses treatment plans, and follows patients with social workers where indicated. The psychiatrist is also a consultant to the Employee Health Service.
Grants and Collaborative Research Attending psychiatrists are supported by grants from several sources: The Sexual Dysfunction Clinic (one third-line), Department of Medicine Educational Grant (one half-line for 5 years, one quarter-line currently), National Institute of Mental Health (“Cost Offset of a Psychiatric Intervention with Elderly Hip Fracture Patients,” in collaboration with the Department of Orthopedics (one half237
J. J. Strain et al.
line) ]12,16], and the National Cancer Institute (“Physician and Patient Noncompliance with Breast Cancer Chemotherapy Protocols”) in collaboration with the Department of Neoplastic Diseases (one full line).
Contributions A generous annual contribution from a Mount Sinai Hospital trustee to provide excellence in scholarship, research, teaching, and exemplary clinical care augments the divisional budget. This grant has permitted the development of software to undertake epidemiology and health services delivery research, to document C/L psychiatry efforts to track the patients of the residents, and to develop core literature for research and teaching that can be appended to a computer-generated chart note as a pedagogic vehicle for psychiatric and medical residents [ 17-201. Assisted by an Upjohn Company Educational Grant, this program has now been offered to C/L psychiatry at 100 medical schools. All five of these methods for funding C/L psychiatry services are available to any teaching or community hospital in New York State. And these paradigms could be increased at The Mount Sinai Hospital if there were additional space and secretarial support. For example, the HIV Clinic supports 5 hours of an attending psychiatrist who treats Medicaid patients, and this will be augmented as the number of cases and the need for treatment escalate. Furthermore, a liaison screen method does not require psychiatric residents. In fact, on some services it may not be possible to have residents care for all the consultation patients because of their limited time availability. Optimally, residents have a carefully titrated clinical experience with sufficient supervision to make the C/L psychiatry rotation an excellent teaching experience. Municipal, state, Veterans’ Administration, and military hospital systems that offer care at no fee to their patients, and where departments of psychiatry are dependent on funded lines, would not be suitable for many of these alternative methods of funding psychiatry.
Social Work Service-Screen
Model
From another perspective, C/L psychiatry can well afford to take notice of the evolution in the practice and funding patterns of social work (SW) [21]. The referral model has often been replaced by the li238
aison model in which a social worker is assigned to a unit as a member of the team and as such is in an ideal position to screen or triage every patient. There are several advantages that SW accrues by not waiting to be called in: they are not dependent upon the housestaff or nursing staff, who may be insufficiently trained to identify patients with psychosocial needs [22]. In addition, their constant presence makes SW the first echelon to assist the ward staff with whom they work daily. Finally, because they are regarded as an essential part of the hospital system, funds for their payment are secured from three important sources at The Mount Sinai Hospital: (1) Medicare Part A (inpatients); (2) departmental funds including grants (e.g., neoplastic diseases, geriatrics, renal dialysis, etc.); and (3) Medicaid-$72.79 per visit for ambulatory patients. It is important to note that in New York State to qualify for Medicaid reimbursement for mental health care for patients seen in the general hospital clinic setting (e.g., psychotherapy, in contrast to concrete services), social workers are required to have their mental health treatment plan reviewed periodically by a physician. As a result of the changing role of SW and their creative access to funding, The Mount Sinai Hospital has the services of approximately 100 workers in a 1200-bed hospital that averages 38,000 inpatient admissions and 350,000 outpatient visits per year. C/L psychiatry could profit from observing the important advantage that SW has accrued by moving from the referral mode to the liaison-screen model and their impressive access not only to funding, but to patients and physicians.
Research Because of the essential need for data to understand the outcome of C/L psychiatry interventions, the National Institute of Mental Health has promoted initiatives to examine their therapeutic and cost-offset effects [12,16]. This information should have an important impact on C/L psychiatry services and their funding in the 1990s. For example, provisional data demonstrate a decrease in hospital length of stay after a C/L psychiatry intervention with elderly hip fracture patients [12,16,23]. Smith has shown that primary care physicians use less health care resources for somatoform patients after being informed of their diagnosis [24]. Fulop and Strain have determined that the geriatric inpatients exposed to a liaison screen, in contrast to the tra-
C/L Psychiatry:
psychiatric consultation model, remain in the hospital 2 days less [25]. In many medical centers, basic research is underway in disease risk factors, behavioral noncompliance, psychotropic drug mechanisms in patients with physical illness, mechanisms of transduction, immune response and mood states, and so on. Medical/surgical patients at risk for psychiatric morbidity have been identified. These patients may be the target of brief, focused psychiatric interventions rather than costly global screening of large populations. New diagnostic batteries are under development [26]. Psychotropic drug trials in the medically ill will provide needed information with regard to relative effectiveness [27]. Current research in all these areas should augment the armamentarium of the C/L psychiatrist to offer more effective psychologic care to the medically ill. ditional
Conclusion In order for C/L psychiatry to obtain a more important place and funding, it needs to conduct carefully designed outcome studies that will demonstrate its clinical effectiveness to other disciplines in medicine, departments of psychiatry, hospital administration, third-party payors, and patients. As an example of such an efficacy demonstration, we can cite the collaborative study of hip fracture patients that found a 2-day reduction in length of hospital stay in the C/L intervention year in comparison to the control year at two sites (Mount Sinai Hospital and Northwestern Memorial Hospital) [12,16]. When the Department of Orthopedics at Mount Sinai observed this outcome, they were enthusiastic about offering C/Lpsychiatry care to all their elderly hospitalized patients, especially as those with hip fracture were exceeding the DRC reimbursement rate because of prolonged lengths of stay. Such results at The Mount Sinai Hospital (like those demand colleagues at onstrated by Weiner Southwestern Medical Center) show that when C/L psychiatry has a scientific base for its action and a visible and useful role, funding follows. With a change in structure when it can be employed (from consultation to the screen methodology), with the development of scientifically derived outcome data of C/L psychiatry interventions, with adequate documentation of the evaluation and treatment by C/L psychiatry, and with the new tools biologic psychiatry and psychopharmacology will provide, the 1990s could and should be an exciting time for this subspecialty of psy-
Possibilities for the 1990s
chiatry. Psychiatric and medical comorbidity-the province of a physician trained in biology, psychiatry, and social perspectives-offers a golden opportunity to display psychiatry’s unique skills to provide mental health care in the general medical setting. Research can buttress that claim. To avoid retrenchment, it is important to devise methods to meet the needs of those patients with medical illness who also have psychiatric morbidity. We appreciate the Southwestern group’s focusing our attention on our future. This work has been supported in part by the Green Fund. The authors
wish to acknowledge Ms. Susan Michele Sonenreich for her editorial assistance.
References 1.
2.
3.
4.
5.
6.
7.
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9.
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11.
12.
Weiner MF, SadlerJ, Fenton BJ et al: A very modest proposal for 1990s C/L psychiatry. Gen Hosp Psy 11:231-234, 1989 Regier DA, Myers JK, Kramer M, Robins, LN, Blazer DG, Hough RL, Eaton, WW, Locke BZ: The NIMH Epidemiologic Catchment Area (ECA) program: Historical context, major objectives, and study population characteristics. Arch Gen Psychiatry 41:934941, 1984 Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine. I. General principles. Psychosom Med 29:153-171, 1967 Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine. II. Clinical aspects. Psychosom Med 29:201-224, 1967 Wallen J, Pincus HA, Goldman HA, Marcus SE: Psychiatric consultations in short-term general hospitals. Arch Gen Psychiatry 44:163-168, 1987 Regier D, Goldberg I, Taube C: The de facto U.S. mental health service system: A public perspective. Arch Gen Psychiatry 35:785-93, 1978 Fulop G, Strain JJ, Vita J, Hammer JS, Lyons JS: Impact of psychiatric comorbidity on length of stay for medical/surgical patients: a preliminary report. Am J Psychiatry l&878-882, 1987 Fulop G, Strain JJ, Hammer JS, Lyons J: DRGs, psychiatric comorbidity and prolonged length of hospital stay. Hosp Community Psychiatry 4080-82, 1989 Lyons JS, Hammer JS, Strain JJ, Fulop G: The timing of psychiatric consultation in the general hospital stay. Gen Hosp Psychiatry 8:159-162, 1986 Strain JJ, Vollhardt B, Langer S: A liaison fellowship in a hemodialysis unit: A self-funded position. Gen Hosp Psychiatry 3:10-15, 1981 Strain JJ, Hamerman D: Ombudsmen (medicalpsychiatric) rounds. An approach to meeting patient-staff needs. Ann Intern Med 88550-555, 1977 Strain J, Hammer J, Lyons J, Fahs M, Lebovits A: Cost offset from the psychiatric iiaison intervention for elderly hip fracture patients. Symposium: 17th European Conference on Psychosomatic Research. Marburg, West Germany, 1988, pp 207-208 239
J. J. Strain et al.
13. Wallack J, Strain JJ, Lucente F, Biller H: Liaison psychiatry (otolaryngology rounds). Laryngoscope 92:125-127, 1982 14. Paddison P, Gise LH, Lebovits A, Strain JJ: Premenstrual syndrome and sexual abuse. Academy of Psychosomatic Medicine, 35th Annual Meeting, New Orleans, LA, November 1988 15. Rowan G, Strain J, Gise LH: The liaison clinic: A model for liaison psychiatry funding, training, and research. Gen Hosp Psychiatry 6:109-115, 1984 16. Strain J, Hammer J, Lyons J, Fahs M, Lebovits A, Paddison P, Snyder S, Strauss E: Hip fractures: Psychiatric and medical comorbidity. Proceedings Orthopedic trauma Association 1988, p. 20 17. Hammer J, Lyons J, Strain J: A stand-alone integrated microcomputer software system for psychiatric services--Part I. Comput Psychiatry Psycho1 7:1-7, 1985 18. Hammer J, Lyons J, Strain J: Core structure and application design of a stand-alone integrated microcomputer software system for psychiatric servicesPart II. Comput Psychiatry Psycho1 78-11, 1985 19. Hammer JS, Lyons JS, Strain JJ: Development of a stand-alone microcomputer system for a consultation/liaison service-Part III. Comput Psychiatry Psycho1 7:15-18, 1986 20. Hammer JS, Lyons JS, Strain JJ: Extensions, enhancements, and computer considerations of a
240
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25. 26.
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stand-alone microcomputer system for psychiatry services, MICRO-CAREsPart IV. Comput Psychiatry Psycho1 7:16-20, 1986 Jansson GS, Simmons J: The ecology of social work departments: Empirical findings and strategy implications. Sot Work Health Care ll:l-16, 1986 Hoeper EW, Mycz G, Cleary PD: The Quality of Mental Health Services in an Organized Primary Health Care Setting. Final report, NIMH contract no 278-79-0013 (DB), 1979 Levitan S, Komfeld D: Clinical and cost benefits of liaison psychiatry. Am J Psychiatry 138:790, 1981 Smith GR, Menson RA, Ray DC: Patients with multiple unexplained symptoms: Their characteristics, functional health and health care utilization. Arch Intern Med 146:69-72, 1986 Fulop G, Strain JJ Psychiatric Consultation versus screen on a geriatric medical unit. Psychosom Med 51:261-262, 1989 Kiernan RJ, Mueller J. Langston JW, Van Dyke C: The neurobehavioral cognitive screening examination: A brief but quantitative approach to cognitive assessment. Ann Intern Med 107481-485, 1987 Rifkin A, Reardon G, Siris S, Karajgi B, Kim YS, Hackstaff L, Endicott N: Trimipramine in physical illness with depression. J Clin Psychiatry 46:4-g, 1985
Psychiatry
Possibilities for the 1990s James J. Strain, M.D., Leslie H. Gise, M.D., and George Fulop, M.D.
Abstract: In order for consultation-liaison (C/L) psychiatry to enhance its acceptance and funding, carefully designed outcome studies that will demonstrate its clinical effectiveness to other disciplines in medicine, departments of psychiatry, hospital administration, third-party payors, and patients are required. The development of alternative methods of funding CIL services is described: (1) high-risk screening, renal transplant, geriatric units (Medicarc); (2) sala y stipends from collaborating disciplines, e.g., medicine, EAT, neoplastics; (3) consultation fees; (4) ambulatory GIL clinics (Medicaid); and (5) grants from collaborative research. With a change in structure when it can be employed (from consultation to the screen methodology), the development of scientijically derived outcome data of C/L psychiatry interventions, adequate documentation of the evaluation and treatment by CIL psychiatry, and the new fools biological psychiatry and psychopharmacology will provide, the 2990s could and should be an exciting time for this subspecialty of psychiatry.
Proposal by Weiner et al. from the University of Texas Southwestern Medical Center at Dallas is an important and timely commentary and perspective on the prospects for consultationliaison (C/L) psychiatry in the 1990s [l]. The authors capture the concern, disappointment, and exasperation of workers in C/L psychiatry and suggest that the “wagons be drawn” to encompass a lesser sphere of influence and espouse more modest goals. The authors state that the primary reasons for the failure of C/L psychiatry to play a more significant role for “all medical/surgical patients in large A Very Modest
From the Division of Behavioral Medicine and Consultation Psychiatry, Mount Sinai Hospital, New York, New York. Address reprint requests to: James J. Strain, MD, Professor/ Director, Division of Behavioral Medicine and Consultation Psychiatry, Box 1229, The Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029.
General Hospital Psychiatry 11, 235-240, 1989 8 1989 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
hospitals . . . is that no adequate funding mechanism has ever been found to support such a large endeavor. The economic climate as we enter the 1990s makes such funding even less likely” [l]. Based on a lo-year experience at the Southwestern Medical Center, the authors suggest that C/L psychiatry accept a lesser role, largely confined to teaching hospitals, and focus on teaching medical students, residents, and postgraduate physicians rotating through psychiatry, offering innovative dispositions for medically ill psychiatric patients, and engaging in interdisciplinary research. In essence, this article presents a case study of one service and attempts to generalize from that experience to the prospects for the discipline of C/L psychiatry in the next decade. And the authors underscore from their experience that the lack of funding appears to be the major impediment confronting the potential breadth and scope of C/L psychiatry. However, other issues that will be important in the 1990s have even more relevance for teaching, future research, patient care, subspecialization, fellowship training, research into the mechanism of transduction, psychotropic pharmacokinetics, stress and the immune response, and determinants of noncompliance. As is so often the case, money appears to be’ the bottom line. Yet are there other issues, such as organizational structures, research findings, outcome data, communication with other disciplines, and the like, that would permit C/L psychiatry to not only let the wagons keep rolling but even impressively progress? C/L psychiatry faces a major dilemma in its breadth and lack of focus. It does not deal with a particular age group (children or the aged), a particular disease (schizophrenia, asthma or cancer), a specific issue (forensic), a des-
235 ISSN 0163-8343/89/!$3.50
J. J.
Strain et al.
ignated approach (pharmacology), or a specific research agenda (biologic, neuroscience, molecular, genetic). Consequently, it has all the problems of a generalist with the lack of concentrated effort and alliances that emanate from a sufficiently narrowed field so that it can be meaningfully tilled, fertilized, and harvested. C/L psychiatry runs the gamut of general psychiatry with the imposed confounds from the comorbidity of medical illness that does not encourage it to have a sufficiently focused constituency to prosper. It is the erroneous impression that anyone can do it and that it only requires the core skills and competence of general psychiatry. The American Cancer Society, The American Heart Foundation, The Tourettes Society, The Pain Society-all have a specified agenda that permits them to combine their efforts. The larger question remains how an appropriate focus can be articulated for C/L psychiatry so that the 1990s will offer unprecedented opportunities. The 1990s are likely to be a heady time for psychiatry, with exciting research, new discoveries, and improved treatments. Why shouldn’t C/L psychiatry be a part of this? Even if it is difficult, C/L psychiatry is obliged to try to implement knowledge about the psychology of medical illness. Furthermore, increasingly sophisticated medical care places additional personal burdens on patients who must make choices, actively participate in their own care, and comply with complicated regimens. These stresses intensify psychologic reactions and often require treatment. In addition, neglect of the psychosocial aspects of medical care decreases efficiency and increases costs. These and other factors make C/L psychiatry timely in the 1990s. In order to address these issues, this article examines the importance of psychiatric and medical comorbidity, traditional consultation versus screen strategies, and alternative methods of funding that could be employed in university or community hospitals. Rather than suggesting a period of retrenchment, the following research agendas and alternative health care delivery systems may provide a template for continued growth for the field.
Psychiatric and Medical Comorbidity Background Recent studies report psychiatric disorders in one of every five Americans in a 6-month period, of whom 62% are seen exclusively in the general medical setting [2]. Among medical and surgical in236
patients, as many as 30%-50% manifest concurrent psychiatric morbidity [3,4], although less than 1% are referred for psychiatric consultation [5]. Similar to the outpatient primary medical setting, medical/ surgical units in general hospitals function as de facto mental health delivery networks [6]. Relatively few patients receive specialized mental health care. Fulop and colleagues have reported that patients with concurrent medical and psychiatric morbidity remain in the general hospital twice as long as patients with medical illness alone [7,8]. Furthermore, Lyons et al. observed that the earlier during the hospitalization that the psychiatric consultation occurred, the earlier the patient was discharged [9]. Consequently, there is no dearth of patients requiring C/L psychiatry services: they consume enormous hospital resources, and this may be altered by early psychiatric intervention. As said before, however, few inpatients with medical and psychiatric comorbidity are referred for psychiatric consultation by physicians, nurses, or social workers. Furthermore, other medical and surgical departments are reluctant to reimburse psychiatrists for routine consultations, as that is a traditionally offered medical service either paid for by consultation fees from third-party payors or included in the per diem charges that support house officer stipends to render patient care. Fulop et al. have also identified the medical/surgical conditions most likely to be associated with psychiatric morbidity that may serve as a focus for C/L psychiatry interventions [8].
Alternative
Methods of Funding
Indeed, we can use The Mount Sinai Hospital as another case example of successful alternative strategies to permit C/L psychiatry service delivery in more settings. Although The Mount Sinai Hospital’s contribution to the Division of Behavioral Medicine and Consultation and its secretarial staff is minimal ($34,000 per year)‘, it has been possible to support six full-time lines for C/L psychiatry functions by five alternative routes to funding. First, this has been partly achieved by organizing the structure of the service so that it is primarily staffed by attendings. Psychiatric residents and medical students see consultations, but they do not direct any services or teams. Second, psychiatric ‘Faculty practice earnings from staff members contributed to the Medical Center exceeded the $34,000 from the Medical Center.
C/L Psychiatry: Possibilities for the 1990s
screening has been ferred consultations Third, grants and other medical and the trustees of the
implemented in contrast to reon certain high-risk services. gifts have been obtained from surgical departments and from Mount Sinai Hospital.
Inpatient Services By utilizing attendings to deliver psychiatric consultations these physicians are able to bill for services rendered. For example, all patients in the hemodialysis/renal transplant program are evaluated by a psychiatrist and offered treatment as indicated. As the majority of these patients are on Medicare, funds generated support a half-time psychiatrist [lo]. Similarly, because of the high prevalence of psychiatric comorbidity among geriatric inpatients, they are all screened and (if necessary) treated on the inpatient service Department of Geriatrics. As the majority have Medicare, a full-time attending is funded. The Department of Geriatrics provides a separate teaching supplement [ll]. One half-line is supported by the Department of Neoplastic Diseases and AIDS-related work. The orthopedic department funds a one quarter-line for an attending psychiatrist to screen all elderly patients admitted for hip fracture. The modal reimbursed fee for psychiatric service is $80 for each patient visit [12]. An otolaryngology department annual stipend provides the majority of one halfline for an attending to screen head and neck patients and conduct weekly ENT-psychiatry rounds [ 11,131. The remainder of this half-line comes from the same attending coordinating the psychiatric consultation service and his or her direct evaluation and treatment of consultation patients with the psychiatric resident observing.
The Consultation Service Between $15,000 and $20,000 is generated annually from the consultation service where patients are evaluated and treated by an attending psychiatrist.
Ambulatory Services With Medicaid reimbursement ($72.79 per patient visit) for outpatient psychiatric care, it has been possible to maintain a full psychiatric attending line in collaboration with the Department of Obstetrics, Gynecology, and Reproductive Science [14]. This service also includes the only premenstrual syndrome program for the indigent in New York City
[14]. Space, secretarial support, and travel to professional meetings are provided for the C/L psychiatry attending by the Department of Obstetrics, Gynecology, and Reproductive Science. Using a similar format, the Division of General Medicine funds one attending half-line in the general internal medicine ambulatory clinic. The attending consults on patients to offset his salary. Support is offered from the Division of General Internal Medicine to attend the weekly team teaching conference and participate in collaborative research. It is planned to reinstitute the behavioral medicine clinic, which will offer a variety of treatments: psychotherapy, cognitive therapy, relaxation treatment, biofeedback, hypnosis, and psychotherapy [15]. This clinic will provide follow-up for all appropriate service cases seen on the inpatient consultation service and for medical/surgical clinic patients requiring psychiatric treatment. It is anticipated that this clinic will generate sufficient revenues from Medicaid reimbursement to support one full-time attending C/L psychiatrist and, more importantly, offer essential services heretofore unavailable at The Mount Sinai Hospital. Treatment time is usually not available for consultation patients with psychiatric and medical comorbidity in either the general psychiatry outpatient department or in sufficient numbers in the general medical clinic.
Funding from Other Disciplines The Department of Social Work Services supports 25 hours of psychiatric attending services per week: 5 for obstetrics/gynecology, 5 for the general internal medicine clinic, and 15 for the other 150 outpatient medical and surgical clinics. An attending psychiatrist reviews cases with social workers, discusses treatment plans, and follows patients with social workers where indicated. The psychiatrist is also a consultant to the Employee Health Service.
Grants and Collaborative Research Attending psychiatrists are supported by grants from several sources: The Sexual Dysfunction Clinic (one third-line), Department of Medicine Educational Grant (one half-line for 5 years, one quarter-line currently), National Institute of Mental Health (“Cost Offset of a Psychiatric Intervention with Elderly Hip Fracture Patients,” in collaboration with the Department of Orthopedics (one half237
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line) ]12,16], and the National Cancer Institute (“Physician and Patient Noncompliance with Breast Cancer Chemotherapy Protocols”) in collaboration with the Department of Neoplastic Diseases (one full line).
Contributions A generous annual contribution from a Mount Sinai Hospital trustee to provide excellence in scholarship, research, teaching, and exemplary clinical care augments the divisional budget. This grant has permitted the development of software to undertake epidemiology and health services delivery research, to document C/L psychiatry efforts to track the patients of the residents, and to develop core literature for research and teaching that can be appended to a computer-generated chart note as a pedagogic vehicle for psychiatric and medical residents [ 17-201. Assisted by an Upjohn Company Educational Grant, this program has now been offered to C/L psychiatry at 100 medical schools. All five of these methods for funding C/L psychiatry services are available to any teaching or community hospital in New York State. And these paradigms could be increased at The Mount Sinai Hospital if there were additional space and secretarial support. For example, the HIV Clinic supports 5 hours of an attending psychiatrist who treats Medicaid patients, and this will be augmented as the number of cases and the need for treatment escalate. Furthermore, a liaison screen method does not require psychiatric residents. In fact, on some services it may not be possible to have residents care for all the consultation patients because of their limited time availability. Optimally, residents have a carefully titrated clinical experience with sufficient supervision to make the C/L psychiatry rotation an excellent teaching experience. Municipal, state, Veterans’ Administration, and military hospital systems that offer care at no fee to their patients, and where departments of psychiatry are dependent on funded lines, would not be suitable for many of these alternative methods of funding psychiatry.
Social Work Service-Screen
Model
From another perspective, C/L psychiatry can well afford to take notice of the evolution in the practice and funding patterns of social work (SW) [21]. The referral model has often been replaced by the li238
aison model in which a social worker is assigned to a unit as a member of the team and as such is in an ideal position to screen or triage every patient. There are several advantages that SW accrues by not waiting to be called in: they are not dependent upon the housestaff or nursing staff, who may be insufficiently trained to identify patients with psychosocial needs [22]. In addition, their constant presence makes SW the first echelon to assist the ward staff with whom they work daily. Finally, because they are regarded as an essential part of the hospital system, funds for their payment are secured from three important sources at The Mount Sinai Hospital: (1) Medicare Part A (inpatients); (2) departmental funds including grants (e.g., neoplastic diseases, geriatrics, renal dialysis, etc.); and (3) Medicaid-$72.79 per visit for ambulatory patients. It is important to note that in New York State to qualify for Medicaid reimbursement for mental health care for patients seen in the general hospital clinic setting (e.g., psychotherapy, in contrast to concrete services), social workers are required to have their mental health treatment plan reviewed periodically by a physician. As a result of the changing role of SW and their creative access to funding, The Mount Sinai Hospital has the services of approximately 100 workers in a 1200-bed hospital that averages 38,000 inpatient admissions and 350,000 outpatient visits per year. C/L psychiatry could profit from observing the important advantage that SW has accrued by moving from the referral mode to the liaison-screen model and their impressive access not only to funding, but to patients and physicians.
Research Because of the essential need for data to understand the outcome of C/L psychiatry interventions, the National Institute of Mental Health has promoted initiatives to examine their therapeutic and cost-offset effects [12,16]. This information should have an important impact on C/L psychiatry services and their funding in the 1990s. For example, provisional data demonstrate a decrease in hospital length of stay after a C/L psychiatry intervention with elderly hip fracture patients [12,16,23]. Smith has shown that primary care physicians use less health care resources for somatoform patients after being informed of their diagnosis [24]. Fulop and Strain have determined that the geriatric inpatients exposed to a liaison screen, in contrast to the tra-
C/L Psychiatry:
psychiatric consultation model, remain in the hospital 2 days less [25]. In many medical centers, basic research is underway in disease risk factors, behavioral noncompliance, psychotropic drug mechanisms in patients with physical illness, mechanisms of transduction, immune response and mood states, and so on. Medical/surgical patients at risk for psychiatric morbidity have been identified. These patients may be the target of brief, focused psychiatric interventions rather than costly global screening of large populations. New diagnostic batteries are under development [26]. Psychotropic drug trials in the medically ill will provide needed information with regard to relative effectiveness [27]. Current research in all these areas should augment the armamentarium of the C/L psychiatrist to offer more effective psychologic care to the medically ill. ditional
Conclusion In order for C/L psychiatry to obtain a more important place and funding, it needs to conduct carefully designed outcome studies that will demonstrate its clinical effectiveness to other disciplines in medicine, departments of psychiatry, hospital administration, third-party payors, and patients. As an example of such an efficacy demonstration, we can cite the collaborative study of hip fracture patients that found a 2-day reduction in length of hospital stay in the C/L intervention year in comparison to the control year at two sites (Mount Sinai Hospital and Northwestern Memorial Hospital) [12,16]. When the Department of Orthopedics at Mount Sinai observed this outcome, they were enthusiastic about offering C/Lpsychiatry care to all their elderly hospitalized patients, especially as those with hip fracture were exceeding the DRC reimbursement rate because of prolonged lengths of stay. Such results at The Mount Sinai Hospital (like those demand colleagues at onstrated by Weiner Southwestern Medical Center) show that when C/L psychiatry has a scientific base for its action and a visible and useful role, funding follows. With a change in structure when it can be employed (from consultation to the screen methodology), with the development of scientifically derived outcome data of C/L psychiatry interventions, with adequate documentation of the evaluation and treatment by C/L psychiatry, and with the new tools biologic psychiatry and psychopharmacology will provide, the 1990s could and should be an exciting time for this subspecialty of psy-
Possibilities for the 1990s
chiatry. Psychiatric and medical comorbidity-the province of a physician trained in biology, psychiatry, and social perspectives-offers a golden opportunity to display psychiatry’s unique skills to provide mental health care in the general medical setting. Research can buttress that claim. To avoid retrenchment, it is important to devise methods to meet the needs of those patients with medical illness who also have psychiatric morbidity. We appreciate the Southwestern group’s focusing our attention on our future. This work has been supported in part by the Green Fund. The authors
wish to acknowledge Ms. Susan Michele Sonenreich for her editorial assistance.
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