Patterns of referral from consultation-liaison to social work services

C-L Psychiatry and Social Work

though 52 patients were referred for concrete services, 30% of the cases did not turn out to require them, and in over half the referring doctor had overlooked psychiatric problems. Furthermore, even when they had identified significant psychiatric problems, physicians actually referred patients for concrete services. This study highlights the issue that direct referrals from the primary care physician may overlook or minimize frank psychiatric morbidity. There is little in the literature about the referral patterns of medical and surgical inpatients from SW to psychiatry, and reports of referrals from psychiatry to SW usually emphasize rates of referral [9-111. In an attempt to understand more adequately psychiatry’s referral relationship with SW in the general hospital, this report focuses on consultation-liaison (C-L) psychiatry’s patterns of referral to social work services (SWS). Since SW generally has workers assigned throughout the medicalisurgical units, SW is in an ideal position to select those patients who they feel are appropriate for referral to psychiatry. The nature of referral from a specialty highlights how each regards the other as well as their expectation of services to be provided. A unique databased schema employed by the Division of Behavioral Medicine and Consultation Psychiatry at The Mount Sinai School of Medicine afforded an opportunity to systematically examine this referral relationship.

centers, e.g., oncology, renal dialysis, transplantation, HIV unit, etc. The study utilized a 384-item structured inventory developed over 10 years that emphasizes [12]: demography; level of urgency; reasons for the consultation, including both those “stated” by the consultee and those that were “assessed“ by the consultant; the Diagnostic and Statistical Manual (DSM-III) diagnoses on five axes [13]; and treatment/management recommendations in five areas-to the unit staff, by the consultation staff, medications, inpatient and outpatient psychiatric treatment, and administrative action. The Missouri Mental Status Examination was employed to determine the severity of the patient’s psychiatric status [14]. Data were collected by attendings, fellows, and PGY-III psychiatric residents on the consultation service (four residents on 4-month rotations) and recorded by them on the consultation form, for which formal training was given. Data were recorded at the time the case was opened and at termination of treatment. Each case was reviewed by the Director or Associate Director of the Service, who observed over 50% of the cases. Student’s t-test and chi-squared analyses were employed for continuous and dichotomous variables, respectively.

Results

Methods

Psychiatric Referral to Social Work

The Mount Sinai Hospital is a 1200-bed university hospital in New York City with 37,000 medical/ surgical discharges a year. The 1170 psychiatric consultations to medical and surgical patients completed by the Division of Behavioral Medicine and Consultation Psychiatry between 1980 and 1986 were divided into two groups: 1) patients referred from psychiatry to SW; and 2) patients not referred to SW (i.e., “others”). The characteristics of those patients “at risk’ for referral to SW are described. The Social Work Department is an independent department within the Mount Sinai Hospital and is integrated into all segments of the hospital’s clinical care and organizational levels. It is administratively linked to the Department of Community Medicine, which sponsors the academic appointments. Many workers have doctorates, while the majority are Masters level. The department conducts research and has over 100 workers assigned to every ward and clinic, and to the major clinical

Of 1170 patients evaluated by the consulting psychiatrist, 24% (II = 280) were referred to SW. This did not vary significantly over 5 years. Patients referred to SW differed significantly from those not referred to SW (“others”) with regard to age, sex, race, marital status, employment, social support, urgency of the consultation, and location of the patient on a unit to which a psychiatrist was assigned (liaison unit) (Table 1). Significantly, fewer referrals to SW occurred for that cohort who were married, had permanent help available, and for whom a “stat” consultation was called. Consultations for patients later referred to SW were more likely to be called for depression (p = O.OOOl), relationship problems (~7 = 0.02), coping with illness (p = 0.004), noncompliance (p = 0.004), past psychiatric history (y = 0.05), anxiety (p = 0.05), and preoperative evaluation (y = 0.05), as compared to those not referred to SW. In contrast to the “others,” those referred to SW

J. J. Strain et al.

Table 1. Demographics

Variable

Psychiatry Referrals to SW (n = 280) 46.1

Age - (vr) _ Sex (female) Married (yes) Education

Table 2. Assessment

27.1%

(yr)

48.4” 34.6%” 11.7

Living alone

12.5%

21%h

Service Medicine Surgery - _

49% 51%

48% 52%

86.4%

76.4%”

Billing Medicare Medicaid Other

16.8% 34.7% 48.4%

15.8% 20.3% 63.9%

Personal help available

89.6%

94.5%”

Employment

(no)

Psychiatry Referrals to SW

Others (n = 890) Severity of psychiatry illness (0 = none, 7 = extreme)

Others

p

3.7

NS

Axis I Adjustment Anxious Depressed

2.8% 17.5%

3.1% 15.0%

NS NS

OMD Substance Affective Psychotic Anxiety

28.1% 14.0% 13.0% 3.9% 2.5%

31.6% 12.8% 10.3% 4.7% 3.1%

NS NS NS NS NS

Axis II

32.6%

23.3%

a

Axis IV

4.7

4.4

o

Axis V

3.9

3.6

’

abuse

Missouri Mental Status Examination

[ 141.

Race White Black Other

36.9% 34.0% 29.1%

44.6% 25.9%” 29.5%

‘$I=
Liaison ward (no)

60.7%

52.6%“

Urgency Stat Today Routine

10.3% 46.3% 43.4%

15.5%” 47.2% 40.0%

mental status (Missouri Mental Status Examination) (Table 2) nor the rank order of the top 10 medical diagnoses (Axis III) was significantly different between the groups. Regression analysis revealed that four variables had the greatest impact on differentiating the group psychiatry referred to SW from the “others”: 1) the recommendation for constant observation (log -586, p = 0.0001); 2) the type of psychiatric management (log -573, p = 0.0001); 3) low socioeconomic status as reflected by Medicaid insurance (log -564, p = 0.0001); and 4) the refusal of tests or treatment by the patient (log -559, p = 0.002).

“p= ‘Co.01.

ap = < 0.05. hp = < 0.01.

had more personality disorders (Axis II), (~7< O.Ol), greater psychosocial stress (Axis IV) (p < O.OOl), but better functioning (Axis V) (p < 0.001) during the previous year (Table 2). The referrals to SW were more likely to have follow-up treatment by the psychiatrist (p = < O.Ol), outpatient treatment recommended (p = < O.OOl), less administrative action taken (p = < O.Ol), and fewer patients whom the psychiatrist felt could leave against medical advice (p = < 0.05) (Table 3). With regard to hospital course, at discharge the group referred to SW was more likely to have SW notes (p = < O.OOl), reasons for the consultation (p =
Discussion Psychiatric consultants referred 24% of their patients to SW. Although these patients were not always the same group as those referred to psychiatry from SW and were more likely to be younger, have families, and not be on psychotropic medications, they had similar psychiatric diagnoses to the nonreferred group. And, although the rate of referral to SW remained constant over the 5-year period of the study [15], should it have increased with the ongoing development of liaison services? As with the question of an optimal refer-

C-L Psychiatry

Table 3. Treatment/Management Psychiatry Referrals to SW Unit Staff Gratify needs Consultant observation Consult needed Diagnostic tests Environmental change Follow-up treatment by consultant Inpatient psychiatric treatment Outpatient

treatment

Administrative Impaired

action

judgment

May leave AMA

Table 4. Hospital course

Others

p Number

19.3%

15.21%

NS

4.9% 9.5% 12.6%

7.8% 12.0% 13.5%

NS NS N’S

11.2%

11.2%

NS

23.0%

16.7%

*

7.0%

7.4%

NS

20.7%

12.5%

’

42.0%

60.0%

’

2.8%

2.8%

NS

0.4%

42.8%

c

“p=
and Social Work


of follow-ups

Psychiatry Referrals to SW

Others

p

3.5

3.4

NS

NS 26.7%’ 25.7%’ 23.3%’ 24.3%

30.3% 30.0% 19.6%’ 20.2%

13.3%

38.4%

I2

76.4%,

51.0%

”

27.3%

25.90/r,

NS

18.5%

30%

‘I

34%

36%

NS

Reason for referral recorded by consultee

61.5%

50.3%

‘I

Psychosocial services recorded in chart

75.3%

57.0%

I’

Lag time (days) o-1 2-5 6-15 15+ Patient informed consultation Social service chart Unit conflict Surgical

of

note in

present

mutilation

Operative

NS

procedures

“p=
“p=
io understand more about their roles in evaluating and treating the terminally ill in the general hospital. It is difficult to determine what the underlying mechanisms are for influencing the psychiatrist to refer to SW from the correlational data presented in this study. A smaller number of those consult patients who were dying were referred and the referred cohort had their initial contact with the psychiatrist described as Iess urgent. Therefore, of the consultant psychiatrists’ patients, the less urgent or physiologically ill were more likely to be referred. Those patients under greater stress, but with better previous functioning may have seemed to be better candidates for the assistance of the SWS in counseling, assistance in coping with illness, stress reduction, family intervention, or obtaining placement and services to strive for preillness levels of adaptation. Future studies need to ascertain the reasons for encouraging psychiatrists to refer and what patient and illness characteristics inhibit the use of SW referrals. Finally, it is essential to develop rigorously data on product efficiency [17], the “substitutability” of

91

J. J. Strain et al.

Knowledge SW mental health

base

competencier

in acute medical

Figure 1. A model of domains of knowledge

surgical

vnrds

and skills.

mental health disciplines in treating psychiatric and medical comorbidity both on the basis of competencies for rendering diagnosis and treatment, and comparability of costs. Using a grid developed by Burns et al. that identifies domains of mental health skills and knowledge [18], the previous Director of SW at the Mount Sinai Hospital described where he felt the competencies of the majority of his workers lie with regard to the acutely ill medical and surgical inpatient (Figure 1). Hammer et al. reported on an integrated human services approach where it is possible to examine simultaneous diagnoses by multiple disciplines, treatment recommendations, and the amount and kind of service delivery [19]. Using a cross-discipline database, this group examined interdisciplinary referral patterns, the timing of referrals, and their impact on length of stay, after-hospital discharge placement, simultaneity of services, etc. Although this paper focuses on referrals from psychiatry to SW, it invites the question of SW’s referrals to psychiatry. This is complicated by the nature of the consultation process, which is traditionally initiated by a doctor. The effort of SWS to effect a psychiatric consultation is difficult to track, since much of its work may be “behind the scenes” and not easily documented by the psychiatric consultant. To understand more about the low referral rate (6%) from SW to psychiatry in this same consultation cohort, SW reviewed 20 charts at random, and found that social workers were often involved in prompting the house staff to refer to psychiatry [20]. SW’s effort was not always reflected by the psychiatric consultant, who had been asked to fer-

92

ret out who really precipitated the consultation, and not to attribute immediately the initiation to the individual, usually the house officer, who called in the request or signed the consultation request form [20]. The documented rate of referral from SW to psychiatry of 6% recorded by the consultant in no way taps the effort SW may have put forth to secure a consultation through the patient’s physician [20]. However, if one were to assume that SW is responsible for all the referrals to psychiatry, the question still remains as to why the referral rate is so low. At The Mount Sinai Hospital, the consultation rate is 3%-4% of all admissions. Wallen et al. report from a random survey of general hospitals throughout the nation that the psychiatric consultation rate was 0.2% for rural and 0.8% for academic centers [21]. If 19% of persons in the general population have major psychopathology in any 6-month period [22], and 30%-50% of inpatients in general medical surgical wards have primary psychiatric morbidity or significant psychological dysfunction secondary to their medical illness [23], it is surprising that the psychiatric consultation rate nationwide is not higher. This is especially true given the fact that SW is built into the system of the hospital, functions on every inpatient ward, has developed high-risk screening procedures [24-261, and is trained to be aware of altered mental states that may require further psychiatric diagnosis and/or treatment including psychotropic medications. In fact, the following factors should encourage the development of mechanisms to enhance referrals from SW to psychiatry: 1) the prevalence of psychiatric morbidity in the community setting [22]; 2) the frequency of psychiatric morbidity in the general hospital [23]; 3) the doubling of the length of hospital stay (50%) for those patients who have both psychiatric and medical comorbidity [27]; 4) the relationship between early psychiatric consultation and early hospital discharge [28]; 5) the psychiatric consultation rate in general hospitals [21]; and 6) the fact that SW is on the wards often seeing the majority of patients and with highrisk screening as a goal [24-261. Several possibilities may account for the overall low psychiatric referral rates in general hospitals. First, despite the fact that SW identifies psychiatric morbidity, it is unable to prevail upon the patient’s physician to precipitate a psychiatric consultation. Second, the reported rates for psychiatric mor-

C-L Psychiatry

bidity in the community do not accurately reflect the amount actually present in the general hospital setting. Although the majority of psychiatric morbidity studies are flawed by 1) the possibility of measurement errors resulting from the use of traditional psychiatric assessment instruments in the medically ill [29], and 2) the infrequent use of appropriate sampling methodology (e.g., population or denominator studies), several studies show a significant rate of psychiatric pathology among hospitalized, medically ill patients [30,31]. it is highly unlikely that the Furthermore, Epidemiological Catchment Area rates for the general population (19% in a 6-month period) would be less when these same patients are hospitalized with severe medical/surgical illness [22]. In fact, one would speculate that psychiatric morbidity would increase with the stress of illness and hospitalization, surgery, postoperative states, and the administration of chemotherapy. Third, SW does not regard the psychiatric morbidity it perceives (e.g., depression) to require the involvement of a psychiatrist. If the depression being observed is not distinguished into its five diagnostic domains [i.e., normal mood disturbance, bereavement (V 62.82), adjustment disorder with depressed mood (309.00), dysthymic disorder, or major mood disorder], the need for pharmacotherapy, hospitalization, or even ECT may not be discerned [27]. Fourth, SW does not appropriately identify psychiatric morbidity or feel that it requires a medical diagnosis (e.g., biopsychosocial assessment) or psychopharmacological intervention. Fifth, high-risk screening is not necessarily sensitive to nor has it been specifically designed to identify psychiatric morbidity. model comSixth, the “problem” assessment monly employed by SW may emphasize phenomena at the problem level and not necessarily promote exploration of possible observed psychiatric morbidity. Research efforts are needed to determine whether C-L psychiatry is referring the appropriate kind and number of consultation patients to SW. It is imperative that decisions regarding referral or substituting one mental health discipline for another be based on rigorously controlled studies that examine the incidence of the identification of the psychiatric/psychosocial problem, the intervention prescribed, and the outcome of the intervention on several parameters: medical outcome, psychiatric/

and Social Work

psychosocial morbidity (including compliance with medical treatment), quality of life, and costs. Such studies would enhance the C-L psychiatrist‘s capacity to refer appropriately to SW and offer a scientific basis for those patients he or she is at risk for not referring. It is undetermined how many of the 76% not referred by C-L psychiatry and who were not actively being seen by SW would have benefited from a SW consultation. Similarly, it would be important to learn from SW how many of the 24% of the C-L cohort referred to them were appropriate from their perspective and how many of the unreferred should have been referred. Interdisciplinary collaborative studies would offer a sounder footing for the mental health disciplines in the general hospital on how and when to involve each other for the optimal care of the patient and when their simultaneous work with a patient is redundant. C-L psychiatry is in an excellent position to work with SW as well as clinical nurse specialists and psychologists toward achieving these important answers.

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22. Regier DA, Myers JK, Kramer M, et al: The NIMH Epidemiologic Catchment Area (ECA) Program: Historical context, major objectives, and study population characteristics. Arch Gen Psychiatry 41:934941, 1984 23. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine. II. Clinical aspects. Psychosom Med 29:201-224, 1967 24. Berkman B, Rehr H, Rosenberg G: A social work department develops and tests a screening mechanism to identify high social risk situations. Sot Work Health Care 5:373-385, 1980 25. Becker NE, Becker FW: Early identification of high social risk. Health Sot Work 11:26-34, 1986 26. University of Virginia Medical Center, Division of Social Work, Charlottesville: Appendix A: High-risk categories. Discharge Planning. Chicago, American Hospital Association 1980, p 10 27. Fulop G, Strain JJ, Vita J, Hammer JS, Lyons JS: Comorbidity and length of stay. Am J Psychiatry 144:868-882, 1987 28. Lyons JS, Hammer JS, Strain JJ, Fulop G: The timing of psychiatric consultation in the general hospital and length of hospital stay. Gen Hosp Psychiatry 8:159-162, 1986 29. Strain JJ: Diagnostic considerations in the medical setting. In Strain JJ (ed), The Medically I11 Patient. The Psychiatric Clinics of North America, ~014, no 2. Philadelphia, W.B. Saunders, 1981, pp 287-300 30. Bukberg J, Penham D, Holland JC: Depression in hospitalized cancer patients. Psychosom Med 46: 199-212, 1984 31. Cavanaugh S, Wettstein RM: Prevalence of psychiatric morbidity in medical populations. In Psychiatry Update, vol 3. Washington, DC, American Psychiatric Press, 1984, pp 187-215