Proactive C-L Psychiatry: Re-envisioning Psychiatric Care in Medical Settings

Consultation-liaison (C-L) psychiatry provides essential expertise to medically admitted patients. However, there is considerable variation from institution to institution in how consultations are performed, the nature of the liaison role, and the structure of C-L psychiatry service lines. As in all of medicine, the Triple Aim of health care has prompted the field of C-L psychiatry to re-evaluate its vision of value-based care.

“Proactive C-L psychiatry” is one way to re-envision C-L psychiatry that can enhance its value to institutions, medical colleagues, and patients. Proactive C-L psychiatry is an interdisciplinary model of inpatient C-L practice that incorporates four components:

• Systematic screening, either by a proactive C-L psychiatry team member or by computerized means, aims to identify active or potentially serious mental health concerns at the time of medical admission. The goal is to prevent crises rather than respond to them.

• Proactive clinical engagement occurs when patients identified on screening are discussed with hospital floor staff (both the primary team and nursing staff) to evaluate for potential mental health needs. A psychiatric social worker may also perform brief in-person evaluations for clinical stability or to identify anticipatable mental health needs.

• An interdisciplinary team approach allows for each member of the proactive C-L team to collaborate and provide care based on his or her expertise.

• Care integration allows for medical and proactive C-L team members to build rapport with one another and develop a joint approach to clinical care.

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How does proactive C-L psychiatry work? Let’s begin with a case study that illustrates what, unfortunately, happens too often. A 55-year-old man with bipolar disorder, stable for several years on lithium, is admitted with pneumonia and acute kidney injury. The admitting team discontinues lithium because of concerns that he could develop a supratherapeutic level due to reduced renal clearance. The primary team changes two days later, and lithium is never re-started. As discharge approaches a week later, he begins to exhibit accelerated speech; elevated mood; and grandiose, overvalued ideas leading to nonadherence with care. The primary team recognizes the medication oversight, restarts lithium, and consults with psychiatry. The C-L psychiatrist diagnoses mania and recommends adding quetiapine to augment lithium. Ultimately, discharge is delayed by several days.

Although predictable, the case is emblematic of the prevalent form of C-L psychiatry as practiced across the United States today. In most hospitals, psychiatric needs go unmet; the needs that are addressed are often crisis driven; and the C-L psychiatrist chiefly provides medication recommendations to the primary medical team with variable consideration of collaborative decision-making or difficulties faced by nurses and other hospital staff—especially if these concerns are not specified in the consult question.

But let’s re-envision this case applying proactive C-L psychiatry. A proactive C-L team member would have identified the patient on admission chart review either because of a preexisting diagnosis of a serious mental illness or because his home medications included a mood stabilizer—either of which indicates a clearly anticipatable mental health need. An early conversation with the primary team would have led to discussion about medication adjustments in the context of acute kidney injury, such as obtaining collateral about the nature of previous mood episodes including prodromal features, lithium level monitoring, or tailored medication adjustments.

This is a model hospitals and health systems can begin to incorporate without significant disruption to the existing workflow. A “Resource Document for Proactive C-L Psychiatry” will be forthcoming from APA’s Council on Consultation-Liaison Psychiatry. In addition, several resources on proactive C-L are available on the Special Interest Group webpage through the Academy of Consultation-Liaison Psychiatry. These include documents detailing various aspects of this model of care, materials for those interested in piloting a proactive C-L service at their institution, and a regularly updated bibliography. The proactive C-L Special Interest Group also offers a listserv in which members can ask questions and learn from those who practice on a proactive C-L service.

Over the past decade, proactive C-L psychiatry has been shown to reduce overall hospital length of stay, improve medical and nursing staff satisfaction, enhance the volume of mental health care delivery, and reduce latency to psychiatric consultation. This model has emerged as a means of enhancing the value of C-L psychiatry to patients and their families, the full range of floor hospital staff, and institutions by way of cost-effective care. It also enhances the value to each C-L psychiatry team member in that care is delivered as a team rather than by solo providers. ■