C-L Psychiatrists Uniquely Qualified to Lead Treatment of Psychosocially Complex Medical Patients

Consultation-liaison psychiatrists are uniquely positioned for leadership in health care systems moving toward collaborative, team-based care, said APA President Rebecca Brendel, M.D., J.D., and APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a joint address at the annual meeting of the Academy of Consultation-Liaison Psychiatry (ACLP) in Atlanta.

“Consultation-liaison [C-L] psychiatrists have unique skills that make us leaders in the future of psychiatry—understanding complexity, innovative thinking for the future, and working in teams and systems of care,” said Brendel.

She described her work as an embedded psychiatrist in a multidisciplinary team at Massachusetts General Hospital (MGH) seeking to improve patients’ outcomes and reduce lengths of stay (LOS) and the cost of caring for psychosocially complex medically ill patients.

MGH’s average LOS in 2006 was six days, but about 4% percent of these psychosocially complex patients had stays longer than 20 days. “The question was how to identify this 4% of patients. We knew that [focusing on this group] was where we would be able to innovate and provide better outcomes for our patients stuck in the hospital and [enable] the system to admit more patients [by decreasing the LOS for these long-stay patients].”

Inpatients requiring guardianship—a surrogate to make decisions when the patient is incapacitated—became a focus of the multidisciplinary group; the search for a guardian is often legally cumbersome and time consuming. “For patients requiring guardianship, we had more than 1,100 potentially avoidable days in hospital,” Brendel said. “This corresponded to more than 180 additional patients the hospital could admit if we [shortened the stay for patients requiring guardianship].”

The hospital began collaborating with the courts in Massachusetts and developed its own internal pilot program focused on managing patients requiring guardianship. “We were able to bring down the median time to discharge [for patients requiring guardianship] from about 25 days to 16 days in 2008. Over the ensuing decade, this collaboration between C-L psychiatry, social work, case management, and medicine really led to significant results. We had a sustained reduction in internal processing time of 5.6 days compared with baseline, a decrease in average LOS of 8.9 days, and a reduction in potentially avoidable days of 2.6 days compared with baseline. “

The effort also made clear that social determinants of health were a key driver of longer hospitals stays, but also of greater outpatient costs and utilization. In 2006 MGH began a Medicare demonstration project focusing on 2,500 of the sickest patients in the MGH system based on cost and medical risk. Just 10% of these had no current or past psychiatric diagnosis. “So we learned that mental illness was a driver of medical complexity on the inpatient and the outpatient side,” Brendel said.

With a psychiatry-led mental health component as part of the demonstration project, the hospital succeeded in reducing costs for these patients by 10%.

“We are in the unique position as C-L psychiatrists to be leaders of medical teams because we cross so many different domains,” Brendel said. “We know how to lead and interact with systems of care. This is conducive to solving problems and to setting new norms for how we ought to practice in the future.”

Levin echoed those remarks, saying that C-L psychiatrists and the ACLP have been instrumental in advocating for the Collaborative Care Model. He said the experience of C-L psychiatry has been vital in developing APA resources on integrated care, including the 2016 report “Dissemination of Integrated Care Within Adult Primary Care Settings: The Collaborative Care Model.”

“Input from C-L psychiatrists will be essential as we work to develop innovative ways to deliver care and reimburse psychiatrists for their work,” Levin said. ■