Automated Screening to Enhance Proactive Consultation-Liaison Psychiatry Services in Acute Medicine Units: Evaluation of Service Outcomes.

Objective: Proactive consultation-liaison (C-L) psychiatry aims to meet the mental health needs of medical-surgical populations-many of which go unmet by the conventional C-L model-through systematic screening and integrated care. We implemented an automated screening list to enhance case identification of an existing proactive C-L service and evaluated service metrics along with clinician- and patient-reported outcomes.Methods: Service outcomes were evaluated using historical and contemporary comparison data. Adjusted difference-in-difference analyses were used to determine change in consult characteristics, mean length of stay (LOS), and scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Practitioners and nurses were surveyed regarding service satisfaction, perceived safety, and burnout.Results: During the intervention, the consult rate was 3-fold higher than at baseline. Change in time to consultation was equivocal. Overall mean LOS was not reduced, but observed LOS was 1.2 days shorter than expected among non-COVID patients receiving psychiatric consultation (P = not significant). Mean patient-rated hospital satisfaction on HCAHPS was 1 point higher on intervention units during the intervention. Surveys revealed broad satisfaction with this model among practitioners and improved perception of safety among nurses.Conclusions: Proactive C-L psychiatry enhanced by automated screening was associated with improved service utilization and evidence suggestive of LOS reduction among those most likely to receive direct benefit from this model of care. Further, both patient and clinician ratings were improved during the intervention. Proactive C-L psychiatry provides benefits to patients, clinicians, and health systems and may be poised to achieve the Triple Aim in health care.Prim Care Companion CNS Disord 2024;26(2):23m03647. Author affiliations are listed at the end of this article.

Using Discrete Form Data in the Electronic Medical Record to Predict the Likelihood of Psychiatric Consultation.

BACKGROUND: Manually screening for mental health needs in acute medical-surgical settings is thorough but time-intensive. Automated approaches to screening can enhance efficiency and reliability, but the predictive accuracy of automated screening remains largely unknown. OBJECTIVE: The aims of this project are to develop an automated screening list using discrete form data in the electronic medical record that identify medical inpatients with psychiatric needs and to evaluate its ability to predict the likelihood of psychiatric consultation. METHODS: An automated screening list was incorporated into an existing manual screening process for 1 year. Screening items were applied to the year's implementation data to determine whether they predicted consultation likelihood. Consultation likelihood was designated high, medium, or low. This prediction model was applied hospital-wide to characterize mental health needs. RESULTS: The screening items were derived from nursing screens, orders, and medication and diagnosis groupers. We excluded safety or suicide sitters from the model because all patients with sitters received psychiatric consultation. Area under the receiver operating characteristic curve for the regression model was 84%. The two most predictive items in the model were "3 or more psychiatric diagnoses" (odds ratio 15.7) and "prior suicide attempt" (odds ratio 4.7). The low likelihood category had a negative predictive value of 97.2%; the high likelihood category had a positive predictive value of 46.7%. CONCLUSIONS: Electronic medical record discrete data elements predict the likelihood of psychiatric consultation. Automated approaches to screening deserve further investigation.

Predictors of referrals and depression outcomes among obstetrics and gynecology patients with positive depression screens.

INTRODUCTION: Little is known about the care provided following positive depression screens in obstetrics and gynecology (Ob/Gyn) patients. METHOD: This study evaluated documented care plans and outcomes for 445 Ob/Gyn patients with positive depression screens between January 2018 and December 2020. Logistic regression models were estimated to identify predictors of changes in documented care plans and to test if a documented plan was associated with a reduction in depression severity in 6 months. RESULTS: The sample consisted of 445 patients who were on average 35.5 (SD = 12.8) years; 206 (46.3%) were White and 178 (40.0%) were Black. A total of 64 (14.4%) had a depression care plan documenting antidepressant initiation or change and/or psychotherapy referral. Relative to those aged 18-29, patients 40 or older had approximately 60% lower odds of a documented care plan change (OR = 0.394; p < .05). Relative to those seen by nurses, patients seen by physicians had approximately 70% lower odds of having treatment change (OR = 0.282; p < .05). Patients with a depression care plan documented had approximately 2.7 times higher odds of achieving 50% or more reduction in their Patient Health Questionnaire-9 depression severity score than those without a documented plan (OR = 2.685; p = .009). DISCUSSION: While most patients did not experience an initiation or change in their depression care plan on the same day as their positive screen, those patients with a plan documented showed significantly more improvement than those who did not. Standardized recommendations may improve depression outcomes among patients with positive depression screens. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Racial and Ethnic Disparity in Preference-Weighted Quality of Life: Findings from the Selenium and Vitamin E Cancer Prevention Trial.

Differences in preference-weighted health-related quality of life (HRQOL) scores by race/ethnicity may be due to social factors. Here, Short-Form Six-Dimension (SF-6D) scores are analyzed among men in a prostate cancer prevention trial to explore such differences. Selenium and vitamin E cancer prevention trial participants who completed the SF-6D at baseline, and in at least 1 of follow-up years 1, 3, and 5 were included. This study compared mean SF-6D scores across race/ethnicity at each point using a linear mixed model controlling for demographic and clinical characteristics. At baseline, 9691 men were eligible for analysis, of whom 7556 (78%) were non-Hispanic White, 1592 (16.4%) were non-Hispanic Black, and 543 (5.6%) were Hispanic. Hispanic and White participants had higher unadjusted mean SF-6D scores than Black participants at every time point (P < 0.05), while white participants had lower mean scores than Hispanic participants at every time point after baseline (P < 0.05). After adjusting for covariates, statistically significant differences in HRQOL among the 3 groups persisted. Hispanic participants had higher preference scores than White participants by 0.073 (P < 0.001), 0.075 (P < 0.001), and 0.040 (P < 0.001) in follow-up years 1, 3, and 5, respectively. Black participants had lower scores than White participants by 0.009 (P = 0.004) and 0.008 (P = 0.02) in follow-up years 1 and 3, respectively. The results suggest there is a preference-weighted HRQOL difference by race/ethnicity that cannot be explained by social and clinical variables alone. Understanding how individuals belonging to different racial/ethnic categories view their own HRQOL is necessary for culturally competent care and cost-effectiveness analyses.

The rapid stabilization pathway: impact of a brief inpatient intervention on the length of stay and readmissions among psychiatrically hospitalized adolescents.

BACKGROUND: Suicide is the second leading cause of death among adolescents in the United States (Centers for Disease Control and Prevention [CDC], 2017, Death rates due to suicide and homicide among persons age 10-24: United States, 2000-2017) constituting a significant public health crisis. The demand for psychiatric emergency services and inpatient beds is increasing, while the number of beds available decreases or remains static (National Association of State Mental Health Program Directors, 2017, Trend in psychiatric inpatient capacity, United States and Each State, 1970-2014. www.nasmhpd.org/sites/default/files/TACPaper.2.Psychiatric-Inpatient-Capacity_508C.pdf) leading to delays in treatment and exacerbation of symptoms for some adolescents awaiting care. This pilot project describes the development, feasibility, and acceptability of a creative, values-based safety planning intervention for adolescents hospitalized on an acute inpatient psychiatric unit and the impact of this intervention on length of stay and readmissions to acute psychiatric care. METHODS: Thirty patients experiencing a suicidal crisis participated in the Rapid Stabilization Pathway (RSP) during their inpatient psychiatric admission. RESULTS: Results indicate that, compared to patients who underwent inpatient treatment as usual (TAU), RSP patients were discharged after a significantly shorter length of stay (4 vs. 6.1 weekdays respectively, p < .001). Further, there was no significant difference in readmission to the inpatient unit or to the psychiatric emergency room among RSP and TAU patients at 30, 60, and 90 days postdischarge. CONCLUSIONS: These findings have significant implications for acute inpatient programming. The RSP intervention treated patients in a shorter amount of time without any increase in re-admissions. Further, the shortened length of stay allowed for more patients to be treated on the inpatient unit and a significant cost savings. Future directions for programming and outcome research are discussed.

Impact of mandatory COVID-19 shelter-in-place order on controlled substance use among rural versus urban communities in the United States.

PURPOSE: Mandatory COVID-19 shelter-in-place (SIP) orders have been imposed to fight the pandemic. They may also have led to unintended consequences of increased use of controlled substances especially among rural communities due to increased social isolation. Using the data from the American Association of Poison Control Centers, this study tests the hypothesis that the poison control centers received higher rates of calls related to exposures to controlled substances from rural counties than they did from urban counties during the SIP period. METHODS: Call counts received by the poison control centers between October 19, 2019 and July 6, 2020 due to exposure to controlled substance (methamphetamine, opioids, cocaine, benzodiazepines, and other narcotics) were aggregated to per-county-per-month-per-10,000 population exposure rates. A falsification test was conducted to reduce the possibility of spurious correlations. FINDINGS: During the study period, 2,649 counties in the United States had mandatory SIP orders. The rate of calls reporting exposure to any of the aforementioned controlled substances among the rural counties was higher (14%; P = .047) relative to the urban counties. This overall increase was due to increases in the rates of calls reporting exposure to opioids (26%; P = .017) and methamphetamine (39%; P = .077). Moreover, the rate of calls reporting exposures at home was also higher among the rural counties (14%; P = .069). CONCLUSION: The mandatory SIP orders may have had an unintended consequence of exacerbating the use of controlled substances at home in rural communities relative to urban communities.

Affordability of Forensic Assertive Community Treatment Programs: A Return-on-Investment Analysis.

OBJECTIVE: In this study, the authors assessed return on investment (ROI) associated with a forensic assertive community treatment (FACT) program. METHODS: A retrospective secondary data analysis of a randomized controlled trial comprising 70 legal-involved patients with severe mental illness was conducted in Rochester, New York. Patients were randomly assigned to receive either FACT or outpatient psychiatric treatment including intensive case management. Unit of service costs associated with psychiatric emergency department visits, psychiatric inpatient days, and days in jail were obtained from records of New York State Medicaid and the Department of Corrections. The total dollar value difference between the two trial arms calculated on a per-patient-per-year (PPPY) basis constituted the return from the FACT intervention. The FACT investment cost was defined by the total additional PPPY cost associated with FACT implementation relative to the control group. ROI was calculated by dividing the return by the investment cost. RESULTS: The estimated return from FACT was $27,588 PPPY (in 2019 dollars; 95% confidence interval [CI]=$3,262-$51,913), which was driven largely by reductions in psychiatric inpatient days, and the estimated investment cost was $18,440 PPPY (95% CI=$15,215-$21,665), implying an ROI of 1.50 (95% CI=0.35-2.97) for FACT. CONCLUSIONS: The Rochester FACT program was associated with approximately $1.50 return for every $1 spent on its implementation, even without considering potential returns from other sources, including reductions in acute medical care, crime-related damages, and public safety costs. ROI estimates were highly dependent on context-specific factors, particularly Medicaid reimbursement rates for assertive community treatment and hospital stays.

Trauma, Mental Health Distress, and Infectious Disease Prevention Among Women Recently Released From Incarceration.

Background: U.S. women recently released from incarceration experience significantly higher rates of trauma and exacerbation of mental health conditions, and the period following release has been identified as a window of heightened risk for mental health distress and human immunodeficiency virus (HIV), sexually transmitted infections (STI) and hepatitis C (HCV) transmissions. Despite these vulnerabilities, and an urgent need for supports, optimal engagement strategies remain unclear. WORTH Transitions is a program made up of two evidence-based interventions focused on improving the health of women returning to the community from incarceration with substance use disorders. Combining the two was designed to reduce HIV/STIs/HCV risks and increase overall health treatment engagement using a community health worker led intervention. Methods: We examined associations between trauma, mental health symptomology, and HIV/STI/HCV outcomes among women who engaged in the WORTH Transitions intervention (N = 206) Specifically, bivariate and longitudinal multivariate models were created to examine associations between trauma and mental health distress (defined as depressive and PTSD symptoms), on (1) types of engagement in HIV/STIs/HCV prevention and behavioral health services; and (2) HIV/STIs/HCV risk outcomes. The women who engaged in the intervention were 18 years and older and some were White, Black and other racial or ethnic minority. Results: PTSD symptomology and being a Black or indigenous woman of color was significantly (p = 0.014) associated with individual or group session engagement. Neither trauma nor PTSD symptoms were associated with higher HIV/STIs/HCV risks. Instead, relative to those who did not engage in HIV/STI/HCV risky behaviors, PTSD symptomology (p = 0.040) was associated with more than 3-fold increase in the probability of being lost to follow up (relative risk ratio = 3.722). Conclusion: Given the impact of PTSD-related symptoms on driving both engagement in HIV/STIs/HCV prevention services and intervention attrition among women leaving incarceration, physical and behavioral health interventions must be both overtly trauma- and mental health-informed. As was the case with WORTH Transitions, physical and behavioral health services for this population must include intentional and active support of the forms of treatment participants endorse to ensure maximal engagement.

Primary Care Behavioral Health Integration and Care Utilization: Implications for Patient Outcome and Healthcare Resource Use.

BACKGROUND: Behavioral health (BH) integration in primary care (PC) can potentially improve outcomes and reduce cost of care. While different models of integration exist, evidence from real-world examples is needed to demonstrate the effectiveness and value of integration. This study aimed to evaluate the outcomes of six PC practice sites located in Western New York that implemented a primary care behavioral health (PCBH) integration model. OBJECTIVE: To assess the impact of PCBH on all-cause healthcare utilization rates. DESIGN: A retrospective observational study based on historical multi-payer health insurance claims data. Claims data were aggregated on a per-member-per-month basis to compare utilization rates among the patients in the PC practice sites that had implemented PCBH to those in the sites that had not yet done so. PARTICIPANTS: The sample included 6768 unique adult health plan members between October 2015 and June 2017 with at least one BH diagnosis code who were attributed to one of the six newly integrated PC practice sites. INTERVENTIONS: Under the PCBH integration model, BH specialists were embedded in PC practice sites to treat a wide range of BH conditions. MAIN MEASURES: Rates of all-cause ED visits and hospital admissions, along with rates of PC provider and BH provider visits. KEY RESULTS: PCBH implementation was associated with reductions in the rates of outpatient ED visits (14.2%; p < 0.001) and PC provider visits (12.0%; p < 0.001), as well as with an increased rate of BH provider visits (7.5%; p = 0.018). CONCLUSIONS: PCBH integration appears to alter the treatment patterns among patients with BH conditions by shifting patient visits away from ED and PC providers toward BH providers who specialize in treatment of such patients.

Lonely older adults are more likely to delay or avoid medical care during the coronavirus disease 2019 pandemic.

OBJECTIVES: To examine the relationship between loneliness and self-reported delay or avoidance of medical care among community-dwelling older adults during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Analyses of data from a nationally representative survey administered in June of 2020, in COVID-19 module of the Health and Retirement Study. Bivariate and multivariable analyses determined associations of loneliness with the likelihood of, reasons for, and types of care delay or avoidance. RESULTS: The rate of care delay or avoidance since March of 2020 was 29.1% among all respondents (n = 1997), and 10.1% higher for lonely (n = 1,150%, 57.6%) versus non-lonely respondents (33.5% vs. 23.4%; odds ratio = 1.59, p = 0.003 after covariate adjustment). The differences were considerably larger among several subgroups such as those with emotional/psychiatric problems. Lonely older adults were more likely to cite "Decided it could wait," "Was afraid to go," and "Couldn't afford it" as reasons for delayed or avoided care. Both groups reported dental care and doctor's visit as the two most common care delayed or avoided. CONCLUSIONS: Loneliness is associated with a higher likelihood of delaying or avoiding medical care among older adults during the pandemic.

Evaluating the Effectiveness of an Educational Module for the Bush-Francis Catatonia Rating Scale.

OBJECTIVE: Catatonia is widely underdiagnosed, in large part due to inaccurate recognition of its specific features. This study aimed to evaluate the effectiveness of an online educational module to improve theoretical and practical knowledge of the Bush-Francis Catatonia Rating Scale (BFCRS) across a broad range of clinicians and medical students. METHOD: A 1-h online module, including a training manual and videos, was disseminated to medical students, psychiatry residents and fellows, and psychiatrists through national Listservs and through the Academy of Consultation-Liaison Psychiatry. Participants completed pre- and post-module testing consisting of a 50-question multiple-choice test and a 3-min standardized patient video scored using the 23-item BFCRS. Participants accessed the module from October 1, 2020, to April 4, 2021. Immediate improvement and 3-month knowledge retention were assessed using quantitative and qualitative analyses. RESULTS: Study enrollment was high with moderate dropout (pre-testing: n = 482; post-testing: n = 236; 3-month testing: n = 105). Adjusting for demographics, large pre-post improvements were found in performance (multiple-choice: 11.3 points; standardized patient scoring: 4.2 points; both p < 0.001) and for nearly all individual BFCRS items. Knowledge attrition was modest, and improvements persisted at 3 months. CONCLUSIONS: This educational resource provides descriptive and demonstrative reference standards of the items on the BFCRS. This curriculum improved identification of catatonia's features on both multiple choice and standardized patient scoring across all ages and training levels with good overall knowledge retention.

Employer-sponsored behavioral health program impacts on care utilization and cost.

OBJECTIVES: To examine the impact of an employer-sponsored behavioral health (BH) program on all-cause health care utilization and cost. STUDY DESIGN: Retrospective analysis of health insurance claims data obtained from a large employer in western New York covering a 25-month period between 2016 and 2018. Those employees treated by the employer-sponsored BH program were compared against a contemporaneous comparison group of employees of the same employer who had eligible BH diagnoses for the program but were treated elsewhere. METHODS: A difference-in-differences method was used to estimate the program's impact on all-cause care utilization (physician office visits and acute care utilization) and total cost of care, including prescription drug costs. RESULTS: Program participation was associated with a reduction of approximately 28% in total cost of care including prescription drug costs (P = .043) over an 18-month period following the initial program encounter, as well as 27% reductions in primary care provider (PCP) visits (P = .001) and non-BH specialist visits (P = .005). No significant impacts were observed for acute care utilization and BH specialist visit rates. CONCLUSIONS: The results suggest that the employer-sponsored BH program implementation may have shifted treatments of certain BH conditions away from PCPs and non-BH specialists who may not have the proper training or resources to manage such conditions. Therefore, these results are consistent with the expectation that improved access to BH care is likely to improve efficiency in the health care system via provision of more appropriate care for those who need it.

Prevalent Gaps in Understanding the Features of Catatonia Among Psychiatrists, Psychiatry Trainees, and Medical Students.

Background: Catatonia is often overlooked, and a key factor for underdiagnosis may be an inadequate understanding of catatonia's heterogeneous phenotypes. The aim of this study was to identify the current state of theoretical and applied knowledge of catatonic features among psychiatry trainees and practitioners using the Bush-Francis Catatonia Rating Scale (BFCRS), the most commonly used instrument to identify and score catatonia.Methods: We created an online 50-item multiple-choice test and 3-minute standardized patient video to be scored using the BFCRS. Email invitations were sent to medical students and psychiatry residents and fellows through listservs of psychiatry clerkship and residency directors and to consultation-liaison psychiatrists through the Academy of Consultation-Liaison Psychiatry. Participants could access the exam from October 1 to December 31, 2020.Results: In our sample (n = 482), participants correctly answered an average of 55% of test questions and identified 69% of BFCRS items on the standardized patient exam. Multivariable regression adjusting for demographics revealed that, compared to medical students, psychiatrists scored 7 points higher on the multiple-choice test and identified only 2 more items correctly on the BFCRS. Older participants performed worse than younger participants. No meaningful performance differences were identified by region or gender. Several items were consistently misidentified.Conclusions: We found significant inaccuracies in clinicians' understanding of catatonic features irrespective of their stage of training and years of experience. These data suggest prevalent gaps in catatonia recognition among psychiatrists, psychiatry trainees, and medical students utilizing the BFCRS. This has important implications for clinical research and patient care.

Proactive Integration of Mental Health Care in Hospital Medicine: PRIME Medicine.

BACKGROUND: Proactive consultation-liaison (C-L) psychiatry has been shown to reduce hospital length of stay (LOS), increase psychiatric C-L consult rate, and improve hospital staff satisfaction. Nursing attrition has not been studied in relation to proactive C-L. OBJECTIVE: Our primary aim in evaluating the proactive C-L service called Proactive Integration of Mental Health Care in Medicine (PRIME Medicine) is to analyze change in LOS over 10 months using historical and contemporary comparison cohorts. As secondary aims, we assess change in psychiatric consultation rate, time to consultation, and change in nurse attrition. METHODS: PRIME Medicine was implemented on 3 hospital medicine units as a quality-improvement project. Team members systematically screened patients arriving to assigned units for psychiatric comorbidity. Identified patients were reviewed with hospitalist teams and nurses with the goal of early intervention. RESULTS: Including historical and contemporary comparison cohorts, the mean sample age was 62.4 years (n = 8884). Absolute LOS was unchanged, but difference-in-difference analysis trended toward reduced LOS by 0.16 day (P = 0.08). Consultation rate increased from 1.6% (40 consults) to 7.4% (176 consults). Time to consultation was unchanged (4.0-3.8 d). Annual per-unit nursing turnover increased from 4.7 to 5.7 on PRIME units but from 8.5 to 12.0 on comparison units. Nurses citing "population" as the reason for leaving decreased from 2.7 to 1.7 on PRIME units but increased from 1.5 to 4.5 on comparison units. PRIME Medicine led to increased consultation rate, and our unit-wide outcomes provide a conservative estimate of effect. Factors that may have influenced effect size include our cohort's advanced age, considerable emergency department boarding times, increasing proportion of patients discharged to skilled nursing facilities, and concurrent LOS-reduction initiatives on all units. The favorable trends in nursing attrition on PRIME units may be explained in part by our prior finding that PRIME Medicine was associated with enhanced nursing satisfaction. CONCLUSIONS: While PRIME Medicine had no more than a modest effect on LOS, it was associated with a markedly increased psychiatric consult rate and favorable trends in nursing retention. This analysis highlights important factors that should be considered when implementing and determining value metrics for a proactive C-L service.

Demonstrated health care cost savings for women: findings from a community health worker intervention designed to address depression and unmet social needs.

To evaluate the impact of a community health worker intervention (CHW) (referred to as Personalized Support for Progress (PSP)) on all-cause health care utilization and cost of care compared with Enhanced Screening and Referral (ESR) among women with depression. A total of 223 patients (111 in PSP and 112 in ESR randomly assigned) from three women's health clinics with elevated depressive symptoms were enrolled in the study. Their electronic health records were queried to extract all-cause health care encounters along with the corresponding billing information 12 months before and after the intervention, as well as during the first 4-month intervention period. The health care encounters were then grouped into three mutually exclusive categories: high-cost (> US$1000 per encounter), medium-cost (US$201-$999), and low-cost (≤ US$200). A difference-in-difference analysis of mean total charge per patient between PSP and ESR was used to assess cost differences between treatment groups. The results suggest the PSP group was associated with a higher total cost of care at the baseline; taking this baseline difference into account, the PSP group was associated with lower mean total charge amounts (p = 0.008) as well as a reduction in the frequency of high-cost encounters (p < 0.001) relative to the ESR group during the post-intervention period. Patient-centered interventions that address unmet social needs in a high-cost population via CHW may be a cost-effective approach to improve quality of care and patient outcomes.

Taking the Long View in an Inpatient Medical Unit: A Person-Centered, Integrated Team Approach for Patients With Severe Mental Illnesses.

OBJECTIVE: Patients with severe mental illnesses and related conditions, such as substance misuse and suicide attempts, are among the highest utilizers of acute inpatient medical services. The objective of this study was to assess the impact of a specialized medical unit that uses a comprehensive biopsychosocial model to care for patients with severe mental illnesses. METHODS: The study used administrative data to compare patients with severe mental illnesses admitted to a specialized unit with patients admitted to medically similar acute (non-intensive care) medical units in a tertiary academic medical center. With controls for sociodemographic variables, illness severity, and medical complexity, multivariate regression analyses compared utilization outcomes for patients from the specialized unit with outcomes from comparison units. RESULTS: Patients on the specialized unit (N=2,077) were younger, had more mental disorder diagnoses, and were more likely to have less severe general medical illness and less medical complexity than patients from comparison units (N=12,824). Analyses of a subsample of patients with complex behavioral health diagnoses indicated that those on the specialized unit had a shorter average stay, higher odds of discharge to home, and lower odds of 30-day readmission, compared with those on comparison units. CONCLUSIONS: Specialized units targeted to the needs of patients with serious mental illnesses can provide a moment of engagement when vulnerable patients are likely to benefit from more coordinated care. Findings suggest that a specialized unit that capitalizes on this moment of engagement and uses a biopsychosocial model of care can improve utilization outcomes.

Integration of a proactive, multidisciplinary mental health team on hospital medicine improves provider and nursing satisfaction.

OBJECTIVE: Psychiatric comorbidity among hospital medicine patients is common and often complicates care delivery and compromises outcomes. Team-based, proactive consultation-liaison (CL) psychiatry has been shown to reduce hospital length of stay (LOS) and care costs, but staff satisfaction with this model has not been explored in detail. Here we evaluate its impact on hospital medicine provider and nurse satisfaction. METHODS: We implemented a team-based proactive CL service that reviews all admitted hospital medicine patients across 3 units for psychiatric comorbidity and provides unit-wide integrated mental health care. Hospital medicine staff completed surveys before and after a 6-month pilot phase: 10-item provider surveys covered resource adequacy, safety, time for healthcare improvements, and burnout; 26-item nurse surveys included the same 10 items plus 8 on behavioral health assessment competency and 8 on intervention competency. Additionally, we characterized psychiatric comorbidity, calculated consultation latency and volume and also average LOS during these 6 months. RESULTS: The provider response rate was 57% (20/35 before; 21/37 after) and roughly a third for nurses (32/~90 and 31/~90, respectively). Providers rated 9 of 10 items as improved, including one on burnout. Nursing satisfaction improved similarly but with lower effect sizes. During the pilot (n = 1590), 71% had chart-identified psychiatric comorbidity. Consultation latency decreased by 0.86 days; consultation rate increased nearly 3-fold; and average LOS decreased by 0.33 days. CONCLUSIONS: Team-based proactive CL psychiatry enhances provider and nurse satisfaction and may even reduce provider burnout. We also confirmed that this model is associated with reduced average LOS.

Impact of integrating psychiatric assessment officers via telepsychiatry on rural hospitals' emergency revisit rates.

OBJECTIVE: To assess the impact of integrating Psychiatric Assessment Officers (PAO) and telepsychiatry in rural hospitals on their all-cause emergency department (ED) revisit rates. As a pilot project, a full-time PAO was embedded in each of three rural hospitals in New York State and was augmented by telepsychiatry. METHOD: A retrospective data analysis using ED census data obtained from the hospitals. The intervention group, defined as those patients treated by PAOs, was compared via a difference-in-difference method against a contemporaneous comparison group defined as those who visited the same EDs and had PAO-qualifying behavioral health diagnoses but were not seen by PAOs. RESULTS: The intervention group was associated with an approximately 36% lower all-cause ED revisit rate during the first 90-day period (i.e. 1-90 days) following the initial PAO treatment (p = .003). A reduction of the similar magnitude (44%) persisted into the subsequent 90-day period (i.e., 91-180 days since the initial PAO treatment; p < .001). CONCLUSION: The PAO telepsychiatry pilot program suggests a potential way to provide relief for overburdened EDs in rural communities that lack resources to treat patients with severe behavioral health symptoms.

Upstream and downstream revenue of upper gastrointestinal endoscopic ultrasound determined with an episode-of-care approach.

Background and study aims Upper gastrointestinal endoscopic ultrasound (EUS) has clinical advantages that can lead to improved patient outcome. This study seeks to characterize and quantify the upstream and downstream healthcare utilizations and revenues. Patients and methods A retrospective claims data analysis of upper gastrointestinal EUS procedures was conducted at a large health system. Types of care and total revenues associated with each episode of care were characterized by descriptive statistics. Comparisons were made between patients who had Medicare Advantage and commercial plans as well as those with and without cancer diagnoses during the downstream period. Results A total of 436 cases were identified. The most frequent downstream healthcare utilizations consisted of radiology (31 %), pathology services (28 %), and high-revenue services including chemotherapy and inpatient admissions. The most common upstream utilizations included radiology (18 %) and lab services (22 %). Average total downstream revenue was $ 34 231 (95 %CI: $ 28 561 - $ 39 901) per case, and average total upstream revenue was $4373 (95 %CI: $3227 - $ 5519). Average total revenue per case did not differ significantly between Medicare Advantage and commercial plan members. However, patients who were diagnosed with cancer at or immediately following EUS (20 %) were associated with significantly higher total revenue compared to those without cancer diagnosis ( P  < 0.0001). Conclusions This episode-of-care approach to quantifying the revenue impact of upper gastrointestinal EUS to the providers suggests there are substantial downstream as well as upstream revenues associated with upper gastrointestinal EUS procedures, driven by patients who are diagnosed with cancer by the EUS procedures and subsequently require oncologic care.

Utilization of an Employee Behavioral Health Program and Its Effects on Outcomes for Depression and Anxiety Disorders.

OBJECTIVE: To examine the impact of an employer-sponsored behavioral health program on depression and anxiety by assessing dose effect of psychotherapy. METHODS: A retrospective data analysis of patients with baseline scores more than or equal to 10 on the Patient Health Questionnaire (PHQ9) or the Generalized Anxiety Disorder 7-item scale (GAD7). Survival analyses were conducted to assess whether those with a higher number of therapy sessions per episode (dose) achieved faster response (score reduction by 50% or below 10). RESULTS: Patients with medium (8 to 12 visits) or high (more than 12 visits) dose achieved faster response than those with low dose (less than eight visits; hazard ratios more than 1.5, P < 0.05). No significant difference was found between the medium and high dose. CONCLUSION: Higher dose of psychotherapy is correlated with improved behavioral health outcomes, although there appears to be no incremental benefit beyond a certain level.