Proactive C-L Psychiatry Addresses Social Factors Affecting Discharge, Outcomes for Hospitalized Patients With Comorbid Illness

A model of proactive integrated consultation-liaison (C-L) psychiatry can help to shorten hospital stays and improve outcomes for patients with comorbid medical and psychiatric conditions by identifying social factors—such as homelessness—that contribute to delayed discharge and working with an integrated care team to address them from the point of admission.

That’s the message psychiatrists delivered today during a session at the Annual Meeting titled “Social Factors in Proactive Consultation-Liaison Psychiatry: Experience in the U.S. and the U.K.”

“Social factors are intertwined with psychiatric and medical ones and need a coordinated physician-led approach to address them,” said Michael Sharpe, M.D., a professor of psychological medicine at Oxford University, United Kingdom, in a pre-recorded lecture that was shown at today’s session.

Also speaking were psychiatrists Rusty Baik, M.D., and Sofia Matta, M.D., of the Veterans Administration (VA) Greater Los Angeles Healthcare Medical Center. They provided an overview of social factors—especially homelessness—that result in longer hospital stays and poorer outcomes in hospitalized veterans with medical and psychiatric comorbidities. The discussant was incoming APA President Rebecca Brendel, M.D., J.D.

In a February 2021 article in Psychiatric News, Mark Oldham, M.D., and Benjamin Hochang Lee, M.D., said 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.

In contrast, Matta called the current practice of inpatient consultation reactive and typically dependent on direction by the primary care team. “Many psychiatric needs go unidentified, [and] those that are identified are often crisis focused,” Matta said. “Recommendations are made to clinicians rather than involving all members of the care team.”

Matta called the proactive C-L psychiatry model “an inpatient corollary to the outpatient collaborative care model.” She said she and colleagues have received a grant through the VA’s Innovators Network to begin deploying the proactive model.

In the VA, Matta said patients who incur greater costs and have longer stays typically have more social factors that impact their health; these include homelessness, marital separation, and alcohol and substance use disorders. She cited a British Medical Journal Open article that found that in 2010, 5% of the highest cost VA patients accounted for 47% of the VA’s total expenses.

Sharpe outlined social problems affecting older general hospital patients in the United Kingdom who are likely to have multiple medical and psychiatric disorders—delirium and/or dementia and depression and anxiety among others—and taking multiple medications. He described The HOME Study, an ongoing study of 1,359 people over 65 admitted to acute wards of three U.K. general hospitals. The study compares usual care with the proactive model, looking at hospital length of stay, depression and anxiety scores, and quality of life. While results are pending, he said qualitative interviews with patients, hospital staff, and family members indicate satisfaction with the model.

“Patients generally liked having someone take an interest in more aspects of their illness,” he said. “Carers greatly appreciated someone listening to them and helping plan aftercare, and hospital staff have found it helpful in managing problems they have often felt overwhelmed by.”

Commenting on the session, Brendel cited the oft-quoted comment by hockey great Wayne Gretzky “You don’t skate to where the puck is, but to where the puck will be.”

“I think that’s a perfect analogy for us as we think about where we need to go in C-L psychiatry,” she said. “These data that show psychosocial complexity is a driver not only of longer stays but also poorer outcomes are something that we’ve known for a really long time.”

She said that psychiatrists can work for integration of health and mental health care at the institutional level and that advocacy at the policymaking level is crucial. “Reintegrating psychiatric care into general medical care ought to be the low-hanging fruit. But we really have to address the structural stigma around mental health that has led to [behavioral health] carveouts and lack of intervention at the primary point of admission.” ■