Performance and rapid response

The ability to provide a rapid response to a request for psychiatric assessment has become an essential criterion for successfully operating liaison teams, mainly because of increasing scrutiny of the accident and emergency department 4-hour targets ^{Reference Mason, Webber, Coster, Freeman and Locker2} and a desire to reduce length of stay on in-patient wards. ³ Rapid response can have a very positive effect on patient journey and outcome measures. The timing of psychiatric consultation is an essential factor in determining a patient's length of stay in hospital, ^{Reference Lyons, Hammer, Strain and Fulop4–Reference Handrinos, McKenzie and Smith-Graeme6} especially when psychosocial assessment is completed in the first few days of admission to a general hospital ward. ^{Reference De Jonge, Huyse, Ruinemans, Stiefel, Lyons and Slaets7,Reference Hall and Frankel8} The difficultly is that patients presenting with more severe psychiatric symptoms, such as suicidal ideation, florid psychosis or behavioural problems, tend to receive more timely consultations than those with less demanding presentations. Consequently, patients with less obvious psychiatric symptoms have a tendency to either go undetected or wait for a long time before being referred to liaison psychiatry for assessment, ^{Reference Kishi, Meller, Kathol and Swigart9} which can lead to poorer outcomes. ^{Reference De Jonge, Latour and Huyse10} To achieve the best outcome, identifying patients who need psychiatric assessment as early as possible, through an effective triage system, is as important as responding rapidly to a referral for liaison psychiatry. The factors associated with delayed referral to a psychiatry liaison team usually include stigma, ^{Reference Chan and Ovens11–Reference Malone13} lack of mental health training and skills, unclear referral pathways, perceived lack of efficacy to change patient outcomes, and patient's refusal of a psychiatric assessment. The presence of physical illness has been found to delay the identification of psychiatric disorders and hinder referrals to psychiatric liaison teams. ^{Reference Creed, Morgan, Fiddler, Guthrie and House14} On the other hand, rapid response has been associated with higher level of acute hospital staff satisfaction with service provision. ^{Reference Tadros, Kingston, Mustafa, Johnson, Balloo and Sharma15}

The Framework for Routine Outcome Measurement in Liaison Psychiatry (the FROM-LP) clearly identifies performance as a priority, focusing on recording outcomes for patients using the Identify and Rate the Aim of the Contact model. This would be essential in demonstrating the inwards and outwards referrals as well as the services and support offered. For the good reasons identified above, the FROM-LP also collects information regarding response time, whether for a single contact or a series of contacts. However, there is no attempt to quantify the length of time taken before mental health issues are detected and the patient is referred to the liaison team. It is a missed opportunity to encourage proactive work to promote early referral and more accurate detection.

Quality service

Although performance-based data are important to measure activities, they would not mean much unless they bring quality to the services patients receive through those activities. Liaison psychiatry teams should always aim to improve quality of care that is provided to patients with physical and psychiatric comorbidities, as about 27% of patients admitted to medical wards have mental illness fulfilling DSM-IV criteria. ^{Reference Silverstone16} Another layer of quality improvement would be achieved through up-skilling acute hospital staff to manage patients with psychiatric manifestations. Reports suggest that staff attitudes towards patients who attend hospital for reasons other than physical health may be negative, ^{Reference Chan and Ovens11} mainly because of lack of training, ^{Reference Friedman, Newton, Coggan, Hooley, Patel, Pickard and Mitchell17} stigma ^{Reference Rao, Mahadevappa, Pillay, Sessay, Abraham and Luty18,Reference Arvaniti, Samakouri, Kalamara, Bochtsou, Bikos and Livaditis19} and perceived difficulties in managing such patients' complex needs in an environment that is designed mainly for acute medical illnesses. ^{Reference Malone20,Reference Malone21} This is particularly applicable to older persons, especially those with dementia. ²² Staff up-skilling could be achieved through direct and indirect training as well as joint case-working. Research suggests that education can help to both eliminate discrimination of those with mental illness and up-skill acute hospital staff. ^{Reference Mukherjee, Fialho, Wijetunge, Checinski and Surgenor23} The Rapid Assessment Interface and Discharge (RAID) service in Birmingham attributed a significant portion of their cost savings to supporting and training staff to manage patients who have not been referred for liaison psychiatry (RAID influence group). ^{Reference Tadros, Salama, Kingston, Mustafa, Johnson, Pannell and Hasmi24} This sort of quality improvement usually leads to an increase in the number of referrals through enhanced detection of mental illness.

The FROM-LP clearly measures service quality and clinical effectiveness using a combination of clinician-rated outcome measures (CROMS), patient-rated outcome measures (PROMS) and patient-rated experience measures (PREMS). It provides a good description of clinical improvement from the clinician's outlook. In addition, it offers a variety of satisfaction measures from the patient, friends and family, and the referrer perspectives.

The FROM-LP offers an array of service quality outcome measures that are appropriate to liaison psychiatry, easy to administer and create measurable data. There is currently no attempt to measure training activities and their outcomes, nor to identify patients whose care quality has improved indirectly through the work of a liaison psychiatry team. Unfortunately, the FROM-LP authors offered some condition-specific assessment scales which are not related to outcome measures and some of them have already been updated by their authors, for example Addenbrooke's Cognitive Examination (ACE-R), or are inappropriate for older people, for example the Alcohol Use Disorders Identification Test (AUDIT-C).

Cost-effectiveness

Having established that a well-operating liaison team would perform well with rapid response and would deliver valuable quality to patient care, it is still desirable to measure the team's cost-effectiveness for the purpose of future commissioning, which in the current climate is frequently a team survival need and a lever to improve service funding. However, it could occasionally lead to more pressure and a negative effect, especially if a team is compared with better funded teams or expected to achieve some unrealistic or specific cost savings in a short period of time.

Evidence for cost-effectiveness has been frequently established for specific liaison models or services such as hip fracture. ^{Reference Parsonage and Fossey25} The RAID model in Birmingham has been extensively evaluated, first internally, ^{Reference Tadros, Salama, Kingston, Mustafa, Johnson, Pannell and Hasmi24} then by an NHS-Confederation-commissioned independent evaluation, ^{Reference Parsonage and Fossey25} which estimated that the cost/return ratio was £1: £4. More recently, an independent evaluation commissioned by the regional commissioning support unit ^{Reference Whyte26} showed similar savings: cost/return ratio of £1: £2.97. This was achieved through reducing admissions via accident and emergency, length of stay and re-admissions for in-patient groups. The majority of savings come from working with older people, especially those with dementia. ^{Reference Tadros, Salama, Kingston, Mustafa, Johnson, Pannell and Hasmi24,Reference Whyte26} This is despite the fact that two-thirds of hospital beds are occupied by elderly patients. ²⁷ Older patients on acute wards who experience lengthy admission and delayed discharges tend to develop anxiety regarding discharge destination, and report low mood, frustration, anger, disappointment and feeling disempowered. ^{Reference Kydd28,Reference Swinkels and Mitchell29} With increasing numbers of patients with dementia (850 000 according to the latest census (www.alzheimers.org.uk/statistics)), working with this group of patients becomes essential to fully achieving the saving potential. ^{Reference Tadros, Salama, Kingston, Mustafa, Johnson, Pannell and Hasmi24,Reference Parsonage and Fossey25} Hence the stress on good-quality dementia care in general hospitals in the government's National Dementia Strategy. ³⁰ Intelligent outcome measures should provide an encouraging framework for older adult liaison work.

Measuring cost savings provides a further challenge because of the complexity and variations of individual patients' features and the known paucity of clinical information and diagnostic coding concerning retrospective patient groups with mental health issues in general hospitals. There is no easy way to collect cost-saving data as it usually requires sophisticated statistical analysis and computer modelling. Nevertheless, it is essential that liaison teams are prepared for cost-effectiveness scrutiny. Intelligent outcome measures should collect data that would help with measurement of cost-effectiveness, such as illustration of work done to avoid admission, length of stay when admitted, discharge destination, rate of readmission at 28 days and 90 days, and breaches at the emergency department. The FROM-LP does not prompt for cost-saving data collection.

Challenges in using outcome measures in liaison psychiatry

Most liaison psychiatry team members would like to consistently gather data to demonstrate the value that they hold in patient care and their journey through acute hospitals. However, unless electronic patient records are developed to accommodate data collection for outcome measures, the whole concept might be seen as time-consuming, despite its necessity. This perception leads to low response rate and a lot of missing data, which could hinder future analysis power. Most of the suggested CROMS, PROMS and PREMS rely heavily on clinician's and patient's subjectivity, which could lead to unavoidable bias. Moreover, patients' and referrers' satisfaction, or lack of it, could be a reflection of other components of the patient's journey or outcome that is not directly related to liaison psychiatry.

RAID services use an outcome form (RAID Discharge Outcome Form; https://raidnetwork.org/content/resources), which has been developed as part of patient electronic records, to improve compliance and reduce duplication. This electronic outcome form has its own weaknesses and the same inherited subjectivity flaws; however, it could complement the FROM-LP, especially in the cost-effectiveness domain. Nevertheless, there is a real need to have nationally agreed, consistent outcome measures for liaison psychiatry that would allow data combination and comparison for further research and future developments.