Liaison Mental Health Services for Older People: A ... · Liaison Mental Health Services for Older...

SDO Project (08/1504/100)

© Queen’s Printer and Controller of HMSO 2010 1

Liaison Mental Health Services for Older People: A Literature review, service mapping and in-depth evaluation of service models

Research Report

Produced for the National Institute for Health Research Service Delivery and Organisation programme

June, 2010

Prepared by:

John Holmes, University of Leeds

Carolyn Montaňa, University of Leeds

Gwen Powell, University of Leeds

Jenny Hewison, University of Leeds

Allan House, University of Leeds

James Mason, University of Durham

Amanda Farrin, University of Leeds

Phil McShane, University of Leeds

Lucy McParland, University of Leeds

Simon Gilbody, University of York

John Young, University of Leeds



Justin Keen, University of Leeds

Robert Baldwin, University of Manchester

Alistair Burns, University of Manchester

Helen Pratt, Pennine Care NHS Trust

David Anderson, Merseycare NHS Trust

Address for correspondence

Dr John Holmes

University of Leeds

Leeds Institute of Health Sciences

Charles Thackrah Building

101 Clarendon Road

Leeds LS2 9LJ

E-mail: [email protected]



Contents

Acknowledgements ....................................................5

Executive Summary....................................................6

1 Introduction.......................................................8

1.1 NHS context and relevant literature........................................8 1.2 Aims and objectives ...........................................................11

Phase 1-Literature Review...................................................11 Phase 2-Service Mapping ....................................................11 Phase 3-Service Evaluation .................................................11

2 Phase 1: Literature review ...............................12

2.1 Aims ..............................................................................12 2.2 Defining the review question ...............................................12

2.2.1 Population/type of participant .....................................12 2.2.2 Intervention .............................................................12 2.2.3 Study type...............................................................12

2.3 Search strategy .................................................................13 2.3.1 Primary literature......................................................13 2.3.2 Inclusion criteria .......................................................13 2.3.3 Grey literature..........................................................14 2.3.4 Economic literature ...................................................15

2.4 Results.............................................................................16 2.4.1 Primary literature......................................................16 2.4.2 Study categorisation..................................................17 2.4.3 Meta-analyses and systematic reviews .........................17 2.4.4 Evaluative studies .....................................................18 2.4.5 Descriptive studies ....................................................19 2.4.6 Economic literature ...................................................20

2.5 Discussion ........................................................................22 2.5.1 Types of studies........................................................22 2.5.2 Comparing different studies........................................23 2.5.3 Methodological issues ................................................24 2.5.4 Best evidence...........................................................26 2.5.5 Interventions............................................................29 2.5.6 Economic literature ...................................................30 2.5.7 Summary.................................................................31

3 Phase 2: Service mapping ................................33

3.1 Method.............................................................................33 3.1.1 Brief survey .............................................................33 3.1.2 Extended survey .......................................................35

3.2 Response rates..................................................................35 3.2.1 Brief survey .............................................................36 3.2.2 Extended survey .......................................................36

3.3 Service models in the UK ....................................................36 3.3.1 Current service model................................................37 3.3.2 Changes in service models .........................................38



3.3.3 Preferred service models............................................39 3.3.4 Service characteristics ...............................................41 3.3.5 Drivers to development..............................................42 3.3.6 Staff skill mix ...........................................................44 3.3.7 Staff activity ............................................................47 3.3.8 Service activity .........................................................47

3.4 Primary Care Trust service models .......................................53 3.4.1 Staffing levels by PCT boundaries................................55

4 Phase 3: Evaluation..........................................59

4.1 Pilot evaluation..................................................................59 4.1.1 Design.....................................................................59 4.1.2 Site selection............................................................59 4.1.3 Determining the structure of services...........................60 4.1.4 Determining the processes of services..........................60 4.1.5 Determining the effectiveness of services .....................61 4.1.6 Determining the cost-effectiveness of services ..............62 4.1.7 Determining the context of services.............................63

4.2 Formal evaluation ..............................................................63 4.2.1 Service sampling ......................................................63 4.2.2 Recruitment .............................................................69 4.2.3 Evaluation process ....................................................69

4.3 Evaluation results ..............................................................74 4.3.1 Service characteristics ...............................................74 4.3.2 Patient cohorts .........................................................82 4.3.3 Referred patient variables ..........................................91 4.3.4 Statistical inference - Length of stay ............................99 4.3.5 Survival analysis.....................................................118 4.3.6 Discharge destination for referrals .............................125 4.3.7 Prospective study cost analysis .................................130 4.3.8 Staff skills questionnaire ..........................................134 4.3.9 Qualitative data analysis ..........................................161

5 Discussion and conclusions............................172

5.1 Phase 1: Literature review. ............................................... 172 5.2 Phase 2: Service mapping................................................. 173 5.3 Phase 3: In-depth evaluation............................................. 176 5.4 Characteristics of service models........................................ 178 5.5 Cost effectiveness analysis ................................................ 181 5.6 Staff skills, knowledge and attitudes ................................... 182 5.7 Problems encountered ...................................................... 184

6 Dissemination ................................................186

7 Recommendations for future research ...........187

References .............................................................188

Appendices.............................................................199



Acknowledgements We would like to thank all local collaborators at all participating sites. We

also would like to thank all fieldworkers recruited into the study to assist

with data collection. We would like to thank Cheryl Craigs for her valuable

contribution to the service mapping work, Dr Susie Blume for her help with

piloting the evaluation methodology, and Orla O’Donnell for her work on the

qualitative analysis of the project. Finally, we would like to thank the

Mental Health Research Network and their Clinical Studies Officers for their

support in collating missing data from the majority of evaluation sites.



Executive Summary Background Mental health problems are common in older people in general hospitals, with adverse effects on many important outcomes. To address this, some providers have developed specialist mental health services for older people in general hospital settings, called liaison mental health services. These differ from the usual provision in being general hospital based, and in spending time educating and training general hospital colleagues in the management of common mental health problems. Several different service models are possible, each with strengths and weaknesses. Not enough is known about the prevalent service configurations, clinical and educational activity and impact on outcomes of these liaison mental health services for older people. Aims The overall aims of this project were to establish what service models are being used to improve the care of older people with mental health problems in general hospitals, and what impact these service models might have on outcomes, with the objective of informing both service development and the design of an evaluation of services. Methods Our project had three phases:

Phase 1. Literature review. We searched the available literature (including grey literature) on liaison mental health services for older people, using systematic search strategies in appropriate databases and on the internet. This provided descriptions of the different models of mental health liaison for older people, including staffing and skill mix, service activity, effectiveness and applicability to the National Health Service (NHS), and also established the strength of the evidence (or lack of evidence) for effectiveness. Phase 2. Service mapping. We mapped provision of liaison mental health services for older people across the United Kingdom (UK). We surveyed clinicians (old age psychiatrists and care of the elderly physicians) to detect the presence of any liaison service, and obtained further information including the staffing and skill-mix, activity, workload, referral pathways, speed of response and other service delivery markers. This produced a typology of different service models and their prevalence, as well as information that would allow for a pragmatic evaluation of a selection of services in the next phase of the study. Phase 3. Service Evaluation. We provided an in-depth pragmatic evaluation of a sample of liaison mental health services for older people, describing in detail the staffing, activity, management and administrative structures, effectiveness, cost-effectiveness and other relevant markers related to outcomes for older people. We examined traditional service models, liaison



mental health nursing models, and small and large multi-disciplinary hospital mental health teams. Findings Phase 1. Our literature review revealed little in the way of high quality evidence, with much of the literature found being small scale descriptive studies of individual services. We identified eight randomised controlled studies, most of which were inconclusive although some pointed to a beneficial effect of liaison mental health services. We also identified methodological weaknesses that reflect the complex nature of a liaison mental health service intervention. Phase 2. Our mapping revealed wide variations in the provision of liaison mental health services for older people, with many parts of the UK having no specialist provision. Where we did identify specialist services, they had usually been introduced by enthusiastic clinicians rather than as a part of a co-ordinated commissioning structure. Our extended survey revealed a lack of ownership of liaison mental health services for older people, with general hospital colleagues seeing them as an issue for mental health services and mental health providers seeing it as an issue for the general hospital. We also found a wide range of different service structures and staff skill-mix due to a lack of clarity and direction about service specifications and processes. Phase 3. We initially identified twelve sites for an in-depth evaluation, although we had to abandon one site due to a lack of commitment from relevant organisations, and an additional site due to lengthy processes involved in securing the research site. Over the 10 active sites, details of 757 referred patients and 975 who were not referred were compared. Again, we found marked differences between sites in service staffing, clinical and educational activity, administrative structure and processes, and management structures. Overall we found that specialist liaison services models were able to respond to referrals more quickly and were able to carry out reviews more often. We also found that the presence of a specialist liaison service increased access to specialist mental health assessment and treatment. We found services difficult to compare on other measures due to considerable heterogeneity in services, and we also encountered some difficulties with data collection in some sites that led to disappointingly high levels of missing data in some cases. Conclusions Although there are high levels of mental health problems in general hospitals, our literature review failed to identify good quality evidence to guide service provision. Our mapping and evaluations revealed a worrying lack of ownership and responsibility for these services. We also found the research difficult to carry out, due in part to the organisational barriers that also hamper service development. Despite these difficulties, the case for further evaluative studies of liaison mental health services for older people appears strong.



The Report

1 Introduction

1.1 NHS context and relevant literature To date, much of the service development driven by the National Service Framework for Older People (NSFOP) (Department of Health 2001) has related to services for physical problems such as stroke and falls, and the mental health standard is much less detailed than the working age adult focused National Service Framework for Mental Health (NSFMH) (Department of Health 1999). This is part of the reason why the Commission for Healthcare Inspection (CHI) sector review of mental health trusts has reported that “the focus of policy, local priorities and the national performance indicators remain centred around (working age) adult mental health services” (Commission for Healthcare Inspection 2004). This is surprising when mental health services for older people make up a third of all mental health service activity (Philpot et al. 1998).

One place that mental health services for older people can be particularly relevant to the performance of the whole health and social care economy is in the general hospital. Older people occupy two-thirds of general hospital beds (Department of Health 2001), and the ageing of our population means that this is likely to increase. What is less widely appreciated, but vital to recognise, is that mental health problems are extremely common in older people in general hospitals. Rates of 27% for depression (Ames and Tuckwell 1994), 27% for dementia (Bowler et al. 1994) and 29% for delirium (O'Keeffe and Lavan 1996) are typical, with even higher prevalence in particular settings; for example, on orthopaedic wards delirium is found in 61% of older people with hip fracture (Gustafson et al. 1991) and depression and dementia are also more common than in community settings (Holmes and House 2000b). Not only are these mental health problems common, they also have adverse effects on several important outcomes. For example, mortality is increased in depression (relative risk 1.6), dementia (RR 2.6) and delirium (RR 2.9), and hospital stays are longer (by as much as 11 days) after hip fracture in association with these problems (Holmes and House 2000a; Nightingale et al. 2001). Institutionalisation and costs are also greater in the presence of mental health problems (Holmes and House 2000a; Leslie et al. 2005; Unutzer et al. 1997). Delirium leads to long-term symptoms of mental health problems (Cole 2004) and predicts the development of dementia (Rockwood et al. 1999). Also, older people make up only 2% of the self harm population but account for 25% of suicides (Horrocks et al. 2003; O'Connell et al. 2004).

There are several possible reasons for these poor outcomes. One reason may be that there is a lack of effective treatments, but this is not the case; for example, depression can be treated with antidepressants or psychological therapies (National Institute for Clinical Excellence 2004) and delirium incidence and severity can be reduced by multi-component approaches (British Geriatrics Society 2006). Another reason may be the knowledge, skills and attitudes of general hospital staff towards the management of older people with mental health problems (Atkin et al. 2005). General hospital staff often regard mental



health problems in older people as a problem for mental health services rather than for themselves, despite the fact that these older people are under their care and not under the care of mental health services (Holmes et al. 2002, 2003a). They may fail to detect mental health problems (Gustafson et al. 1991; Balestrieri et al. 2002), treat them sub-optimally or inappropriately (Holmes and House 2000a; Rao 2001; Holmes et al. 2003b), and fail to provide access to mental health services for those who may benefit (Holmes et al. 2003a). In turn, mental health services for older people have developed a strong community focus that does not serve the general hospital population well, despite receiving on average 25% of their referrals from general hospital wards and with referrals from this source rising (Holmes et al. 2003a).

In 2002, we found that most mental health services for older people operate a consultation service to general hospital wards (Holmes et al. 2003a). The consultation model relies on general ward staff both to detect mental health problems and to refer appropriately and there are deficiencies at both these steps, as mentioned above. Even when a referral is made the response may be too slow to be of benefit; only 5% of mental health services for older people surveyed in 2002 felt that they could respond to a request for assessment the same day, and only 40% felt that they could respond within a week (Holmes et al. 2003a). The speed of response is particularly important in NHS general hospital departments where turnover is high (such as medical assessment units), and the possibility of a response to an older person with mental health problems in an Accident and Emergency Department is remote at best, leading to inappropriate admissions to avoid breaches of the four hour target set for assessment and management in the department. Even where a mental health assessment is carried out through the consultation model, the advice offered is often not acted upon and the assessment has little influence on practice or outcome (Teitelbaum et al. 1996).

In recognition of this problem, some organisations have developed liaison mental health services for older people. These provide greater input to general hospital settings than the conventional consultation model. Their development provides older people with similar liaison mental health services to those available UK wide for adults of working age (Swift and Guthrie 2003) and therefore offers a solution to the ageist provision of liaison mental health care, as required by Standard One of the NSFOP (Department of Health 2001).

In 2002, we found that several liaison service models for older people are possible, including:(1) liaison mental health nursing; (2) liaison psychiatry; (3) multidisciplinary liaison mental health teams; (4) outreach from psychiatric wards; (5) in-reach from community mental health teams and (6) shared care wards (Holmes et al. 2003a). We also found that in some cases liaison mental health services for adults of working age deliver services for older people in general hospitals in the absence of any input from mental health services for older people (Ruddy and House 2003). The exact choice of model is driven by a complex range of factors such as history, geography, personal interest of clinicians and managers, and resource allocation. However, liaison mental health services for older people share common features. First, staff time is dedicated to working in the general hospital environment, meaning that community work is not prioritised and that time is available for regular review and monitoring of the management of older people with mental health problems in the general hospital. The latter can be particularly important in fluctuating conditions such as delirium. Second, they provide advice on the basics of management of mental health problems to general hospital colleagues from a variety of disciplines, modelling good care and spreading good practice. Third, they are in a position to provide supervision for general ward staff.



Fourth, they provide education and training for general hospital colleagues about issues related to mental health in older people. A typical educational curriculum would include information on dementia, delirium, depression, anxiety, alcohol misuse and withdrawal, mental capacity and consent, managing difficult situations (including behavioural disturbance), mental health legislation and the importance of prevalence and indicators of self harm in older people.

Despite the potential advantages offered by a specialist liaison mental health services for older people, it is far from the prevalent model of service delivery; a survey carried out in 2002 revealed that less than a quarter of mental health services for older people operated any kind of liaison model, and most of those that did provided it on a very limited, sessional basis only. The remainder of services operated on a consultation-only basis. However, 89% of respondents recognised that their input to general hospitals was inadequate and the vast majority would have preferred to operate one of the liaison models listed above (Holmes et al. 2003a).

One reason that the liaison model has not been more widely adopted is because there is little high-level evidence of effectiveness to justify the development of liaison mental health services for older people. A systematic review of mental health services for older people suggests that the liaison approach is superior (Draper 2000a). One randomised controlled trial found that older people with mental health problems in a general hospital setting were more likely to return to independent living if they received specialist multidisciplinary mental health liaison (Cole et al. 1991), and a further controlled trial from the United States of America (USA) of a liaison mental health service suggested that it could reduce length of hospital stay after hip fracture by two days and provide an overall cost benefit (Strain et al. 1991). This evidence was not, however, the main driver of choice of model by the survey respondents in 2002; they were much more concerned about the quality of care that older people with mental health problems in general hospitals received. Nevertheless, the potential for liaison mental health services for older people to benefit the whole health and social care economy (and particularly the performance of acute general hospitals) is evident. This whole-systems view may be particularly important given the approach to examining the implementation of the NSFOP adopted by the Healthcare Commission, the Commission for Social Care Inspection and the Audit Commission, where a whole health and social care community rather than individual organisations were examined (Healthcare Commission 2006).

Our survey in 2002 (Holmes et al. 2002) revealed a great deal of interest in improving the care of older people with mental health problems in general hospital settings, through the development of specialist liaison mental health services for older people. Anecdotal information reveals that specialist liaison services for older people have evolved in many places in the UK since our survey in 2002 (though they are by no means universal), with a wide range of drivers and facilitators mentioned earlier in this section, and with service models broadly conforming to those given above. We are now at the stage where further information is required about the prevalent service configurations and components, together with descriptions of service activity and potential benefits of particular models of service provision, in order both to inform the future of service developments and to inform the design of a formal evaluation of specific service models in order to examine efficacy and effectiveness (including cost-effectiveness) in a trial setting.



1.2 Aims and objectives This study had three phases:

Phase 1-Literature Review

We searched and synthesised the available literature on liaison mental health services for older people. This provided descriptions of the different models of mental health liaison for older people, including staffing and skill mix, service activity, effectiveness and applicability to the NHS, and also established the strength of the evidence (or lack of evidence) for effectiveness. The output for this phase is a clear conceptual overview of the structure of service models and a comprehensive description of outcome measures already employed to determine process and outcomes.

Phase 2-Service Mapping

We mapped the provision of liaison mental health services for older people across the UK. The output of this phase is a description of the prevalence of different service models, and a register of services to be selected for in-depth evaluation in the next phase. This phase also allowed us to identify the places where specialist liaison services do not exist that could be used as uncontaminated trial sites for future trial-based evaluations.

Phase 3-Service Evaluation

We provided an in-depth pragmatic evaluation of a sample of liaison mental health services for older people, describing in more detail the staffing, activity, management and administrative structures, impact, cost and other relevant service markers. The output of this phase was two-fold; (1) allowed us to examine the impact of service configuration on outcomes for older people with mental health needs in general hospital settings (2) provided the detailed knowledge that will place us in the position to be able to design a trial-based formal evaluation of liaison mental health services for older people.



2 Phase 1: Literature review

2.1 Aims The aim of this review was to: (1) identify the literature that describe and/or evaluate liaison psychiatry services for older people; (2) identify the range of service models implemented; (3) identify the range of outcomes and outcome measures utilised. The literature review was carried out between April 2006 and January 2007.

2.2 Defining the review question In order to produce a comprehensive review, a non-specific and fairly broad review question was employed: ‘A literature review on liaison psychiatry services for older people in the general hospital’. This was examined under three sub-headings: (1) population/types of participant; (2) intervention; (3) study type. The criteria were used to delineate selection of relevant material.

2.2.1 Population/type of participant

The population was defined as ‘older people with co-morbidity (physical and mental health problems) in general hospitals’. In the UK, the age cut off for older people’s mental health services is generally sixty-five years of age. However, we could not exclude studies on the basis of age of population as different hospitals have different age cut-off points in order to group older people’s services. Likewise, in countries where liaison psychiatry is relatively more well developed (mainly North America), services do not have age cut-off limits, and are ‘non-age discriminatory’. At the same time, we could not reject articles on the basis that the service did not exclusively see older patients, since in many of these articles older people made up a very significant proportion of their patients.

2.2.2 Intervention

Any form of liaison psychiatry intervention was considered; there are a range of different liaison psychiatry service models available (Holmes et al. 2003a), and it was our intention to identify the prevalent models adopted. We also included articles describing the consultation-only (sector) model in our review, as our previous survey has found that this is the prevailing model in the UK.

2.2.3 Study type

We adopted a pragmatic approach to the types of studies included, and as such did not impose any methodological filters on the search. This would allow us to examine a wide range of methodologies, interventions and outcome measures.



2.3 Search strategy

2.3.1 Primary literature

The search strategy for examining primary literature (academic journals) was developed in accordance with the Centre for Reviews and Dissemination guidance (Centre for Reviews and Dissemination 2006). In addition, the research assistant conducting the review underwent training in systematic reviewing from the Cochrane Systematic Review team.

Bibliographic databases

Initial scoping searches were conducted using the OVID databases, Medline and PsycINFO, with the following keywords: “liaison psychiatry”, “consultation-liaison psychiatry” and “liaison mental health”. This helped to compile a comprehensive list of keywords to be used in the search strategy.

The search strategy used is reproduced in Appendix 1. The following OVID bibliographic databases were searched: AMED (1985-2006), British Nursing Index and Archive (1985-2006), CAB Abstracts (1976-2006), CINAHL (1982-1976), All EBM Reviews, EMBASE (1980-2006), Global Health (1976-2006), HMIC (1976-2006), MEDLINE (1976-2006), MEDLINE In-Process and Other Non-Indexed Citations and PsycINFO (1976-2006). As described in the selection criteria below, we limited our search to the past 30 years; however, not all of these databases went as far back as 1976, and so they were searched from the first available date (dates searched are shown in brackets). Web of Science (1976-2006) and the Cochrane Library (1976-2006) were also searched. E-mail alerts were set up as part of this work that would provide up to date articles matching our search criteria. Cited Ref searches for all the articles retrieved thus far were performed using Web of Science. The purpose of this was to find articles that have cited a previously published work. We also searched the reference lists/bibliographies of all articles retrieved thus far. These two searches were performed in the latter stages of the literature searching process, and produced many additional references that had not been identified previously by other means of literature searching.

Hand searches

The following journals were hand-searched using the date criteria described in the previous section on bibliographic databases: Medical Care, Age and Ageing, Journal of Psychosomatic Research, Psychosomatics, General Hospital Psychiatry, British Journal of Psychiatry, Canadian Journal of Psychiatry, Australian and New Zealand Journal of Psychiatry, International Journal of Psychiatry, American Journal of Psychiatry, Psychosomatic Medicine, Aging and Mental Health, and Psychogeriatrics. Members of the Study Steering Committee compiled the list of journals most likely to contain sources of relevant information. In addition, references already held by members of the Study Steering Committee were hand-searched in order to reveal any potential articles of interest.

2.3.2 Inclusion criteria

The full text of all potentially relevant articles found from the search strategy described above was obtained. The relevance of these articles was examined more closely using the inclusion and exclusion criteria described in Table 1.



Two reviewers (principal investigator and research assistant) were involved in this task in order to ensure concordance in selection.

Table 1. Inclusion and exclusion criteria

Variable Inclusion criteria Exclusion criteria

Patients Older patients only seen by the service

Mean age > 35 years for non-age

discriminatory services, indicating that

the service sees a significant number of

older patients

Working age patients only

If non-age discriminatory service, mean

age is low e.g. < 35 years – indicating that

there are not many older patients in the

study sample

Setting General hospital Psychiatric wards

Nursing or residential homes

Interventions Liaison psychiatry services

Consultation-only services

Non-psychiatric intervention

Geriatric intervention

Multi-component intervention for e.g.

delirium

Outcomes Any N/A

Study design All studies presenting original primary

research on services; descriptive and

evaluative studies included, as well as

previous systematic reviews

Studies with no primary data e.g.

commentaries, editorials, anecdotal

Restrictions Articles written in English

Articles published 1976-2006

Articles not written in English

Articles published prior to 1976

Articles that satisfied the above inclusion criteria as well as a final check for research quality were included in the review. All retrieved articles were imported to Reference Manager 8 software. A data extraction form reproduced in Appendix 2 was used to summarise all included articles.

2.3.3 Grey literature

The means of searching the grey literature are described in Appendix 3. In summary, we identified a range of websites and alternative databases that would potentially yield some further interesting results. Potential examples of interest included guidelines, reports, and criteria for setting up a service. To this end, the inclusion criteria employed with primary literature did not frame this work. We included any documents or reports pertaining to ‘liaison psychiatry’, with no specific focus on particular groups of patients. Through examining literature of services with similar philosophical aims, we would be able apply findings within the context of our group of interest, older people. Lastly, we also contacted our extensive network with lead researchers in the field for their advice, in addition to contacting researchers found as a result of searching the National Research Register.



2.3.4 Economic literature

A separate search of the published literature was undertaken for studies demonstrating the cost or cost-effectiveness of hospital-based old age liaison mental health services. The purpose was to retrieve comparative studies demonstrating the changes in cost and outcomes when providing liaison services. To achieve high sensitivity, the search was deliberately broad, without selection by study design, service model or location. Thus at the search stage controls could be historical, geographical, unmatched, matched or randomised and the design could be observational or experimental. However where studies of better design for attribution of effect were retrieved then lesser designs were discarded, since studies were sought that were of adequate methodological quality to guide policy. It has already been noted that in the UK older age psychiatry as a specialty is distinct from liaison psychiatry for adults of working age although this distinction is not found in the USA, consequently the search was unrestricted and include any type of liaison psychiatry.

Searching was limited to studies published between 1980 and August 2008, as the continuing relevance of evidence from older studies is questionable. No language restrictions were placed at the search stage. Databases were searched using OvidSP and included MEDLINE, EMBASE, CINAHL, PsycINFO, HMIC, EconLit, Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled, Health Technology Assessment and NHS Economic Evaluation Database. A sensitive search was conducted using text word searching. The composite field search term ‘mp’ searches title, original title, abstract, subject heading word, MeSH subject heading, keyword heading, drug coding and manufacturer fields. Addition of MeSH terms complicated the search strategy without improving search sensitivity. The search used on all databases was: (cost$ or financ$ or economic$).mp. AND (liaison and psychiatr$).mp. Studies were abstracted that provided a cost analysis or economic analysis based on randomised controlled trial data, although other designs were commented on. The search strategy, limited from 1980 to 2008 with duplicates removed, provided 364 citations which were screened for inclusion.



2.4 Results

2.4.1 Primary literature

Search results from databases are shown in Table 2. Table 2. Inclusion and exclusion criteria

Database Number of Results

(“Hits”)

Number of results (after

removing duplicates)

AMED 21 0

British Nursing Index 83 45

British Nursing Index Archive 35 12

CAB Abstracts 8 2

CINAHL 413 237

EMBASE 1542 606

Global Health 15 1

HMIC 186 99

MEDLINE 1391 1289

PsycINFO 1700 888

TOTAL 5394 3179

In addition, searching the Cochrane Library generated 4,655 results and Web of Science generated 2,150 search results. Therefore, searching all the electronic databases using the search strategies described in the appendices generated a total of 9984 potentially relevant articles, which were then checked for relevance and inclusion in our review using the selection criteria previously described.

Potentially relevant articles

A total of 484 potentially relevant articles were retrieved from these search strategies. These articles were examined using the defined inclusion criteria shown in Section 2.3.2, Table 1.

A total of 112 articles matched the selection criteria. Reasons for non-inclusion were typically irrelevant primary research, intervention being described or evaluated was not the correct intervention for our review, mean age of study sample was too low (indicating that the study cohort consisted of very few older people) and the study not being set in a general hospital. A further four articles were excluded at the final stage of appraisal which consisted of a check for study quality where there had been an evaluation of a service (this step did not apply to descriptive studies). This was carried out by the Principal Investigator and a research assistant individually appraising each evaluative study (using the tool in Appendix 4), and then agreeing on quality by consensus. This removed four, low-quality evaluative studies and resulted in a total of 108 selected articles.



Selected articles

Table 3 shows the source of selected articles. The greatest number of articles was detected by the literature searches, but there were more than might be expected from other sources, suggesting that the search strategy used was not sensitive enough. However, it is difficult to see how it could be refined without bringing a loss of specificity.

Table 3. Sources of selected articles

Source Number of selected articles

Literature searches (Medline etc) 47

Hand searching relevant journals 19

Cited ref searches 7

Searching reference lists of retrieved articles 14

Personal contacts 8

Study steering committee reference collection 13

2.4.2 Study categorisation

In order to discuss the large number of articles found in this review, we initially organised studies in relation to the three sub headings used to define our review question as outlined in section 2.2: (1) population/types of participant which are identified as old age or non-age discriminatory; (2) intervention which was regrouped according to recognised service models as outlined in ‘Who Cares Wins’ (2006) and reproduced in Appendix 5; (3) study type which was examined with reference to Hierarchy of Evidence (UK NHS Centre for Reviews and Dissemination). This is reproduced in Appendix 6. This allowed us to examine meta-analyses and systematic reviews, and both evaluative and descriptive studies in more detail.

2.4.3 Meta-analyses and systematic reviews

One unpublished meta-analysis was identified. Draper (2006) conducted a meta-analysis of treatment outcomes, comparing the effectiveness of consultation-liaison interventions for older people in the general hospital (short-term care) and residential care (long-term care) setting, and the effectiveness of consultation and liaison styles of service delivery. Of the 14 studies included in this review, random-effects pooled effect sizes of the treatments suggest that treatment outcomes for consultation-liaison services for older people are better on non-mental health measures than on mental health measures: Depression -0.13 (-0.35 to 0.08); Challenging behaviour 0.00 (-0.21 to 0.22); Function 0.10 (-0.40 to 0.18); Length of stay 0.62 (-0.41 to 1.65). Liaison services had pooled effect sizes of 0.60 (-0.24 to 1.45) and consultation services -0.06 (-0.28 to 0.16), suggesting that liaison services are more effective than consultation services.

Four systematic reviews were included in our review (Draper 2000b; Draper and Low 2005; Callaghan et al. 2003; Andreoli et al. 2003). These four reviews assessed the effectiveness of services, and found that liaison services have the potential to be more effective at improving outcomes in older people compared



to the consultation-based sector model. The papers in these reviews are all included in our review and are reported separately in the following sections.

2.4.4 Evaluative studies

Randomised evaluative studies

Our search revealed eight randomised evaluative studies (Kominski et al. 2001; Cole et al. 2006; Slaets et al. 1997; Cole et al. 1991; Baldwin et al. 2004; Cullum et al. 2007; Shah et al. 2001; Levenson et al. 1992).The table in Appendix 7a describes the interventions and service make-up evaluated by each of the eight randomised studies summarised in this section. All of these studies used ‘usual care’ as the parameter for control groups in which patients randomised to this group did not receive the intervention, and requests for psychiatric consultation were complied with in the normal fashion.

The tables in Appendix 7b summarise the outcomes and outcome measures employed by each of the randomised studies, as well as the characteristics of the patients recruited into the studies (both experimental and control groups), such as demographics, psychiatric and functional status. It can be seen that all but one study involved studying liaison services for older patients only, whereas the Levenson study (Levenson et al. 1992) was the only study that evaluated a non-age discriminatory service. The table in Appendix 7c summarises the findings for these randomised studies. The results are modest, and only one study (Slaets et al. 1997) had consistently positive results on outcomes such as physical functioning, length of stay and nursing home placement (see Appendix 7c for full details of these findings). This study used alternate randomisation to either the intervention unit or the usual care unit. Other studies had what could be described as inconclusive results, with no significant differences between study groups.

Non-randomised evaluative studies

Ten non-randomised studies were identified (Baheerathan 1999; Camus et al. 2003; de Jonge et al. 2003; De Leo et al. 1989; Levitan and Kornfeld 1981; Molodynski et al. 2005; Mujic et al. 2004; Scott et al. 1988; Strain et al. 1991; Swanwick et al. 1994). The table in appendix 8a summarises the method, patient demographics and characteristics, outcomes and outcome measures used. Appendix 8b summarises the service make-up and interventions. Findings from these studies are shown in appendix 8c. Some, but not all, of these studies suggest that a liaison service can bring reductions in length of stay in specific populations, and that diagnosis of mental health problems by non-mental health specialists improves with a liaison service present. Referrers also seem more satisfied with a liaison mental health service than a non-liaison service. Considerable difference between models evaluated is apparent.

Evaluation of education/training interventions

Two studies were identified that specifically evaluate the addition of an educational intervention administered by a liaison psychiatrist (Shah and De 1998; Tabet et al. 2005). This was targeted towards the general hospital staff with the aim of improving the detection of psychiatric morbidities in their patients. Both studies were non-randomised, and looked at specific psychiatric problems, with Shah and De (1998) targeting aggressive behaviour and Tabet et al. (2005) targeting delirium.

Appendix 9a describes the patient demographics and outcomes and outcome measures used. The interventions themselves are shown in appendix 9b.



Appendix 9c summarises the findings from these studies. Both studies suggest that implementing an educational intervention can improve detection of mental health problems, at least for aggressive behaviour and delirium.

2.4.5 Descriptive studies

This section describes service audits which allowed us to examine: the setting; information about the service; its make-up and interventions provided; patient demographics; service activity; co-morbidity diagnoses; hospital process data such as length of stay and lag time; recommended interventions. Full reproduction of findings from these studies is shown in Appendix 10. A total of 76 studies were included in this section. Table 4 provides a summary of these studies.

Table 4. Service typology and age of population studied

Old age/non-age discriminatory

Service typology Number of studies

Old age Liaison Psychiatrist 4 (Grossberg et al. 1990; Camus et al. 1994; Leo et al. 1997; Rao 2001)

Old age Liaison Nurse 1 (Collinson and Benbow 1998)

Old age Shared care/medical psychiatry wards

2 (Porello et al. 1995; Flaherty et al. 2003)

Old age Sector model 9 (Pauser et al. 1987; Wrigley and Loane 1991; Roulaux et al. 1993; Loane and Jefferys 1998; Scott et al. 1988; Benbow 1987; Poynton 1988; Anderson and Philpott 1991; McColl et al. 1989)

Non-age discriminatory Multidisciplinary team 15 (Hales et al. 1986; Chandarana et al. 1988; Porter 1988; Huyse et al. 1990a; Schmaling 2002; Dilts et al. 2003; Bourgeois et al. 2005; Kuhn et al. 1986; Schuster 1992; Clarke and Smith 1995; Kissane and Smith 1996; Rustomjee and Smith 1996; Andreoli and Mari 2002; Diefenbacher and Strain 2002; Huyse et al. 1990b)

Non-age discriminatory Liaison psychiatrist 26 (Clarke et al. 1995; Craig 1982; Diefenbacher 2001; Folks and Ford 1985; Freyne et al. 1992; Gobar et al. 1987; Hara et al. 1993; Hengeveld et al. 1984; Juang et al. 2005; Karasu 1977; Kishi et al. 2004; Kramer et al. 1979; Levitte and Thornby 1989; Mainprize and Rodin 1987; McKegney et al. 1983; O'Neill et al. 2003; Ormont et al. 1997; Rabins 1983; Ramchandani et al. 1997; Ries et al. 1980; Rothenhausler et al. 2001; Ruskin 1985; Schofield et al. 1986; Trzepacz et al. 1985; Rosse et al. 1986; Wallen et al. 1987)

Non-age discriminatory Liaison nurse 2 (Newton and Wilson 1990; Kurlowicz 2001)

Non-age discriminatory Shared care 2 (Kathol et al. 1989; Hoffman 1984)

Non-age discriminatory Liaison clinic 3 (Wilkinson et al. 2001; Rowan et al. 1984; Bass et al. 2002)

Non-age discriminatory Sector model 9 (Stoppe et al. 2004; Shevitz et al. 1976; Sobel et al. 1988; Krakowski 1979; Grant et al. 2001; Small and Fawzy 1988; Loewenstein and Sharfstein 1983; Popkin et al. 1984; Perez and Silverman 1983)

Non-age discriminatory A&E setting 3 (Callaghan 2006; Callaghan et al. 2001; Ryrie et al. 1997)

These descriptive studies use both prospective and retrospective designs to describe clinical and educational activity, clinical case-mix, and process outcomes such as medication use, reviews and follow-up arranged. Wide



variations in these factors are seen between different services, making further comparisons difficult to achieve. The methodology employed by these studies does not allow meaningful conclusions to be made about the clinical effectiveness of any particular service model. It is also apparent that the typology used to describe services in the way that we have tried to do does not reflect the wide variation seen in service structure and function, with considerable heterogeneity making like for like comparisons impossible.


Cost effectiveness analyses

Two cost-effectiveness analyses meeting inclusion criteria are reported here in detail, although neither enrolled a purely older patient general medical inpatient population. One (Levenson et al. 1992), reported a randomised controlled trial with an assessment of the incremental cost of liaison psychiatric consultation to three months following discharge. The trial was conducted during 1987 to 1989 on general medical wards in a large US urban academic hospital. Consequently an adult (rather than older patient) population was enrolled (mean age 47 years). Patients were screened for depression, anxiety, confusion, and pain, and were excluded due to early discharge, or low levels of psychopathology or pain. Randomisation occurred at ward level to avoid problems and potential contamination effects from patients in neighbouring beds receiving different care. However, the clinical teams rotated wards, spending time in and out of active intervention. No mention of adjustment for clustering due to randomisation at the level of the ward is discussed. In addition to the randomised control group an historical control group was included. The randomisation delivered 256 patients in the experimental group and 253 control subjects. Analysis was by intention-to-treat although 77 patients in the experimental group did not receive the intervention due to early discharge, transfer or mortality. Telephone survey follow-up at three months from discharge was included but this only involved contact with 41% of recruited patients. Data on length of stay, re-hospitalisation and cost were 100% complete, taken from the hospital database, although re-hospitalisation at other sites was not captured. The year of origin of unit costs and charges used is unclear.

At baseline there were no demographic or major diagnostic related group differences between the experimental and control groups, but a significantly poorer baseline disease severity in the experimental group assessed by previous hospitalisation and disease staging was evident. Consequently the experimental group had longer lengths of stay (I: 11.3 days vs. C: 10.2 days, p=0.02), more procedures and higher hospital costs and charges. These differences were no longer statistically significant when adjustment was made for disease severity.

No comparable health outcome data are reported in the study and the conclusion is that (brief) liaison psychiatric screening and intervention does not substantially increase cost. Little description is provided of the intervention provided to all experimental group patients. Consultation with a psychiatrist (N=158) took 1.3 hours on average for the initial visit and 11.4% (N=18) had an average further 1.5 visits averaging 0.7 hours. The authors noted that the findings might have differed if the study had been conducted on a different patient population. The majority of their patients were black, poor and working age and about a third had a diagnosis of substance abuse. Patients with older age, greater disease and longer hospital stay tended to be excluded as they



were deemed too difficult to study. Finally, the cost of the psychiatric intervention is never explicitly stated although it is assumed this was added to the overall charges and costs.

A second cost-effectiveness study (Gater et al. 1998) was based on a randomised controlled trial conducted on medical wards at the Manchester Royal Infirmary. A liaison psychiatry service had already been established and the effect of adding a psychiatric screening procedure was being evaluated. Exclusions consisted of: patients already receiving psychiatric care; admissions for deliberate self-harm; day patients; and patients who were unable to participate due to the disease severity or language difficulties. The mean age of participants was around 50 years. Patients scoring over the threshold on a 28-item version of the General Health Questionnaire (GHQ-28, Goldberg and Hiller, 1979) were randomly allocated within three study groups: (1) “assessment by psychiatrist” group (N=68); (2) “physicians informed” group (N=70); and (3) “control group” (N=71).

In the “assessment by psychiatrist” group, the psychiatrist wrote detailed recommendations in the patient’s medical notes discussing these with staff, but took personal responsibility for patients who required psychiatric follow-up. In the “physicians informed” group, GHQ-28 findings were added to medical notes, with clinicians left to assess and treat the patient, including referral to the liaison psychiatry service if appropriate. For the control group, scoring over the threshold were not communicated to clinicians and these patients received routine care. The primary follow-up assessment occurred at 6 months with interview by a psychiatrist blinded to allocation. Outcomes included the Psychiatric Assessment Schedule (Dean et al., 1983); Nottingham Health Profile (Hunt et al, 1986); and the Rosser Index (Rosser and Watts, 1972)at baseline and 6 months. Extensive attempts were made to capture primary and secondary health service costs and medical social work costs during the study period. Additionally patient-borne expenses and loss of productivity were investigated. The year of origin of unit costs used in their data is unclear.

Groups were well matched at baseline, except for lower employment status in the “assessment by psychiatrist” group. At six months, the study found no statistically significant differences in any health outcome measure, total NHS costs or overall costs including productivity changes. The authors offered some reasons for the lack of demonstrated benefit or change in costs. First, they suggested the screening threshold may have been too low thus diluting the benefit that would be seen with more severe patients; second, they note the heterogeneity of patient diagnosis, prognosis and cost; third, while psychiatric treatments were acted upon during the index admission, limited reporting and poor communication drastically reduced effective continuation of care following discharge.

Other studies

A further UK cost-effectiveness study used RCT methodology to evaluate liaison psychiatric nursing in the management of older medical inpatients (Cullum 2004), but the trial appears underpowered (Cullum et al. 2007) and no economic analysis has been reported to date. Two small controlled studies (Hengeveld et al. 1988 with 68 participants and Verbosky et al. 1993 with 48 participants) have been reported of psychiatric liaison intervention for medical inpatients with depression. However, lack of randomisation means the results are not reported further, with both studies featuring important design limitations. One small randomised controlled trial assessing the cost-effectiveness of psychiatric consultation in primary care outpatients (N=38) was



also identified (Smith et al. 1986) although this was not a relevant patient population for the current review. A historically-controlled cost-benefit analysis of an enhanced specialist liaison nurse service for patients with aneurismal subarachnoid haemorrhage was similarly identified (Pritchard et al. 2004), albeit not relevant for our purposes. One systematic review was retrieved of studies published before 1999 addressing the cost-effectiveness of mental health consultant-liaison interventions, and could find no effect on length of stay, but suggested an improvement in depressive symptoms; this review did not identify additional studies (Andreoli et al. 2003).

Cost-offset analyses

A more partial analysis of ‘cost-offsetting’ is briefly reviewed. This is the extent to which the introduction of a liaison service reduces other service costs such as length of stay, readmission or use of drugs.

In 1984, the US Academy of Psychosomatic Medicine created a taskforce to address what it saw as a funding crisis in consultation-liaison psychiatry (Saravay and Strain 1994). The taskforce was to lead to the commissioning of methodologically robust cost-effectiveness research that that would encourage appropriate reimbursement for consultation-liaison services within the US healthcare financing system. Findings from the subsequent research were summarised in 1994. A review of cost-offset studies included psychiatric liaison screening and interventions, psychosocial screening, and standard consultation conducted in the medical inpatient setting (Strain et al. 1994). Studies used a variety of outcome variables including: altered psychiatric morbidity; delay in identifying psychiatric morbidity; delay in referral; cost-offset and discharge destination. The review found that methodological and design limitations meant that most findings were confounded. Of particular note was the lack of appropriate randomisation. There were pointers towards liaison services reducing cost but these were not convincing.

2.5 Discussion Our literature review has revealed that evidence about the effectiveness of liaison services is limited and much of it is methodologically weak. The majority of the literature identified here is descriptive. Differences in service models, care settings and the factors measured mean that any kind of comparison or meta-analysis is difficult. The small amount of higher level evidence is often inconclusive; however, our findings suggest that liaison mental health services in general hospitals have the potential to be effective in improving outcomes such as length of hospital stay, discharge disposition and hospital costs. Nevertheless, several important concerns about the reliability and validity of these studies persist.

2.5.1 Types of studies

It is apparent from this review that overwhelmingly, most of the studies included in the review were of the descriptive type, presenting data on uncontrolled service audits, and, in many instances, in the absence of any identifiable outcome data. These studies are useful in informing us about the range of service models utilised, and the interventions provided by these services, as well as characteristics and demographics of patients referred for psychiatric consultation. However, although a minority of these studies do discuss some outcomes such as discharge disposition and length of hospital stay, we cannot fully rely on the findings for such outcomes as these studies



have not controlled for confounding factors such as severity of physical illness or social support available, which have important effects on primary outcomes. For example, recently, there has been a reduction in the length of stay of older people in UK hospitals because of ward closures and transfer of resources to community facilities such as intermediate care teams. The results from a study of any healthcare intervention performed during these transitions may wrongly suggest that the reduction in length of stay occurred as a consequence of the intervention, not the service transition. It may be the case that the intervention would have a beneficial effect on reducing length of stay, but without controlling for confounding factors, we cannot deduce this from descriptive studies. With regard to the evaluative studies, a total of eighteen studies (eight randomised controlled trials and twelve non-randomised studies) were included in the review. In terms of the quality of evidence presented by these studies, generally speaking, this was comparatively low. The data from the randomised studies may be unreliable as a consequence of inappropriate methodology for evaluating this type of intervention that was adopted by the authors. One major difficulty is the unit of randomisation that is employed. Liaison mental health services have both direct and indirect impacts. Direct impacts include mental health assessment of individual hospital patients, with provision of advice, prescription of medication and recommendations regarding mental health follow-up. As the descriptive literature tells us, these are relatively easy to measure, although they reflect process rather than outcomes. Indirect impacts of liaison mental health services include the educational activity that is considered the cornerstone of a successful liaison mental health service. Improving general hospital staff knowledge, skills and attitudes will improve detection and management of common mental health problems without direct involvement of the liaison mental health team in clinical care, and once staff have gained these new skills they are unable to turn them on and off, meaning that patients in the control group receive a component of the intervention. This contamination will reduce the difference between the comparison groups and could result in a type II statistical error. There are also clearly ethical issues when we consider that a large number of patients who could potentially benefit from a liaison mental health service have significant cognitive impairment due to dementia or delirium, and consent to take part in research may be difficult or impossible to obtain. It is clear that these services are complex interventions that are difficult to evaluate successfully.

2.5.2 Comparing different studies

It is difficult to generalise and to make deductions on patterns where the characteristics and demographics of patients referred to services are concerned. The main reason for this is that different studies use different criteria for recording their findings. It has not been possible to directly compare the characteristics and demographics of patients referred for psychiatric consultation in the studies included in this review, for several reasons. Firstly, and perhaps most importantly, studies have employed different diagnostic criteria for psychiatric and physical diagnoses, which may make it difficult to provide a valid direct comparison. Furthermore, because we have included studies from the past thirty years, some of the diagnostic criteria employed by some studies may be outdated, such as DSM-II and DSM-III (American Psychiatric Association, 1968, 1980), for example, whereas many studies do not even state which diagnostic criteria they have employed. In spite of the fact that most studies in this review have adopted the DSM-III criteria, a further difficulty arises because authors, presumably for the sake of simplicity, have grouped diagnoses together. For example, some authors have



grouped diagnoses of dementia and delirium together, categorising them as “Organic Mental Disorders”. Difficulties arise here because this categorisation of diagnoses is inconsistent, although each study is different and it cannot be expected that every study would utilise the exact same classification criteria. Furthermore, Molodynski et al. (2005) discuss that, in their study, broad diagnostic categories were used, which may hide important differences between the particular problems managed by the two services being examined in their study. This remark applies equally to the other studies included in this review. As an aside, following on from the example of grouping diagnoses of dementia and delirium together; although both dementia and delirium can be classed as “Organic Mental Disorders”, they are different disorders with different aetiologies and management, and the reasons for grouping them together are questionable. For this review, it would have been useful to know the individual proportions of referred patients diagnosed with dementia or delirium (as well as patients with delirium superimposed on dementia), as it is known that both disorders are highly prevalent in older people in general hospitals. Although there are drawbacks to grouping diagnoses together, on the other hand, some grouping has to occur, as otherwise the data presented would be very complex. Therefore, it is difficult to resolve this issue of how to categorise diagnoses. Although fewer studies commented on the physical diagnoses of referred patients, these same principles apply to physical diagnoses as well as psychiatric diagnoses.

Reasons for referral are even more difficult to compare, as substantial differences exist in terms of how researchers categorise and document reasons for referral; comparing reasons for referral is made more difficult because there are no criteria for documenting them. However, with regards to reasons for referral, many studies emphasised comorbidity, and the interface between psychiatric and medical symptoms (for example, see the study by Karasu (1977)). For example, requests for support with depression, memory problems, and competency evaluation as well as advice were all common. Depression, organic mental disorders (dementia and delirium), suicide, somatoform disorders were all frequent psychiatric diagnoses, whereas cardiovascular disorders were the most common physical diagnosis.

We can make some general remarks about the patient characteristics, although the numbers vary between studies. There was a definite pattern with regard to sources of referrals; the vast majority of studies indicate that most of the referrals for psychiatric consultation came from the medical wards, with fewer referrals from other departments such as surgery, neurology or obstetrics-gynaecology.

No discernible differences could be found in patient characteristics between service models; again, for the reasons discussed above, it was not possible to provide direct comparisons. A comparison of patients referred to liaison and non-liaison mental health services would have been useful for this review, as we could have examined whether the characteristics of patients differ according to what type of psychiatric service they were being referred to. Moreover, it would also have been useful to examine which disorders are under-referred, as in a sector model service, this could potentially infer that the general hospital staff have difficulties in detecting some psychiatric symptoms and making the appropriate referral to the mental health service.

2.5.3 Methodological issues

In terms of the evaluative studies, collectively, the results are inconclusive. Judging whether these studies indicate whether liaison mental health services



are beneficial is complex, as some methodological limitations exist, which means that we cannot fully rely on some of the findings. Consequently, the findings from the evaluative studies should be interpreted with due caution, as it is likely that the methodological limitations discussed below have impinged on these results.

As was seen in the results section, the findings from the randomised studies have overall been very modest, indicating that liaison mental health services may not be as effective in improving outcomes. However, these findings may be rendered invalid by the inappropriate methods of randomisation employed by the authors of these eight studies, suggesting that these mostly negative results from the randomised studies may have been obtained as a result of the incorrect randomisation procedure, and not because the intervention was not effective.

According to the MRC guidelines for evaluating complex interventions (Medical Research 2000), a cluster randomisation procedure may be required. However, as was mentioned in Section 4.2, all but one of the randomised studies included in this review have not adopted the recommended cluster randomisation, and instead have opted for randomising participants at the individual level. This not only indicates a general lack of understanding regarding the methods of evaluating complex interventions but also renders the findings invalid and unreliable because of the inappropriate unit of randomisation adopted.

Most of the studies individually randomised the study participants, which meant that study participants who were allocated to the intervention group and other participants who were assigned to the control group resided on the same ward. This is not an acceptable means of randomisation, as it would be feasible that some of the control group patients would also receive the intervention. This is because it would be difficult for hospital staff to administer the intervention to some patients on the ward, and not to others; in this manner, some contamination would have occurred between the two groups. Therefore, from this example, we can see that cluster randomisation would be the most suitable means of randomisation. As patients allocated to the intervention and control groups would be on different wards, this would minimise the risk of contamination between the two groups.

With the exception of the Slaets et al. (1997) study, the results from these randomised studies are mostly negative. It is feasible that these negative results arose as a consequence of the incorrect means of randomisation, although establishing this link between the non-cluster randomised methodology and negative results would be difficult to establish. The Baldwin et al. (2004) and Cullum (2004) studies are notable examples, because both these studies evaluate the addition of a liaison psychiatric nurse. Both studies have indicated that introducing such a post has no effect on outcomes such as quality of life, length of stay and rates of re-hospitalisation and change in mental health status. However, these negative results may also be attributable to the confounding effect of employing individual randomisation.

The study by Slaets et al. (1997), in contrast to the other randomised studies, produced some consistently positive results on all outcomes. Outcomes studies included physical functioning, length of hospital stay and disposition to a nursing home. Data on the costs and economics of the new service suggested that the service could also potentially be economically viable. However, in spite of these positive results, the authors employed an alternating randomisation, which is not a true randomisation procedure and may have led to the introduction of bias in the study.



Although some of these randomised studies were not as high quality as we had hoped, we felt that it was important to include these articles in our review, as they provide the best evidence for effectiveness of liaison mental health services that we have been able to identify.

An MRC guideline on cluster randomised methodology (Medical Research 2002) gives the following three examples to illustrate the scenarios in which cluster randomised trials should be considered:

1 “The intervention to be studied is itself delivered to and affects groups of people rather than individuals. Examples include changes in primary care organisation and use of local radio for health promotion”.

2 “The intervention is targeted at health professionals with the aim of studying its impact on patient outcomes. An example would be education about guidelines for a particular medical condition; it would be difficult for professionals receiving such education not to let this affect the management of all of their patients”.

3 “The intervention is given to individuals but might affect others within that cluster – i.e. contamination. For example, recipients of a behavioural intervention to promote weight loss or reduce smoking might share their information with others attending the same clinic”.

We believe that all three of the above examples apply to liaison psychiatry interventions. Specifically, with respect to the second example, it is feasible to suggest that this may have already occurred in some of the individually randomised trials discussed earlier in this review; as both patients receiving the intervention and patients randomised to the control group resided on the same ward in many of the studies, it would be difficult for the hospital staff to apply their newly-gained knowledge from the liaison team/psychiatrist/nurse to only the patients receiving the intervention. This may, in part, explain why patients from both the intervention and control groups improved on some measures, and why there were no statistically significant results between the two groups. It is likely that in the majority of randomised controlled trials considered here, patients in both groups may have received the intervention, or parts of the intervention.

2.5.4 Best evidence

In terms of complex interventions, the same MRC guidelines (shown above) state that “[t]hese are interventions in which several components may act interdependently to affect key processes and outcomes. Thus, components may affect several levels of an organisation such as a stroke unit, and it will often be appropriate to randomise at the highest level of the intervention such as the team rather than to randomise practitioners or patients”. Although the authors use a stroke unit as an example here, these ideas apply equally to liaison psychiatry interventions. In order to control for the various confounding factors that may affect outcomes and results in a randomised controlled trial, a well-designed cluster randomised trial is required. The lack of a well-designed trial to evaluate liaison psychiatry services for older people is apparent; although several trials have been performed thus far, none of them have followed the stringent requirements for designing a trial to evaluate a complex intervention.

In terms of the non-randomised studies, more positive results were found, pointing towards the potential of liaison mental health services to improve outcomes such as length of stay and discharge disposition; however, with the



exception of the Strain et al. (1991) study, many of these studies are retrospective in design or used historic controls, which may affect their reliability. However, one particular study does stand out in terms of findings. In spite of the fact that is it not randomised but is a before/after study parallel group design, the study by Strain et al. (1991) remains the study that appears to present the best evidence in support of implementing liaison psychiatry services for older people. The significant results from this study specify that initiating such a service would result in substantial reductions in length of hospital stay and hospital costs. The liaison unit was implemented at two separate sites; these significant results for the two outcomes of length of stay and hospital costs were obtained for both sites. These results strongly suggest that liaison mental health services for older people have the potential to improve outcomes. However, they have not, as yet, been replicated in a randomised trial. At the same time, the before/after design cannot take account of changes elsewhere in the healthcare system that may also be independently affecting the outcome of interest (in this case, length of stay).

We can also make some anecdotal inferences regarding liaison and non-liaison mental health services from the descriptive studies that may suggest that the interventions and educational activities provided by the liaison mental health services are beneficial. However, it must be stressed that these deductions are anecdotal. Firstly, it can be deduced that liaison mental health services have a higher rate of referral of overall admissions of older people, compared to sector model services. For example, rate of referral for sector model services (including both old age and non-age discriminatory services) range from 2% to 3.4%, with an average of roughly 1.5% to 2%, whereas the rates of referral for liaison services (including all liaison service models) range from 1.2% to 16.9%, with an average of roughly 4-5%. Even from these rudimentary data, it is clear that the liaison services have a higher rate of referral, which may indicate that more patients with mental health problems are being appropriately referred to, and accessing, a mental health service. It is possible that this higher rate of referral is a consequence of the liaison service’s educational activities, resulting in the general hospital staff being better equipped at detecting mental health problems in their patients, and referring these patients for psychiatric consultation. The higher rate of referral may also be as a result of direct liaison on the wards by members of the liaison service, identifying those patients who have manifested mental health problems, and who would benefit from a psychiatric consultation. It is of interest that, amongst the different service models examined in this review, the highest rate of referral was to be found amongst studies describing a multidisciplinary team service model. In addition the rate of referral in these studies was highest for the services providing psychiatric consultations to specific units, particularly the oncology and renal units (Kissane and Smith (1996) and Rustomjee and Smith (1996), respectively), where the rates of referral were 10.4% and 16.9%, respectively.

Paradoxically, two studies (by Baheerathan (1999) and Swanwick et al. (1994)) indicated that the rate of referral decreased after the liaison component is introduced; as described above, the rate of referral for the most part is normally elevated if a liaison service is in place. However, this decrease in rate of referral can be explained by the educational activities of the liaison service; if the general hospital staff are being periodically educated and trained by members of the liaison service to detect and manage psychiatric symptoms in their patients on the wards, theoretically, fewer patients should be referred for psychiatric consultation. Furthermore, Collinson and Benbow (1998) saw a reduction in the number of referrals for psychiatric consultation after the old



age psychiatric liaison nursing service was set up, but there was an increase in the number of “liaison” referrals – referrals made from direct liaison work performed on the wards by members of the service.

Some further deductions can be made from the descriptive studies. Generally speaking, there are fewer inappropriate referrals for psychiatric consultation if a liaison service has been set up; from the referrals to a liaison service, the psychiatrist concludes that fewer of the referred cohort have no psychiatric diagnosis, compared to referrals from a sector model service. For example, the study by Collinson and Benbow (1998) indicated that, after the service was set up, 10% of referred patients had no psychiatric diagnosis, compared to 22% before the service was initiated.

At the same time, the concordance rate between the reasons for referral (as stated by the referring physician) and the resulting psychiatric diagnosis (as stated by the psychiatrist) is improved when a liaison service is in place, compared to a sector model service. For example, Scott, describing a sector model service, mentions the disparity between the number of patients (4%) referred to the service with symptoms of delirium and the number of patients (22%) subsequently diagnosed with delirium by the psychiatrist. The concordance rates reported by Dilts, Jr. et al. (2003) (liaison multidisciplinary team) varied: concordance rates for identifying cognitive disorders was 100% accurate, whereas concordance rates for other disorders were less impressive. Folks and Ford (1985), reporting on a non-age discriminatory liaison psychiatrist service model, also described some data on psychiatric disorders unrecognised or misdiagnosed by the referring physicians that could be improved upon. There is some extensive data on concordance rates for all three studies, indicating that, although concordance rates were mostly high, there is still room for improvement. Clarke et al. (1995) examined the concordance rates for depression, calculating that the overall discordance for depression was 26%. Lastly, two studies describing sector model services (Loewenstein and Sharfstein (1983) and Perez and Silverman (1983)) also presented some data on concordance rates; concordance rates were comparatively low for these two studies. However, the validity of examining concordance rates as a measure of the effectiveness of a liaison service is an important, albeit low level indicator of effectiveness.

Lastly, some studies have also reported on the compliance rates with the psychiatrist’s recommendations; again, these compliance rates appear to be higher when a liaison service is in place. For example, Huyse et al. (1990b) specifically studied compliance rates with the psychiatrist’s recommendations in a liaison service, indicating that compliance rates were high for some psychosocial recommendations, but rates for others were low. Reasons for these differences remain unexamined. Nevertheless, these examples do hint that the educational activities performed by a liaison service have an effect in reducing the number of inappropriate referrals, teaching non-psychiatric staff about detecting psychiatric symptoms and about the management of such patients. Other factors that are clearly a beneficial result of liaison services include total time spent on consultation, number of follow-up visits, response times and lag-time between admission and referral. However, it must be stressed that these examples are only general, and we should not fully rely on these deductions, as they have been inferred from uncontrolled, descriptive studies.



2.5.5 Interventions

There are some deductions we can make regarding the service make-up and interventions provided by each service. Again, these are only general and subjective presumptions. As we have already seen, studies vary widely with respect to how much detail they provided about the service itself, and the service’s activities. However, we can deduce that, liaison services have a definite wider range of interventions on offer, as well as means of educating non-psychiatric staff about the manifestation of psychiatric disorders, whereas the sector model services offer nothing, or very little in the way of educating non-psychiatric staff. The liaison services often hold regular ward rounds to identify patients with mental health problems who would benefit from a psychiatric consultation, as well as meetings and discussions with the ward staff in order to develop their skills and aptitudes with regard to detecting psychiatric symptoms in their patients on the ward, in contrast to the sector model services. For example, the article by Kissane and Smith (1996), describing the set-up of a multidisciplinary consultation-liaison team in an oncology unit is particularly detailed in its account of the service, detailing several outputs of the service. This includes: daily ward visits; weekly multidisciplinary team meetings; attendance at other ward rounds, as well as other activities not described by other studies including: nursing and medical debriefings; psychosocial education input; bereavement outreach; supportive group therapy; undergraduate medical student teaching; postgraduate teaching and research. Moreover, Porello et al. (1995) describes a range of staffing in his shared care unit, including psychiatrists, internists, psychologists, occupational therapists, physical therapists, nurses and social workers. Furthermore, it would also appear (from subjective evidence) that liaison services follow-up referred patients appropriately, whereas it appears that when a sector model service is in place, the referred patients receives only one consultation or visit from the psychiatrist, with little scope for follow-up or liaising with and assisting the ward staff in implementing the recommendations. (see Hales et al. (1986).

In terms of the liaison activities performed by the services described in this review, Callaghan et al. (2001) was the only study to provide some data on the specific liaison, non-clinical activities carried out by their service, stating that they performed a wide range of liaison activities, including advice and information, support and teaching. Furthermore, two studies, by Shah and De (1998) and Tabet et al. (2005), specifically evaluated these educational interventions, and concluded that they were effective.

In addition to the studies describing services specifically for older people, numerous other studies (describing non-age discriminatory services) also indicated that older people made up a substantial proportion of their total referrals; these studies include Schuster (1992), Folks and Ford (1985), Ruskin (1985), Mainprize and Rodin (1987), O'Neill et al. (2003), Hengeveld et al. (1984), Trzepacz et al. (1985), Krakowski (1979) and Stoppe et al. (2004). With regards to the proportion of the total referrals constituting referrals from older patients, this varies from about 20% to over 50%, with the mean roughly between 25%-30%.

Although it is clearly encouraging that the general hospital staff are recognising mental illness in older patients and referring them for psychiatric consultation, given that it is known that mental illness is common in hospitalised older people, some studies have suggested that older people may not be referred for psychiatric consultation as frequently as they should be. Possible reasons for this disparity include staff attitudes towards older people, and particularly older people with mental illness, and lack of skills and knowledge to be able to



identify patients manifesting psychiatric symptoms. Nevertheless, this data indicates that, although progress is being made with respect to improving outcomes for co-morbidly ill older patients with the development of liaison mental health services for older people, there is still some improvement to be done. For example, the following studies all demonstrate that older people are referred for psychiatric consultation disproportionately less frequently than younger patients, or that the proportion of older people comprising the total referrals to the service is considerably less than the proportion of older people comprising the total admissions: Roulaux et al. (1993), Folks and Ford (1985), Kramer et al. (1979) (USA), Wallen et al. (1987), Rabins (1983) and Rosse et al. (1986). These studies comprise both liaison and non-liaison studies, and the comparison studies comparing referrals from older and younger patients have been particularly useful in studying this. Furthermore, a significant difference in rate of referral was noted between younger and older patients in Popkin et al. (1984). However, three studies do not fit into the pattern; Levitte and Thornby (1989) indicated a higher rate of referral for older people, whereas Juang et al. (2005) indicated a similar proportion of older admissions and older psychiatric referrals, and Perez et al. (1985) showed that the rate of referral for psychiatric consultation was similar in both age groups. These findings are more encouraging.

It is difficult to compare outcomes such as length of stay and lag times between descriptive studies on liaison and sector model services, as it is likely that individual conditions, probably differing between different studies and that have not been controlled for, would affect these outcomes. To illustrate, Roulaux et al. (1993), studying a sector model service for older people, describes some interesting data on discharge disposition. Of those referred patients admitted from home, there is a considerable decrease in those allowed to return home upon discharge, whereas conversely, a considerable increase is seen in the number of patients discharged to residential homes and psychiatric hospitals, compared to the number of patients who were admitted to hospital from these types of facilities. This data may initially suggest that this sector model service is ineffective at improving disposition at discharge; however, this information does not take into consideration other factors that may affect these data, such as the observation that the referred patients are older, and suffer from comorbid illnesses.


No economic analyses were identified which directly related to addressing older inpatients admitted to medical or surgical wards and receiving a liaison psychiatric intervention. In addition, a number of factors may make it difficult to interpret existing or newly emerging evidence that could be interpreted as relevant for our purposes. The content and delivery of liaison services varies considerably across and within settings; patients are heterogeneous with respect to prognosis and resource use. Thus a randomised controlled design is necessary to achieve reliable attribution of the effects of liaison services. Most research has not included randomisation, is now quite old (conducted in the 1980s and early 1990s) and was conducted in the US setting where there is less distinction between working age and older people services. The balance of psychiatric problems encountered is different in working age and older patients admitted to general wards, the former focuses on addiction, substance abuse and self harm, the latter focuses on dementia, delirium and depression. Additionally patient lengths of stay, although dependent on the reason for admission, tend to be different when comparing working age admissions (of the order of several days) and older age admissions (of the order of 15-35 days).



In the British setting, a further potential concern is that the scope to show change in length of stay may be confounded by hospital conventions of discharge or by ‘bed-blocking’ where delays occur finding a suitable discharge destination for patients with ongoing physical and mental health needs.

On another level, the unit costs applied to resources used in a different countries and hospital contexts is of limited value and it is more informative to assess changes in the use of resources themselves, such as length of stay. If resource savings from research are thought to be relevant to, and achievable in particular NHS contexts then these can be costed for the NHS using its own national tariffs and costs. Considerable research has addressed whether liaison psychiatric services lead to a cost offset. Research designs have been inadequate for this task since patients are highly heterogeneous within studies and settings and services are heterogeneous between studies. Thus confounding factors both within and between studies are considerable.

A consistent mindset when studying the cost of liaison services has been the desire for cost-offsetting that goes as far as to cancel altogether the cost of liaison service intervention i.e. a cost-neutral outcome. This might, in part, reflect difficulties finding suitable health outcomes, which might demonstrate worthwhile change. However, if liaison psychiatric interventions are addressing genuine clinical need these may legitimately extend (not reduce) hospital resource use (at least during the index admission), and the key issue is one of measurable psychological outcomes and patient quality of life not just of cost-offsetting.

The study by Strain (1991) indicated significant reductions in hospital costs, whereas the study by Hosaka (1999) indicated that the liaison service brought in more medical reimbursements, in addition to a steady increase in the number of referrals to the service for psychiatric consultation. Slaets (1997) also briefly describes the economics, suggesting that a liaison service has the potential to be cost-effective, whereas Schuster (1992) details the economics of their service, concluding that the reimbursements and revenue brought in from the psychiatric consultations performed means that the service is economically viable. Overall, very few studies identified in this review, apart from the four mentioned here, discuss their services with respect to cost-effectiveness.

2.5.7 Summary

We already know (albeit from anecdotal evidence) that liaison services are efficient/effective in improving quality of patient care. However, evaluative studies are unable to reliably demonstrate this, and in instances where this has been attempted, we do not know whether poor quality design exaggerates or dilutes the impact of an intervention. One of the main difficulties is the nature of designing trials for complex interventions such as liaison psychiatry. It is clear that many of the evaluative studies discussed here have methodological flaws that dilute the impact of the intervention being investigated, in particular the use of randomisation methods at the level of the individual patient. It is likely that there has been some contamination (hospital staff would not be able to just “forget” the knowledge gained from the liaison psychiatrist, and not utilise this knowledge when faced with a patient who is in the control group). These trials are setting themselves up for inconclusive results. A multi-site, cluster-randomised trial coupled with formal economic analysis appears to be the best design to evaluate liaison mental health services further. The evidence to date does provide us with a comprehensive list of important variables to consider and factor into any evaluation of effectiveness, summarised in Table 5.



Table 5. Outcomes, methods of measurement and confounding factors

Outcome Outcome measures used Examples of studies

Patient demographics Mean age, proportion male/female

All evaluative studies

Psychiatric morbidity - depression

Geriatric Depression Scale Hamilton Depression Rating Scale ICD-10 defined depressive disorder Beck Depression Inventory

Cole et al (1991); Baldwin et al (2004); Slaets et al (1997); Strain et al (1991) Cole et al (2006); Shah et al (2001) Cullum et al (2004) Camus et al (2003)

Psychiatric morbidity - cognitive

Mini-Mental State Examination Abbreviated Mental Test Score

Cole et al (2006); Levenson et al (1992); Shah et al (2001); Strain et al (1991) Cullum et al (2004)

Psychiatric morbidity - anxiety Anxiety Status Inventory Spielberger State-Trait Anxiety Inventory

Strain et al (1991)

Psychiatric morbidity – alcohol use

CAGE Questionnaire Alcohol Use Disorder Identification Test

Cole et al (2006); Shah et al (2001) Kominski et al (2001)

Psychiatric morbidity - general DSM-III Short Portable Mental Status Questionnaire Crichton Geriatric Behavioural Rating Scale

Cole et al (1991) Cole et al (1991) Cole et al (1991)

Functional / health status Severity-of-illness score Charlson Co-morbidity Index Diagnostic Interview Schedule Cumulative Illness Rating Scale-Geriatric SF-36 Hopkins Symptom Checklist General Health Questionnaire Singh Index of Bone Density Arthritis Impact Measurement Scale

Cole et al (2006) Cole et al (2006); Shah et al (2001) Cole et al (2006) Cullum et al (2004) Shah et al (2001) Kominski et al (2001) Levenson et al (1992) Camus et al (2003) Strain et al (1991) Strain et al (1991)

Length of Stay N/A Cole et al (1991); Baldwin et al (2004); Camus et al (2003); Levitan et al (1981); Strain et al (1991)

Readmissions Readmissions at 3 months Baldwin et al (2004)

Mortality Death at 3 months Not specified

Baldwin et al (2004) Cole et al (2006)

Discharge disposition N/A Cole et al (1991); Levitan et al (1981); Strain et al (1991)

Compliance with recommendations

N/A Cole et al (1991)

Antidepressant use N/A Cole et al (2006)

Suicide and suicide attempts N/A Cole et al (2006)

Health services utilisation Not specified Cole et al (2006)

Quality of Life EuroQol Quality Adjusted Life Weeks

Cullum et al (2004) Cullum et al (2004)

Level of disability ADL SIVIS Dependency Scales

Cullum et al (2004); Slaets et al (1997) Slaets et al (1997)



3 Phase 2: Service mapping

3.1 Method

3.1.1 Brief survey

Design

The survey is shown in Appendix 11. All identified participants (described below) were sent either a postal survey or emailed the survey where this address was available. This work commenced in May 2006 until August 2006. Respondents were asked to provide information on:

1. The general hospitals within each acute trust for which they provided a psychiatric service for older people to.

2. The type(s) of psychiatric services model(s) in use for older people in general hospitals. Respondents were asked to indicate the service models currently in use for their sector from a list of seven models described in the survey (taken from previously typologies identified (Holmes et al. 2002; Royal College of 2005) or to describe their model separately if different to those typologies given. The list of potential service models are shown in Table 6.

Table 6. Potential service models described in the survey

Model Description

Traditional sector model (TSM)

Psychiatric service is provided by psychiatric medical staff from the Community Mental Health Teams (CMHTs)

Enhanced sector model (ESM)

Psychiatric service is provided by psychiatric medical staff, working in the CMHTs, with additional dedicated time from other CMHT professionals

Outreach from mental health wards (OMHW)

Psychiatric nurses based on psychiatric wards provide the input, referring on where necessary

Liaison psychiatry nurse (LPN)

Psychiatric service is provided through dedicated sessions from liaison psychiatric nurse/s based in the general hospital; possibly working across a number of sectors, referring on as necessary to the CMHTs

Liaison psychiatry medical team (LPMT)

Psychiatric service is provided through dedicated sessions from a consultant Psychiatrist and other psychiatric medical staff based in the general hospital, working across sectors

Hospital mental health team (HMHT)

Dedicated multi-professional team based within the general hospital provide the psychiatric service, working across sectors

Shared care (SC)

Psychiatric service is provided in a dedicated ward within the general hospital, covering a number of sectors; staffed jointly by psychiatric nurses, general nurses, psychiatrists and physicians

Other Services not covered above, e.g. clinical or health psychology, occupational therapy

3. Any changes to the way in which the service is delivered within the last 3 years

4. Any planned changes to the way in which the service will be delivered in the future



5. Respondents were also invited to provide any further comments on the service provision for older people in general hospital settings.

Sample

In order to identify specialist services operating within general hospital settings, a comprehensive list of acute hospital trusts was drawn up using electronic and paper-based resources including Binley's online (www.binleys.com), Specialist info (www.specialistinfo.com) and various NHS website data. Different services are often found at different hospital sites within the same acute trusts; hence all general hospitals within trust catchment areas were identified using the same information systems. This did necessitate personal communication with some hospitals as the nature of their current services was not always clear. The primary focus was on general hospitals with acute admissions for people with medical and/or surgical needs. Table 7 shows exclusion criteria that were applied to hospital types.

Table 7. Exclusion criteria for hospital type

PCT/GP run

Rehabilitation or intermediate care site

Specialist hospital (i.e.: orthopaedics, dental, eye, psychiatric)

Day hospital

Out-patient only service

Specialist elderly hospital

This allowed us to map services per hospital of interest and therefore provide a comprehensive picture of the majority of services currently in place for older people admitted to general hospital either as an emergency or for elective procedures.

Participants

A comprehensive list of all Old Age Psychiatrists identified through Specialist info.com was compiled. The work place of these clinicians was matched to either the acute trust of the hospital(s) of interest, or to the mental health trust providing services for the neighbouring acute trust population. This helped to ensure that all acute trusts and/or hospitals of interest were surveyed. In instances where several Old Age Psychiatrists were identified as working within the same hospital, key personnel who had responded to the previous service mapping exercise conducted in 2002, and who had established contacts either through an annual conference on liaison mental health services for older people (established in 2002 and organised by the study principal investigator), or with the research team, were sent the survey initially. In the event that a response had not been received from an identified hospital within a period of four weeks (allowing for summer holiday period), follow-up telephone calls to the identified clinicians were made. If this did not yield a response, any other mental health clinicians known to have a connection with hospitals from where no response had been received were sent the survey. These were also followed up with



phone calls within two weeks of sending the questionnaire. The survey was also administered at the Liaison Psychiatry for Older People conference in May 2006.

The methods mentioned above produced information on approximately 50% of the hospitals identified. Further work included sending the questionnaire to the following:

1. All Mental Health Leads within each acute trust or health board for Scotland, Wales and Northern Ireland from where no response had been received (number = 39)

2. Members of the Faculty of Old Age Psychiatrists from where no response had been received (number = 84)

3. Members of the British Geriatric Society (BGS) who were located within trusts where no response had been received (number = 194) were also surveyed to ask who they contact for referrals, as well as the opportunity to comment on the current service provision for older people with mental health needs (see appendix 12 for survey and covering letter). The brief survey was also sent to Geriatricians with a request to forward this to key clinicians they referred to for psychiatric input.

3.1.2 Extended survey

Design

This survey is shown in appendix 13. The final survey consisted of four sections which were designed to collect both qualitative and quantitative data. This survey was drafted in consultation with five professionals, typical of target respondents (i.e.: three consultants in old age psychiatry, one nurse consultant and one liaison mental health nurse). This allowed us to test for ambiguity of questions, ease of completion and for general feedback on the content and design of the survey. Participants for this questionnaire were identified through the survey described in section 3.1. The majority of these surveys were posted out within three working days and an incentive to return the survey within three weeks was given (opportunity to win Amazon voucher). This work commenced in August 2006 until September 2006. The covering letter also gave participants the opportunity to download the survey from the project website, and to contact investigators for further information. A follow-up telephone call was made to all non-respondents two weeks after the survey had been posted out in an attempt to increase the response rate. In the follow-up period, surveys were also emailed to recipients where this address was available.

3.2 Response rates Numbers of responses to the two surveys are shown in Table 8.



Table 8. Response rates to the two service mapping surveys

Survey Number sent

Recipient Number responded

Response rate %

468 Mental Health clinicians 341 73

194 Geriatricians registered with BGS 33 17

Brief

662 TOTAL 374 56

165 Key clinicians identified through brief survey 82 50

39 Mental Health leads of non-response services 0 0

Extended

84 Clinical leads of non-response services 0 0

288 TOTAL 82 28

3.2.1 Brief survey

Between May and August 2006, 662 surveys were distributed to clinicians identified as described in section 3.1. Of these surveys, 7 were returned with no details and 3 were returned marked as no longer practicing. 374 surveys were returned completed (56%). This yielded brief information on service models for 232 (76%) of general hospitals within the UK.

3.2.2 Extended survey

Throughout August and September 2006, 165 extended surveys were sent to key clinicians identified from the brief survey, covering 232 (76%) of hospitals across the UK (a proportion of the clinicians surveyed covered more than 1 hospital). 82 completed surveys were returned (50%); a further 2 were returned with insufficient information contained within them. None of the mental health leads or clinical leads surveyed responded. This yielded comprehensive information on 80 (34%) of the 232 hospitals concerned, a total of 25% of the 314 hospitals identified within the UK. In order to understand the nature of this low response rate, 20 clinicians were selected at random from the list of those that had not responded. These clinicians received a telephone call from a member of the research team and were asked to discuss their views on completing the survey. Responses given are summarised in Table 9.

Table 9. Range of responses from recipients on non-completion/return

of survey

Response Number

Do not have enough time to complete it 8

Do not have ready access to the information required 4

Haven’t received it, will download from website 2

Returned it 1

Will have another look at and feedback in due course 3

Do not provide an age-specific service 2

3.3 Service models in the UK The following section describes findings from respondents to both our surveys which incorporate information on 76% of services currently operating in the UK.



3.3.1 Current service model

Identification

Respondents were asked to describe their model of service through the seven typologies shown in the previous section, or to describe their service if it wasn’t typical of these models. In most cases, respondents felt that their service was adequately described by the models listed. In instances where the model was not so clear, further clarification was sought from the respondent through follow-up telephone calls, which resulted in the model being described as one of the previously identified typologies, or categorised as ‘other’. Table 10 shows other described models, all of which show a configuration linked to the original service typologies.

Table 10. Other service models described by respondents

Service typology Additional service Number

shared care ward 1

accelerated discharge dementia team 1

dementia discharge co-ordinator 1

dedicated discharge team 2

Traditional sector

outreach from mental health wards 1

for discharge arrangements only 1

shared care ward 3

Occupational Therapist and shared care ward 1

Liaison Psychiatric Nurse

Clinical Psychologist 1

Liaison Psychiatry Medical Team Dementia care Nurse 1

Hospital Mental Health Team shared care ward 1

In some instances, several responses were received from the same hospital which did not always demonstrate inter-rater reliability. Whilst every attempt was made to speak to a key clinician within the hospital in these circumstances in order to clarify the model, where this was not possible the response from the clinician deemed to have organisational responsibility for patient caseloads was taken as that hospitals’ model. These were agreed through consultation with three key members of the research team.

Royal College of Psychiatrists' guidelines

Guidelines on the number of dedicated sessions required to provide a service, which is dependent on hospital size have been published in the Raising Standards report. This framework was used to determine the existence of typical service models. In instances where respondents reported a liaison psychiatric medical team model but described medical staff providing fewer than three dedicated sessions per week in a large hospital (500 bedded +), or less than two sessions a week in a moderate sized hospital (300-500 beds), this was deemed as insufficient to be able to provide a dedicated liaison psychiatric medical team service and were re-categorised as traditional sector models. Similar re-categorisation was used in instances where an insufficient liaison psychiatry nursing service was reported. Some respondents indicated that they had a dedicated liaison psychiatry nurse and a dedicated liaison psychiatric medical team. In these cases, where there was evidence of a multi-professional approach, the service was categorised as a hospital mental health team.



Prevalence of different models

Figure 1 shows the current service models reported by respondents.

Figure 1. The range and number of current psychiatric service models for

older people in general hospitals

A total of 232 services are described. The traditional sector model was most predominant: 82 (35%) of surveyed hospitals, but only slightly more than the liaison psychiatric nurse model: 69 (30%). 14 services (6%) were reported as using two models concurrently.

3.3.2 Changes in service models Matched-pairs analysis of our survey conducted in 2002 enabled comparison, and therefore identification of changes to service models over the past four years. Figure 2 shows shifts in configuration during this period of time. nb: hospitals matched from both surveys = 210

Figure 2. Service delivery models in 2002 and 2006

0

10

20

30

40

50

60

70

80

90

Traditional-sector

Enhanced-sector

Outreach MH wards

Liaison Psychiatric

Nurse

Liaison Psychiatric

Medical Team

Hospital Mental Health Team

Shared Care Other

Num

ber o

f hos

pita

ls

Service model

0102030405060708090

100110120130

Traditional-sector

Enhanced-sector

Outreach MH wards

Liaison Psychiatric

Nurse

Liaison Psychiatric

Medical Team

Hospital Mental Health

Team

Shared Care Other

Num

ber o

f hos

pita

lss

Service model

2002

2006



The prevalence of the different service configurations shows a marked development, with a shift away from medical based sector services to more specialised services, in particular, liaison nurse based delivery. This is a remarkable development, in spite of the lack of strategic planning and policy driven initiatives which would be expected to drive such changes at that time. However, it still remains that huge gaps exist between that which is available and that which is deemed necessary to meet needs by clinicians. None of the services we have had contact with meet the minimum requirements set out in the raising standards report.

We felt it was important to look at the increase in ‘other’ models, which are described in Table 6. Frequently, these ‘other’ services are a development on the traditional sector or liaison nurse model with additional dedicated time and staffing being provided for condition specific patients, those with dementia. Whilst this will likely improve the care for this group of patients, who have obviously been recognised as having enhanced need, it is not yet known whether this resource allocation depletes the service offered to other sub groups of patients. In addition, these are generally short-term funded projects without longevity and are clearly the result of personal interests of key clinicians.

3.3.3 Preferred service models

Figure 3 shows the pattern between respondents’ current and preferred method of service organisation. It indicates that although services have progressed towards specialisation, the majority of services require shifts which quite often indicate a need to increase staffing levels.

Figure 3. Current and preferred models of service delivery in the UK

0

10

20

30

40

50

60

70

80

90

100

110

120

130

Traditional sector

Enhanced sector

Outreach MH wards

Liaison Psychiatric

Nurse

Liaison Psychiatric

Medical Team

Hospital Mental Health Team

Shared Care Other

Num

ber o

f hos

pita

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Service model

current

preferred



Although the most widely used service delivery model is traditional sector and liaison nurse, there is a remarkable preference for a multidisciplinary team based within the general hospital (99 hospitals, 51%), or, at least, an increase in dedicated liaison staffing and activity (191 hospitals, 92%). Other methods of preferred service delivery are shown in table 11.

Table 11. Other preferred service models

Interestingly, there was no preference for condition specific services which suggests that although there is no hard evidence on their effectiveness, there is a local recognition that this service is not adequate to meet the needs of the population it was designed to serve. A selection of typical respondent’s comments on their preferred service model are shown in Table 12.

Table 12. Respondents comments on preferred service model

‘we need expansion of the clinical team to include social workers, psychologists and

occupational therapists’ (032)

‘we need a full-time Doctor working in conjunction with the nurses to provide a more efficient

service, with a more rapid and seamless management’ (065)

‘having dedicated consultant time to support the liaison nurse has avoided duplication of

work’ (004)

Responses indicate that those services that have developed liaison models recognise that individual professional groups (either nurse or medical led) are not in a position to provide the most effective service, and highlights that developed liaison services recognise the need for increased staffing activity to a greater extent than less developed services. This suggests that direct experience with different service configurations possibly influences the recognition that a multi disciplinary approach is best suited to meet need in the majority of general hospitals surveyed.

One respondent did feel that traditional sector services may be sufficient for the population within their specific catchment areas. Comments from this respondent included ‘small population, model is sufficient for catchment area’. It is possible therefore that of those 26% of hospitals where no response was received, clinicians felt that their service was also adequate for the needs of the population covered. However, the lack of engagement with research after several attempts forewarns of an inability to contribute towards development, hence these services could actually be less effective than those we are currently reporting on.

Service typology Number

Liaison Psychiatric Nurse and Shared Care Ward 4

Liaison Psychiatric Nurse and Clinical Psychologist 1

Liaison Psychiatric Medical Team and Shared Care Ward 2

Hospital Mental Health Team and Shared Care Ward 8



Sixty-nine (84%) of responses to the extended survey provided comments on their reasons for choosing different preferred models to those currently in operation. Ninety-six percent of these respondents preferred an increase in staffing skill mix from their current service provision. Typical reasons for choice of preferred model are shown in table 13.

Table 13. Respondents reasons for choice of preferred service model

‘Split site provision – mental health unit and acute hospital not based on same site and often

involving extensive travelling’ (012)

‘Increases chances of co-ordinating training of acute trust staff’ (014)

‘Teams work better than single professional groups’ (022)

‘Avoids staff having to divide loyalties and priorities’ (002)

‘Dedicated staff meets the needs of our hospital population’ (041)

‘Reduces strong medical hierarchy in patient care’ (012)

‘Improves relationships and develops expertise within the acute hospital’ (015)

Responses demonstrate that the majority of clinicians identify a need to be integrated within general hospital settings, thereby removing physical and psychological barriers to providing effective care.

3.3.4 Service characteristics

Service accommodation

Few established liaison services reported access to accommodation within the general hospital site. (17%, n=82). Thirty respondents provided further comments on accommodation. The majority of these revealed that access to computers and phones were limited, and space to accommodate all the staff involved in the delivery of the service was sparse, suggesting that the means from which to deliver a service effectively is severely compromised by available accommodation for specialist services. However, this situation does appear to be a vast improvement on the services being provided in 2002, where virtually no liaison services had suitable accommodation within the general hospital setting. Typical comments from the current survey are shown in Table 14.



Table 14. Respondents comments on service accommodation

‘Very basic – no windows, no natural light’ (012)

‘We are very disparate – I am in one building with a secretary on a different floor, and a

liaison nurse in a different building and site’ (051)

‘Normal accommodation for our service. We are based 5-10 minutes walk from the general

hospital – this is new and a great benefit’ (052)

‘no dedicated space – team meetings held in consultant’s office – no dedicated computer or

phone line’ (014)

Funding and management arrangements

Funding for services is in itself thwarted with political and bureaucratic impediments, evidenced by the lack of engagement with responsibility for services being taken by acute trusts. Over half of the services in our survey are managed solely by acute trusts (53%), with 23% of these being specialist services. The majority of specialist services (65%) are managed solely by mental health trusts. All services in our survey are funded through mental health trusts and/or primary care trusts. Only two specialist services reported additional secured funding through social services. This suggests a lack of ownership of services and blurred lines of responsibility for management and therefore funding. In a climate where demands are made on services that are stretched and often desperate, it is hardly surprising that clinicians cannot or in some cases choose not to negotiate this bureaucratic minefield. Typical comments are shown in Table 15.

Table 15. Respondents comments on funding and management

arrangements

‘The challenge is getting the acute trust to own and develop the service.’(056)

‘No-one accepts responsibility for the services’(065)

‘No clear responsibility taken for service delivery’(002)

‘Our service is not managed by anyone’(042)

3.3.5 Drivers to development

Service delivery organisation

Respondents reported on what factors had led to the development and adoption of their current service model. The majority of developments were attributed to key reports and service development guides designed to help prepare business cases for proposed funding, (81%, 73 responses). Of those services that had a level of specialism (number = 50), almost all had developed out of personal interest of clinicians concerned in the delivery of the service, (87%). Only 28% of services reported development through pilot studies or audits of



local needs. Similarly, only 18% of all respondents reported definite plans to change the model in the future. These planned changes were all concerned with securing funding to increase or maintain the current level of specialist liaison service. Thirty percent of these changes were driven by the results of pilots and/or audits. Typical reasons for developments are shown in Table 16.

Table 16. Respondents comments on reasons for development

‘the need to respond to acute hospital demands and requests’

‘the need to reduce bed blocking on medical wards’

‘dissatisfaction with sector-based model, knew we were missing cases’

‘reduction in funding has led us to reduce the service dramatically, from 400 assessments a

year to 20-50 assessments a year’

Responses demonstrate that development is not spearheaded by directives. The production of clear guidelines on what is required and how to put this into action, coupled with a willingness to engage in the subject are the main reasons for movements towards more effective services. However, this is systematically blocked through several impediments. Respondents reported on what factors they felt were impeding change, although there is evidence that several respondents are satisfied with the way in which their service is organised. Satisfaction tends to be centred on services that deem that they are responding to local needs. Typical responses are shown in Table 17.

Table 17. Respondents comments on factors impeding change

‘Current trust in process of reorganisation, unsure if service will continue’

‘I am appalled by the short sightedness of our managers. The service provided by the liaison nurse is excellent, and they have done invaluable work in education and support for their general nursing colleagues. Without a liaison nurse I will find the whole job of liaison much more difficult and stressful, and I do not have the nursing experience to advise as well on behavioural issues.’

‘Probably lack of a champion for change. We have other service developments we’re more interested in. Also no-one from the acute trust will come to our wards without a paid contract except for medical staff, so our managers are not keen for us to increase unfunded input and the acute trust don’t want to pay anything. So the medical staff on both sides have a bad system.’

‘Lack of funding and lack of clarity on government targets. Review of business plan to access funding from PCT.’

‘There is no additional funding likely at present, therefore we have had to “re-jig” existing resources’

‘Lack of funds. Large geographical area. Staff burnout’

‘Need resources. All resources are directed to the adult psychiatry and old age services are neglected’

‘Nil – we are happy with the service’

Research priorities

Respondents were asked to indicate what they considered to be important considerations for future research to assist in the provision of quality care for



this group of patients. The general consensus about cost effectiveness of services is demonstrated in Table 18.

Table 18. Respondents comments on research priorities

Cost-effectiveness needs to better known. The epidemiology of mental illness on medical wards is not sufficiently persuasive.

Benefits of delivering care to separate groups i.e. clients with dementia and depression What prompts admission? And has it been avoided? What happens to individuals on discharge? Admission Avoidance Schemes

Detection and treatment of delirium Detection and treatment of depression Quality of life Education of medical staff on mental health problems Nutrition of medically ill and relation to mental health problems

Unnecessary admission – how can this be prevented Auditing the type of referrals received A review of medical SHOs opinions on delirium in the older patient – whose responsibility? Do they regard delirium as a medical or psychiatric problem? How much time do they think an elderly person with delirium should be given to recover, before assuming they will need residential care

Standardised assessment tools for delirium – the majority of our referrals are delirium though often with an underlying dementia.

Use of antipsychotics Outcome of shared care wards Nutritional needs patients with dementia Educational needs of staff

Establishing outcome data to show effectiveness of liaison teams Given “needs-based” policies rather than “age-based” policies, exploring ways of working more closely with “working age” liaison services (where they exist) or considering a joint service where they don’t.

Low

1 Does depression in medical illness resolve spontaneously 2 If not, is psychiatric intervention effective?

High

Role/effect of nurse vs. medic in liaison

Much more work on joint medical/psychiatric units – benefits, costs, design of ward.

Delirium – prevention, treatment and management How to effectively teach/train and impact positively on care by general hospital staff Effectiveness of brief interventions in patients with depression, mood disorders Psychology service input with conditions/chronic illnesses – nature of interventions required

3.3.6 Staff skill mix

Levels

Recommended minimum weekly staffing requirements for a moderate sized general hospital (300-500 beds and large hospital 500-1000 beds) are shown in Table 19. (Source: Raising the Standard Royal College of Psychiatrists, 2006).



Table 19. Minimum weekly staffing level recommendations

Professional Number of hours 300 – 500 beds

Number of hours 500 – 1000 beds

Registered Mental Health Nurses 75 112.5

Senior Occupational Therapist 37.5 75

Social Workers 56 94

Support Worker or OT Technical Instructor 37.5 75

Consultant Old Age Psychiatry 8 12

Clinical Psychology 4 8

Medical Secretary 37.5 37.5

Administration secretarial support 0 37.5

The relationship between recommended levels and actual levels found in our service mapping exercise are shown in Figure 4.

Figure 4. Service model staff complement and percentage of dedicated

time meeting minimum requirements

Figure 4 shows the percentage of different service models staffing levels that meet the required minimum, controlling for size of hospitals concerned. It is possible to see from this that none of the liaison models reported meet the required standard of combined staffing levels. Whereas some services do have the minimum required staffing, and indeed exceed this for particular professions, none of the services in our survey match the staffing level required within different sized hospitals. In certain hospitals, two HMHTs have additional Consultant input. However, professional skill mix is well below that required, with some professionals (i.e. clinical psychology) having no input into the team. At the same time, the two services operating atypical models are generally clinical psychology led, with very little psychiatry input. None of the models are anywhere near meeting requirements for occupational therapy and social work,

0 20 40 60 80 100 120 140 160 180 200 220

Consultant

Mental Health Nurse

Support Workers

Clinical Psychology

OT

Social Work

Admin support

Pro

fess

iona

ls

% of recommended staff hours

Other

HMHT

LPMT

LPN



which is typically less than 10%. Similar findings are reported in the amount of dedicated administration support that services have available ranging from between 5 and 50%.

On another level, liaison model services do not have the same configuration with some services having considerably less or more than indicated above. Liaison Nurse based services range from having one band 7 nurse for the entire service, to 6 band 7 nurses with additional dedicated hours from Old Age Psychiatric Consultants. Liaison Psychiatric Medical teams can range from as little as 3 hours dedicated Consultant time supported by 2 hours Senior House Officer time, to 2 Specialist Registrars. Similarly, hospital mental health teams can range from 1 band 7 nurse with dedicated support from Senior House Officers to 2 Consultants, 1 Specialist Registrar, 3 band 6 nurses or 2 band 7 nurses and 3 support workers. None of the services reported here had medical secretary input although it is not clear if this was seen as the equivalent of secretarial/administrative support. Nevertheless, this also falls far short of that which is required.

Specialist training

If liaison services are to function effectively and develop they need adequately trained clinicians with clear lines of management by line managers who have an understanding of the nature of liaison work and the special aspects of providing mental health services in the general hospital environment. The clinical problems and their resolution are not the same as community or ward-based mental health services and the priorities and demands for liaison teams are not the same in the community or mental healthcare settings. Specific training is required to ensure that service leads have a sense of the priorities of the service. However, very few respondents have undertaken any formal training. This is an undeveloped need and has led to an over reliance on networking and informal training events. This runs the risk of not being prioritised as they are often structured as voluntary events and in a hard pressed service, clinical need should take precedence. Thirty two respondents from our service mapping survey provided comments on training undertaken in liaison psychiatry for older people. Typical comments are shown in Table 20.

Table 20. Respondents comments on specialist training

‘No specific training’

‘Attending Leeds liaison conference’

‘attending College Liaison meeting and European Liaison conference’

‘Regional one day liaison meetings’

‘SHO’s are trained through Consultant power point presentation’

‘None done formally’

This suggests that the 10 essential shared capabilities in pre and post registration education and training for all mental health staff are far from being reached. When asked what training priorities should be, respondents typically responded with: ‘liaison psychiatry; services available in locality; risk assessment and management; nurse prescribing course; effects of physical illness on mental health; audit; presentations; clinical skills; requires generic and specific skills which requires specific training.’



3.3.7 Staff activity

One of the primary functions of a liaison team is to improve the detection and management of common mental health problems in general hospital settings. One obvious way of achieving this is to ensure that teaching and training in assessment and management is delivered in an effective and acceptable manner to general hospital staff. Another primary function of any service is its contribution to the body of evidence for its effectiveness through research and audit. However, this will likely only be achieved if effective administration procedures are in place to manage caseload data. Figure 5 shows the average amount of time professionals providing the service can dedicate to its different activities across a typical working week.

Figure 5. Dedicated time spent engaged in different service activities

Of those that have administrative support, only one service (HMHT) reported that 5% of their time is spent in audit and research activity. Other specific staff activity undertaken on a regular basis includes, Dementia Care Mapping, supervision of junior colleagues, attending meetings aimed at securing funding for liaison services, interfacing with service users and carers. However, the amount of time and services dedicating time to these invaluable activities was miniscule.

3.3.8 Service activity

Several factors will affect the effectiveness of a service. Most important of these are level of staffing and staffing skill mix, the number of referrals received, how responsive the services are to these demands, and what impact the service has on follow up for patients referred into the service. This section discusses the findings of our survey in relation to service activity.

Referral rates

In order to understand the workload of services for older people with mental health problems in general hospital settings, respondents were asked to approximate how many referrals their service had received within the last year

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ESM LPN LPMT HMHT Other

other

audit

admin

research

teaching

clinical



from general hospital settings, and what proportion of the total number of referrals their service receives that this figure represents. This would allow for analysis of the level of service activity being undertaken by different models of service delivery.

Sixty respondents completed data on their service activities. Whilst this is a small proportion of those services currently operating, it does provide some insights into the capabilities of different service models to respond to service demands.

The traditional sector model tended to have the lowest number of referrals (median=201, 24 responses) and the enhanced sector model (median=104, 3 responses). This comprised 25% of total referrals received over the last year. A similar finding was reported in ‘between two stools’, indicating that this type of service delivery has not undergone any significant changes in its ability to respond to service demands from general hospital settings, or the ability of general hospital staff to recognise the need for specialist intervention and refer accordingly. The magnitude of referrals tends to increase incrementally with level of service specialisation, and is certainly higher than undeveloped services, providing valuable evidence for the need and utilisation of these services. This can be seen in Figure 6 which shows the average number of referrals per model.

Figure 6. Median number of referrals over previous 12 months

The number of referrals from general hospital wards to specialist services comprises between 50-100% of all referrals to the services over the last year. This demonstrates that some developed services continue to provide a service to care facilities other than the general hospital. The low number of responses per service delivery model to this item renders any further statistical analysis fruitless, and so it is difficult to determine whether those services receiving referrals from other sources have been organised to meet local needs, or whether community resources do not exist as an alternative referral point. The conflict between doing what has to be done, and doing what needs to be done is not likely to be reduced drastically with the current service provision levels. An analysis of referral rates over the last three years is shown in Table 21. This shows an increase in 75% of services. Only one reported a decrease due to severe staff shortages. A similar report was made in the service mapping undertaken in 2002 where 69% of respondents described an increase in referral rates.

0

100

200

300

400

500

600

LPN LPMT HMHT other

Service model

med

ian

num

ber o

f ref

erra

ls



Table 21. Referral rates over the last 3 years

model responses increased % increased same % same decreased % decreased

TSM 22 15 68 6 27 1 5

ESM 5 5 100 0 0 0 0

LPN 10 9 90 1 10 0 0

LPMT 7 7 100 0 22 0 0

HMHT 16 14 88 2 12 0 0

Other 2 2 100 0 0 0 0

It is possible to see that with the number of referrals generally increasing, there does not tend to be the typical pattern of a waning off period in which referral rates stabilise. This suggests that urgent action is needed to ensure that services with none or very few dedicated hours and staff are supported in meeting the demand. If the demand cannot be met, not only are these patients not receiving an adequate service, but it will also increase the pressure on the already stretched community and hospital services.

Response to referrals

There is little evidence to suggest that of those services receiving referrals from both community and general hospital settings that referrals are prioritised differently. (72% of respondents who received referrals from both hospital and community settings said that each were given equal priority, number = 30). Traditional sector models prioritised community referrals in 18% of services, whereas specialist services prioritised general hospital referrals in 10% of services. The report in 2002 did find a significant bias towards community based referrals for traditional sector services, whereas this remapping does not. Nevertheless, the current response rates are much lower and must be interpreted with caution.

The tendency for traditional sector services to be a first point of contact with primary care services is clear. However, both types of models share referrals from intermediate and secondary care services which suggests that referral criteria may cause some confusion over who and where to refer to in and between different hospitals, and indeed once a patient is discharged from hospital. The traditional sector model not only has to attend to referrals as a first point of contact, but must be able to respond at any point along a patients’ care pathway, within and between institutional and community care. It is possible to see from this that such a workload makes demands on the service that may lead to patients being missed to follow-up, especially when they are already in hospital.

On another level, it has not been possible to explore the relationship between referral rates and size of catchment areas covered. Respondents were asked to include details of all institutions that they provided services to (including community hospitals and intermediate care facilities). However, responses to this were not consistent, which is likely a result of ambiguous wording of the survey. At the same time, there is evidence that liaison services are developing specifically for acute hospitals in some instances, whilst other services tend to receive referrals from any establishment that may accept transfers from the acute general hospital, suggesting some continuity. However, demonstrable effective management of mental health needs should be seen in its detection earlier in a patients care pathway (i.e. during their acute hospital admission) hence the majority of referrals should be generated at this stage.



No important differences were found between different models ability to respond to urgent referrals. All service model types report that they can respond to urgent referrals within two working days of receipt, although there is a tendency for specialist models to have a quicker response rate than this, either within four hours or the same day (83%).

This finding may influence service development as predominant guidelines emphasise speed of response of services. If no demonstrable difference is shown between models, there may be a tendency to conclude that the service is suffice to meet needs. However, a response from a service does not tell us anything about the impact the service has on the outcomes for the patient, or indeed whether it has any impact on outcomes.

Patient review capacity

Respondents were asked to indicate what percentages of assessed patients were reviewed. For some patients, such as those with a resolving delirium or a depressive adjustment disorder, review whilst still in hospital allows monitoring of response to the management plan and the provision of ongoing advice to colleagues. Figure 7 shows what percentages of patients are reviewed on the general hospital ward or post discharge by different service models. Other typical reviews include psychiatric outpatient clinics, memory services/clinic and reviews by Community Mental Health Teams.

Figure 7. Reviews undertaken for referred patients by different service

models

Source of referrals

Sources of referrals other than general hospital wards are reportedly similar in undeveloped and developed services, with the exception of one respondent who highlights that the services should be primarily focused on the general hospital setting. This is shown in Table 22.

0 20 40 60 80 100

TSM

ESM

LPN

LPMT

HMHT

Other

Serv

ice m

odel

% of patients reviewed

no rev iew

other rev iew

on general hospital w ard



Table 22. Other sources of referrals

Traditional Sector Model GPs

GPs; other Consultants in Psychiatry and other Specialties; CMHT; Home Treatment team

GPs; Social Services; General & Psychiatric hospitals; voluntary groups

GPs; Hospital Doctors

Adult Psychiatry – at the 65th birthday!

GPs

GPs; General & Community hospitals; Social Services; Residential and Nursing homes

Inpatients; CMHTs; GPs; Hospitals; Out of areas; Nursing and Residential homes; Memory Clinic

Primary care

GPs; in-patient units; Social Services

Intermediate care; CMHTs; GPs

Nil

CMHTs; Mental Health wards; Intermediate care

Other Mental Health services

Specialised services (LPN; LPMT; HMHT) GPs; Social Services; CMHTs; General Psychiatry; Voluntary sectors; Individuals

CMHTs; Memory clinic; Social Services

CMHTs; in-patient units; Day hospital; Geriatric day hospitals; medical day hospitals; memory clinic; community resource centres

CMHTs; in-patients; Social services

We only take referrals from the hospital

Specialist referrals

Although there is evidence supporting dedicated training and teaching time for general hospital staff, the amount of time engaged in this valuable activity is strictly minimal. It is possible to see that less time spent attempting to alter the pattern of missed identification and effective management will prolong the evidence required to show effectiveness of liaison services. This is witnessed in the persistence of lack of referrals from areas where they would be expected, and where there is no evidence to date to suggest that mental health needs do not occur in these patients or that the specialities concerned have advanced detection and treatment skills, negating a need for referral. To illustrate, respondents were asked to comment on areas that do not tend to refer. 40% of respondents reported less than expected numbers from general surgery and orthopaedics. Comments include: ‘we don’t get many from surgeons. I think the emphasis on rapid discharge across the hospital means that unless the problem is dramatically evident they don’t bother’.

Use of protocols

The English Older Peoples Mental Health service development guide Everybody’s Business (Department of and Care Services Improvement 2005) states that protocols developed jointly to improve the management of uncomplicated mental health problems should be available. These should support and supervise general care teams dealing with common mental health problems. In addition, one of the milestones set in the National Service Framework for Older People (Health 2001) was that healthcare organisations should have agreed protocols in place for the care and management of older



people with depression and dementia by April 2004. At the time of this survey, more than two and a half years later, this milestone is still far from being met. Our survey revealed that a high proportion of respondents did not have protocols in place for the detection and management of common mental health problems. There is a tendency for this to be related to the type of service model being used for some mental health problems although the pattern is not consistent across all conditions, with alcohol withdrawal and delirium taking some precedence. Models that have an enhanced medical input (ESM and LPMT) do seem to have developed protocols more so than other services, suggesting that existing protocols are primarily medically based. This may be one of the consequences of having increased skill mix in liaison services as different professionals may have different views as to what can and should be managed at general hospital level, thereby impeding development of clear protocols. However, protocols can be used to define referral criteria (and in some cases limit the amount and case mix of who is referred for specialist input), and are often seen as working against the ethos of those providing the service i.e. they are seen as a way of restricting referrals. Likewise, as a lot of these services are in their infancy, it is only through experience that they will be able to produce details of who is and is not responsible for managing care. Figure 8 shows the pattern of protocol development by service model for common conditions.

Figure 8. Service models and their use of protocols for common mental

health problems

Only two services reported the use of protocols for other conditions. These included risk assessment tools for levels of after care and capacity issues. One service reported the use of guidelines on the nursing management of patients with common mental health problems, providing help with day-to-day delivery of care by inputting into nursing care plans.

0 20 40 60 80 100

TSM

ESM

LPN

LPMT

HMHT

Serv

ice m

odel

% of protocols in use

self-harm

depression

dementia

delirium

alcohol withdrawal



3.4 Primary Care Trust service models Primary Care Trust (PCT) boundaries are the recognised denominators that allow us to discuss services for different patient populations. We wanted to explore service model configuration in this way to help with communicating our findings. We mapped every general hospital within England (242) onto their corresponding PCT area (305) (pre-mergers 2006). In instances where PCT’s did not map onto general hospitals, the nearest general hospital geographically to that PCT area was identified, and the service model used there was deemed as the service model available to the population within that PCT.

However, our survey provided information on 76% of hospitals within England. Therefore, in those instances where we had received no response from services, we consulted the data being collated in 2007 as part of the Care Services Improvement Partnership mental health service mapping process, then held by Durham University. This data consists of lead managers’ self-reporting of service model configuration and staff activity. This describes only the presence or absence of a liaison mental health service for older people with no information on specific models. This allowed us to identify services in hospitals and PCTS areas where we had previously had no response, thereby allowing us to report on 100% of the hospitals within England. For ease of reporting, the original service model descriptors have been grouped into larger categories as shown in Table 23.

Table 23. Service model configuration and number of services in England

Service model configuration Details Number

Traditional Sector Model

Enhanced Sector Model

Outreach from Mental Health Wards

No dedicated service

153

Liaison Psychiatry Nurse Liaison Psychiatry Nurse 79

HMHT (small) More than 2 and not more than 4 wte staffing of at least 2 different professions

14

HMHT (large) More than 4 wte staffing of at least 2 different professions

10

Other type of liaison service Other 29

Mixed models within same PCT Mixed 21

nb: No dedicated service - services were categorised as having no dedicated service if clinicians were providing fewer than three dedicated sessions per week in a large hospital (500 beds +), or less than 2 sessions a week in a moderate sized hospital (300-500 beds), as per Royal College of Psychiatrists guidance on levels of service provision (Faculty of Old Age 2006).

This data is shown geographically in Figure 9. This map shows that liaison services are far from universal and that there is no particular pattern, apart from a degree of clustering which may be influenced by local spread of service models from one locality to another. In particular, there is no link between Strategic Health Authority (or equivalent) boundaries, suggesting no overall strategic drive to develop services.



Figure 9. Map of liaison services in England by PCT area and the rest of the UK by health region



3.4.1 Staffing levels by PCT boundaries

In order to examine shifts in staffing levels, and thereby level of specialisation within services in England, we compared the staffing levels reported in 2002 to those reported in our current survey. These changes are shown in Figure 10.

Figure 10. Map of staffing level changes in England



In order to examine staffing levels further, we analysed actual staffing levels within each service model by hospitals receiving that service. Figure 11 shows staffing levels by percentage distribution on number of hospitals.

Figure 11. Staffing levels by percentage distribution on number of

hospitals

This shows that what seem to be larger teams have their size (and possibly impact) diluted by providing services to more than one hospital.

We also wanted to examine whether staffing levels were strategically related to number of patients aged 65 years and over based within these hospitals. We therefore analysed staffing levels by Finished Consultant Episodes per PCT (data from 2006 HES). Figure 12 shows mean number of FCE grouped by staffing level.

Staffing levels by service model 2007: Percentage distribution based on number of hospitals

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No DedicatedService (126)

Lision PsychiatricServices (49)

Small HMHT (10) Large HMHT (5) Other LiaisonService (14)

Mixed Models(16)

Service Model (No. hospitals)

% H

osp

ital

s

None Up to one WTE Over one and up to two WTE At least three WTE



Figure 12. Average number of hospital in-patient FCEs, grouped by

staffing level

There is a statistically significant difference in average FCEs between the groups (F(3,216)=8.57, p<0.001). Post-hoc tests revealed staffing levels None and Up to one WTE were significantly different to staffing levels Over one and up to two WTE, and At least three WTE. There were no significant differences between None and Up to one WTE, and Over one and up to two WTE and At least three WTE.

Core standards analysis

The Department of Health published Standards for Better Health in 2004, which contains a list of core standards which all health organisations should achieve to ensure they are delivering high quality, equitable services. Seven domains were identified: safety, clinical and cost effectiveness, governance, patient focus, accessible and responsive care, care environment and amenities, and public health. Figure 13 compares how compliant the NHS acute trusts within England were to the core standard elements within these seven domains.

Average number of hospital inpatient FCEs aged 65 years and over, grouped by staffing level

0

5000

10000

15000

20000

25000

30000

35000

None (130) Up to one WTE (47) Over one and up to two WTE(32)

At least three WTE (11)

Staffing level (No. hospitals)

Mea

n n

um

ber

of hosp

ital o

rdin

ary F

CE

s ag

ed 6

5+

95% Confidence intervals



Figure 13. Mean number of compliant elements by domain, comparing

trusts with and without psychiatric liaison services

The histogram shows that while trusts with psychiatric liaison services were slightly more compliant to the elements within the safety, governance, patient focus, accessible and responsible care, and public health domains, there was no significant difference in mean number of compliant elements between trusts with and without liaison services for any of the seven domains.

One of the national targets indicators for acute and specialist trusts is to reduce delayed transfers of care. Comparing 2006/07 figures, there was a significantly greater percentage of delayed transfers of care for trusts without psychiatric liaison services than trusts with psychiatric liaison services in place (2.78% compared with 2.21% respectively). New indicators for 2006/07 include the experience of patients in five areas; access and waiting; safe, high quality, coordinated care; better information, more choice; building closer relationships; and clean, friendly, comfortable place to be. While overall trusts with psychiatric liaison services performed better in all five areas than trusts without psychiatric liaison services, there was no significant difference in scores between the two groups.

Summary

Overall the results from the service mapping exercise demonstrate that there has been significant development in the specialist liaison services across the UK. The nature of this development is less well understood. Even within the service model typography used in this study, there is considerable variation in structure, clinical activity, and management structures that point to a lack of strategic planning and ownership; services appear to have evolved without any benchmarking to direct them, and many can best be described as in the early stages of evolution.

0 2 4 6 8 10 12 14

Safety (9)

Clinical and cost effectiveness(5)

Governance (12)

Patient focus (9)

Accessible and responsiblecare (2)

Care environment andamenities (3)

Public health (4)

Do

mai

ns

(No

. tr

ust

ap

plic

able

co

re s

tan

dar

d e

lem

ents

)

Mean number of complient elements across trusts

Liaison service

No liaison service



4 Phase 3: Evaluation The aim of the third phase of our study was to provide a comprehensive description of a representative sample of liaison mental health services for older people, includiong service structure, processes, clinical and cost effectiveness, and the local context in wehich the service was operating. In order to carry this out, fieldworkers used a wide range of sources and methods. Service structure included: staffing levels and staff qualifications and liaison mental health training; service history and evolution; funding source(s); management structure; and commissioning framework. Service processes included: activity levels for the overall service and individual staff; response times; source of referrals by admitting speciality; and educational activity. Clinical effectivenss was determined through a mixture of high-level quantitative data including length of stay and rates of institutionalisation, condition-specific outcomes such as level of cognitive impairment and qualitative data about staff and patient satisfaction with the local service model obtained from questionnaires, focus groups and in-depth interviews with key stakeholders. Cost-effectivness utilised staff costs and generalisable estimates of resource consumption by referred patients during and after the hospital admission. Finally, the context in which individual services was operating was determined by established the presence or absence of other services such as intermediate mental health care teams.

4.1 Pilot evaluation

4.1.1 Design

The exact methodology for evaluating liaison services was determined through pilot work conducted between July and December 2006. A range of different measurement tools and techniques were used to extract data from locally based services. A combination of quantitative and qualitative methods, which is described in more detail below, was piloted throughout this period. This work was designed to determine (1) The structure of services (2) The process of services (3) The effectiveness of services (4) The context of services.

4.1.2 Site selection

Three local sites were initially selected to be involved in the pilot work. This selection was based on existing working relationships with neighbouring trusts, thereby ensuring co-operation and ease of access to the information required. However, the process of seeking ethical and clinical governance approval at neighbouring trusts proved to be lengthy and it was quickly established that we would exceed our pilot time frame if we pursued this further. Therefore we concentrated our pilot work within the two main teaching hospitals in Leeds, collaborating with neighbouring trusts in instances where this was relatively easy to achieve.



4.1.3 Determining the structure of services

In order to determine the exact components of each service, a detailed description of the service was required. This involved collating information on:

Qualifications and training of staff delivering and supporting the service

Length of service

Sources of funding

Management structure

Service accommodation

Local commissioning framework

Evolution/history of service development

Key drivers and barriers to service development A topic guide to be used in semi-structured interviews/focus groups with all staff and key stakeholders was developed to assist in obtaining this information. (see Appendix 14). Semi-structured interviews (n=9), informal interviews (i.e. field notes, n=5) and, focus groups with different service personnel (mixture of hospital and mental health liaison staff grades, n=5) were conducted across several hospital districts.

Transcripts and field notes from these interviews underwent a process of thematic analysis in order to determine the service characteristics of each agency involved. Variables included in this analysis are shown in Appendix 15.

4.1.4 Determining the processes of services

Service-level activity data

In order to examine service-level activity data, a tool for collating prospective information on patients referred to specialist mental health services was created through (1) determining what factors are important in being able to describe the patient characteristics of referrals into these services (using the output from the literature review as a guide) and (2) collaboration with administration staff employed by Leeds Mental Health Trust and Leeds Teaching Hospital Trust in order to determine where to source this information. This yielded a 15 page data collection form (see Appendix 16).

A tool for use by individual staff to record their activity was also developed. This encompassed clinical work (assessment, therapeutic work and review), supervision (of general hospital and mental health staff, including details of the disciplines involved), training (opportunistic and structured and again including details of the disciplines involved together with any service user and carer training), administration, management, audit, research, and professional development. See Appendix 17.

The points of possible response and intervention on typical care pathways (developed with service users and carers who have experienced general hospital care) were explored for each service. This was through selecting at least five patients at random, and describing their care pathways in more detail than that described above.

The degree of team-working and the leadership style in each service was to be assessed using the Team Climate Inventory (Anderson and West 1996), a validated measure. See Appendix 18.



4.1.5 Determining the effectiveness of services

The effectiveness of each service was determined using a broad range of measures employing both qualitative and quantitative methodologies.

Descriptors

Descriptors were obtained through the local Patient Administration System of the acute trust including:

Age

Gender

Admission date

Where admitted from

Type of admission

Specialty admitted to

Primary and secondary diagnosis

Discharge date

Where discharged to

Utilisation of intermediate care, social care and institutional care

This allowed us to describe basic demographics, length of stay, specialty dispersion, primary and secondary diagnoses, mortality rates and institutionalisation rates.

Condition specific outcomes

Symptom severity and duration was measured through:

The Mini-mental State Examination (MMSE) (Folstein et al. 1975)

The Blessed Dementia Scale (Blessed et al. 1968)

The Geriatric Depression Scale (Yesavage et al. 1982)

The Delirium Rating Scale (Trzepacz et al. 1988)

The Charlson physical co-morbidity rating (Charlson et al. 1986)

Self-health rating

User and carer satisfaction

Initially, we planned to measure user and carer satisfaction through focus groups involving service users and semi-structured interviews with users and carers close to the point of discharge. However, both of these tasks proved difficult to track and set up within our evaluation time frame. Therefore, a questionnaire developed from the existing hospital patient satisfaction questionnaire was put in place to determine user and carer and staff satisfaction, (using appropriate condition-specific measures where necessary). This was developed through consultation with our User and Carer Reference Group. (See Appendix 19a and 19b).

A telephone interview schedule was also constructed to be used soon after discharge from the general hospital. See Appendix 20.



Staff skills, knowledge and attitudes

In order to determine the level of general hospital staff skills and knowledge of, and attitudes towards, older people with mental health problems, we designed a questionnaire survey. A review of the literature failed to identify a suitable measure; therefore we used the principles of established questionnaire design procedures to create and pilot a questionnaire specifically designed for this purpose. The questionnaire pilot was conducted at Leeds, with 87 staff members completing it in order to ensure that questions were able to extract the information required and the content and format were acceptable to respondents. see Appendix 21.

Knowledge and attitudes was further assessed through devising a focus group and individual interview schedule for general hospital staff members. This was piloted through two focus groups held within LTHT. (See Appendix 22).

Referrer feedback

In order to obtain feedback from referrers to the service, a questionnaire was designed and piloted with the help of general hospital colleagues. See Appendix 23.

Outcomes for the general hospital population

Determining outcomes for all the general hospital population of older people to compare with the users of a liaison service is not a particularly useful comparison, since the target population for a liaison service will have an index condition that independently worsens outcome. We also do not know the outcome for potential service users since we cannot identify them without screening everyone in the general hospital (this is the only way we would be able to identify them since ward staff miss many mental health problems, and many do not come to the attention of mental health staff); this would necessitate assessment of several thousand older people at each general hospital site. Therefore, we collated information on a cohort of 100 admitted patients, selected at random throughout the evaluation period. This included (1) determining what information is necessary in order to be able to describe patient characteristics (2) collaboration with administration staff employed by Leeds Mental Health Trust and Leeds Teaching Hospital Trust in order to determine where to source this information. This yielded a 13 page data collection form similar to that designed for the referred patient data collection (see Appendix 24).

4.1.6 Determining the cost-effectiveness of services

This proved a methodological challenge, since directly comparable data is difficult to obtain. Liaison service users have an index condition that itself drives up the cost of healthcare. However, this stage would provide information that will be invaluable in informing future work. The costs of providing the service were related to the staffing, accommodation and administrative expenditure and were relatively easy to determine. We also estimated the costs incurred by those who are seen by each service. This encompasses time spent in hospital, rehabilitation and intermediate care facilities and any consequent institutional care. National per diem unit costs would be applied to the use of these resources to provide generalisable estimates of cost, since these constitute the substantial cost elements of healthcare. Reflecting the age of the population served and co-morbidity,



indirect costs (production losses) were not to be explored. (See separate section on cost effectiveness of services).

4.1.7 Determining the context of services

The context that a liaison mental health service for older people operates is extremely important to determine, since there are many other factors that affect whether a liaison service can operate successfully. For example, the presence of an intermediate mental health care service for older people will vastly increase the options available for an older person with a mental health problem who presents in crisis in an accident and emergency department. Conversely, where there is no intermediate mental health care, all a mental health assessment could do in a similar situation is identify a need that cannot be met. A description of the service context was therefore required. This encompassed:

(1) a description of local services and who provides them, encompassing statutory and voluntary organisations, such as community mental health teams, day treatment services, social care providers, institutional residential and nursing care (including institutional care for older people with mental health problems) and intermediate care (including access criteria excluding people with mental health problems from physical intermediate care and the presence of any intermediate mental health care).

(2) a description of the context within the general hospital; the presence of specialist care of the elderly departments and peripatetic older people’s specialist teams described by the National Service Framework for Older People. This information was obtained through interviews with key stakeholders within the acute trust setting (see Appendix 25 for schedule).

Routine hospital data

In order to describe the hospital population of interest prior to, and during the evaluation of the services, a proforma for extracting this information was created (see Appendix 26) which was based on information that is easily obtainable from hospital statistics. This allowed us to describe basic demographics, length of stay, specialty dispersion, primary and secondary diagnoses and institutionalisation rates.

Routine referral data

In order to describe service activity prior to the evaluation period, a proforma for collating information on service activity was created which included measures of service activity.

This work culminated in a comprehensive evaluation manual containing 7 areas for prospective cohort data collection.

4.2 Formal evaluation

4.2.1 Service sampling

It has previously been noted that our survey findings revealed variances in service typologies and differences in respondents reporting of their service. As we were not aware of these differences prior to more detailed communication



between different services, we originally selected services based on the typologies initially identified, i.e. Traditional Sector Model, Liaison Psychiatry Nurse, Liaison Psychiatry Medical Team and Hospital Mental Health Team. Existing services that were not operating these models were not included in the initial purposive sample. We also did not include services from the sample from which we had not received a response to our service mapping request. A total of 155 possible sites were identified. Table 24 shows the service typology numbers in each category.

Other inclusion criteria included sites that were not less than 6 months old or were not likely to change during the period of evaluation. Young services were excluded as they were unlikely to have bedded in and the impact of the educational programme they offered was likely to be minimal. Service stability was chosen to ensure that there was not a significant service reconstruction during the evaluation period that would have changed the activity or typology during the evaluation period. (It is worth noting that the prediction of service stability is at best an indirect science.) Further stratification did not include services in Northern Ireland, Scotland and Wales due to several factors. These included: the different policy drives and managerial and funding arrangements for mental health and social care services in different parts of the UK; the practicalities of managing a multi-site study from one base (i.e. Leeds); and access to hospital activity and other information about different populations in the United Kingdom.

Table 24. Number of services included in the initial purposive selection sample

Service model configuration Details Number %

Traditional Sector Model


Outreach from Mental Health Wards

No dedicated service

66

43

Liaison Psychiatry Nurse Liaison Psychiatry Nurse 50 32

LPMT Liaison Psychiatry Medical Team 19 12

HMHT Hospital Mental Health Team 20 13

We aimed to control for a number of variables in order to ensure that we had a wide range of services included in the evaluation that could be matched on different criteria which has been shown to be important in service planning. We therefore wanted to control for the following variables:

Population served; controlling for deprivation levels i.e. similar deprivation levels in different service models looked. We used the latest deprivation indices (2004) listed per local authority region. These were obtained through The Office of the Deputy Prime Minister (ODPM), who commissioned the Social Disadvantage Research Centre (SDRC) at the Department of Social Policy and Social Research at the University of Oxford to update the Indices of Deprivation 2000 (ID 2000) for England. Indices of deprivation are ranked per local authority population from 1 – 354 with an average score of 4.17 – 49.78 (low scores = less deprived). Services were grouped into high or low deprivation of the area served.

Population size; Size of population being served by the model will have an impact on activity and therefore effectiveness of the service. Information on the number of hospital beds per hospital site is not easily attainable. We therefore listed number of general and acute beds in total for acute trusts of interest (source: department of health report published 22nd September 2006-Average



daily number of available and occupied beds by sector, NHS organisations in England, 2005-06). These were grouped into small, medium and large.

Size of service (i.e. number of referrals received, who else refers etc.). As previously stated, information on size of service was not complete from our surveys. We therefore looked at number of hospital beds per site and number of elderly admissions per site to ensure there were no outliers and within the national average (40-60%). This data is available from HES online (2006 – latest available). However, the age range of admissions is reported differently to that which we have used here i.e.60-74 years and 75 years+ per acute trust. These were grouped into elderly admissions as a percentage of the total admissions calculated which allowed us to identify 2 groups; high elderly admissions and low elderly admissions. We would also have liked to control for number of staff delivering the service and other services available, however this information was incomplete at time of selection.

Figure 14 shows the pattern of cells from which to recruit sites (stratified by model, deprivation group and number of elderly admissions (dg1 – high deprivation area; dg2 – low deprivation area; ea1 – high number of elderly admissions; ea2 – low number of elderly admissions. This figure also shows how many sites in England match these cells (total = 120).



Figure 14. Ideal sampling strategy for site recruitment and number of

sites in each cell

ea

1 2

TSM

dg1 X X

Number 15 10

dg2 X

Number 10 12

LPN

dg1 X

Number 12 10

dg2 X X

Number 9 9

LPMT

dg1 X

Number 2 7

dg2 X X

Number 0 5

HMHT

dg1 X X

Number 7 1

dg2 X

number 4 7

As one cell has no sites to recruit, the sampling strategy was altered, as shown in Figure 15.



Figure 15. Altered sampling strategy for site recruitment

ea

TSM 1 2

dg1 x x

dg2 x

LPN 1 2

dg1 x

dg2 x x

LPMT 1 2

dg1 x x

dg2 x

HMHT 1 2

dg1 x x

dg2 x

Our aim was to evaluate twelve sites operating four different service models, three of each model in total. In the early stages of our evaluation we felt it was important to pre-select sites on the basis of location, as this would help facilitate frequent visits in order to ensure that the methodology was well structured before asking colleagues to undertake this methodology in sites that were further afield. Therefore, four sites (each falling within a different sampling cell) were deliberately selected for proximity to base. The remaining eight sites were randomly selected from the final list of potential sites. In addition, two further sites per sample cell were randomly selected in the event that we could not confirm agreement from provisionally selected sites.

The recruitment process commenced in October 2007 and continued through to January 2008. During this process we found that further discussion with clinical leads revealed some sites as having atypical service models to those originally proposed; for example, services had just had funding withdrawn or funding increased, or the remit of the service had been reduced or increased. In these instances we requested evaluation of the second and third ‘back-up’ site. We were also mindful not to over-represent recruitment to capacity of service or deprivation groups.

We particularly struggled with recruiting LPMT sites. Typical reasons for this included; shifts in service model configuration; service capabilities severely limited; lack of identification of local collaborator within these services. Given the under-representation of LPMT models in the sample, and the primary requirement to sample different service model configurations, a different approach to the models to be sampled was required. The initial service mapping identified an increase in HMHT model, however the criteria for this model was two or more different professionals providing a liaison based service. Services categorised under this umbrella term are likely to vary widely in the actual amount of time and number of professionals providing the service. It is not known to what extent the size of a hospital based team impacts on quality of care received. Therefore, further site selection was aimed at looking at these different configurations. Sites were re-categorised as follows:



HMHTa (small team) – not less than 2 professionals and not more than 4 professionals involved in providing the service – total number = 4

HMHTb (large team) – more than 4 professionals involved in providing the service – total number = 4

(As already stated in the service mapping report, a service was deemed to exist if 2 or more sessions were available in a small hospital – less than 500 bedded, and 3 or more in a moderate-large sized hospital – 500 + bedded).

Ideal sampling of these sites is shown in the configuration in Figure 16. There are no large HMHT’s identified for cells a and b. Potential sites for this model are all in deprivation group 1 and elderly admission group 1.

Figure 16. Ideal sampling strategy for site recruitment

ea

1 2

HMHTa

dg1 X

Number 2

dg2 X X

Number 1 1

HMHTb

dg1 X X

Number 4 1

dg2 X

Number 1

In order to ensure an adequate number of HMHT sites were included, 3 out of the 4 (ea1, dg2) were selected, attempting for balance for geographical spread. The final sampling strategy is shown in Figure 17.



Figure 17. Sampling strategy for evaluation sites

The sample would therefore be weighted towards high rates of elderly admissions (8/4) and highly deprived areas (7/5).

4.2.2 Recruitment

Services selected for evaluation were approached via a standard letter to the key contact identified in phase 2 of the study. This consisted of an invitation from the Chief Investigator (see appendix 27). Recruitment commenced in October 2007 and work continued on this until agreement had been reached at 12 sites. The original plan was to evaluate 4 sites at any one time over a 3 month period with a total evaluation time of 9 months. However, significant delays in recruitment of sites, recruitment of staff and alterations to the evaluation methodology undertaken in response to these factors meant that we evaluated sites as the opportunity arose, causing variations in the number of sites being evaluated at any one time. This is explained in further detail in the sections below.

4.2.3 Evaluation process

Appendix 28 shows the time length involved in pre- and post-evaluation tasks. Each section is discussed in further detail below.

ea

1 2

TSM

dg1 X X

dg2 X

LPN

dg1 X

dg2 X X

HMHTa

dg1 X

dg2 X X

HMHTb

dg1 X

dg1 X

dg1 X



Ethics and Research and Development approval

Guidelines on the ethical and research and development (R&D) process for research within NHS trusts were adhered to. NHS ethics committee approval was obtained for the evaluation, and site specific approval was granted at each site. However, the nature of the research meant that we needed to seek separate research governance approval at the majority of sites both within the mental health trust providing the service and the acute trust receiving the service. Variations in this requirement appeared to be related to the local collaborator’s experience with neighbouring trust research and the acute trust Research and Development Department adherence to requirements for a local collaborator to hold a substantive contract with the acute trust. This did raise the issue of clinician’s holding honorary contracts at different research sites which did vary widely, and in some instances revealed that the mental health service was operating without the required employment contracts with the acute trust in place. Steps have been taken at all these sites to rectify this. In summary, LREC approval was sought 20 times for 12 evaluation sites and R&D approval 24 different times for the same number of sites. It can be seen that this raised issues in terms of timeliness of the evaluations. We found that different sites had slightly different requirements in order to meet their approval which caused several delays in commencing the evaluations. At the same time, changes within departments not only with regards to staffing but also procedural changes challenged the timeframe of our work. On one occasion, R&D approval was on hold for 4 months whilst that department underwent an internal investigation.

Local collaborators

It can be seen from the above that not only was there a need to identify a local collaborator within the mental health service, but also within the acute trust. Given the nature of employment contracts, management and funding of liaison services, this necessitated having 2 collaborators at the majority of sites. The ability to identify a collaborator within the acute trust rested with the mental health service. This ability was affected by the nature of relationships across trusts and between colleagues caring for the same group of patients. It is of interest that all 3 TSM services found this comparatively easy and straightforward compared to some of the more specialised services. Indeed, one small hospital mental health team had to be withdrawn from the sample directly because of the failure to identify an acute trust collaborator, despite several meetings being held involving the two trusts concerned. At the same time, one liaison nurse model saw the acute trust collaborator withdraw their interest during the evaluation which tends to reflect the fragile nature of relationships across trusts and the priority given to this type of clinical work and evaluation.

Fieldworkers

The original protocol to recruit fieldworkers through PSSRU was not implemented due to difficulties with site selection and location of these staff. Instead, steps were taken to recruit local staff using the following methods: Secondment of existing staff within the mental health trust; Secondment of existing staff within the acute trust; Internal advertisement; National advertisement. This resulted in variation in staff skill mix and staff availability at each site.



Our estimate of two whole time equivalent fieldworkers per site per evaluation was aimed for although we failed to achieve this level at any site. Fieldworkers consisted of trained mental health nurses, support workers, audit personnel, NHS management trainees, assistant psychologists and PhD students. Fieldworker availability ranged from 22.5 hours per week per evaluation site to 1.5 whole time equivalent for the evaluation period.

We also experienced several staffing changes throughout the actual evaluation periods which led to amendments being made to the evaluation method. This was mainly in terms of priority given to different areas of proposed data collection, with an emphasis on collating patient data from cohorts referred and admitted during the evaluation period. This variability in staff availability also led to varying lengths of time being invested in securing interviews with key stakeholders and disseminating the staff skills questionnaire. This is reported in further detail in the results section.

All fieldworkers required honorary research contracts with both the acute trust and mental health trust involved in the evaluation site. This was another factor that delayed commencement of evaluations. At one site, clearance was not permitted for the fieldworkers to assess patients as the hospital trust felt that the fieldworkers employed by the research team did not have the necessary skills required for this task. However, other sites had found the level of skill involved acceptable i.e. assistant psychologist with previous experience of direct contact with patients. At a different site, we were not able to complete any one part of the evaluation due to delays in receiving honorary research contracts and difficulties with co-ordinating activities across neighbouring trusts. This was despite lengthy meetings and discussions with all agencies concerned. The evaluation here was further impeded by the fieldworkers’ lack of skill and over-reporting of evaluation actions throughout the period of evaluation.

Length of employment also varied across sites; the length of the evaluation period did not i.e. 13 weeks. Reasons for variances in length ranged from delays in receiving honorary research contracts balanced against the need to recruit staff immediately lest they withdraw their interest and difficulties in accessing data at individual ward level and hospital level.

Access to information (including collaboration within hospitals)

Prior to commencing the evaluation at different hospital sites, ethical and research and development approval was granted. Following this, we compiled a list of key personnel to inform about the evaluation with a view to this information being disseminated widely across the hospital trust and the mental health trust. This list is included in the appendix 29. The ability to produce a contact list of key personnel was facilitated through the R&D office and local collaborators. A standard letter was sent to those colleagues identified through this process with a request to disseminate information and contact the research team if they had any questions. (see appendix 30). This also included an introduction to the local research staff with their contact details. As the majority of data of interest was held within the hospital trust, the emphasis was on ensuring that access to data was facilitated through contact prior to the evaluation taking place.

Fieldworkers followed up this central communication through arranging meetings with the Director of Nursing or a colleague delegated to oversee their work. The focus on the Director of Nursing was to ensure that information about the study was cascaded to all wards where patients of interest were



admitted to. An information sheet to be given to all ward staff is shown in appendix 30. The availability and preferred method of communication with the Director of Nursing varied across sites ranging from decline of offer of meeting with staff to request for formal presentation about the study to ward managers from the core research team. Regardless of whichever method was used, cascading of information about the study was found not to be uniform across sites. Researchers were trained to introduce themselves to ward managers on entering any ward to collect information and provide a brief overview of the study. Whilst the majority of ward managers found this acceptable, they consistently commented that they were not aware of the study. On a number of occasions, fieldworkers were not permitted to collect the data as ward managers and attending doctors were not aware of the study and refused access. This was despite all fieldworkers having locally produced ID badges, honorary contracts, copies of the ethics and R&D approval and key contact details of collaborators within their colleague’s trust with them at all times during data collection phases. Although this did not seriously affect the ability to carry out the evaluation at the majority of sites, it highlighted that co-ordinating research across different directorates within the same hospital is complex, particularly in non-teaching institutions, and this may well be a precursor to preventing others from wanting to undertake this type of research in the future.

In terms of accessing routine hospital data, we found that the ability to do this also varied across sites and was not related to the service model typology. In some instances, local collaborators identified staff within the trusts of interest that could facilitate this process, whereas at others, fieldworkers were required to undergo PAS training and locate the data of interest themselves. Access to this training was often delayed and prevented data being collected in a timely manner. However, the amount of data to be collected did not vary across sites and this leads us to conclude that the ability to access data was a direct consequence of the relationship the local collaborator has with their IT and R&D Department.

We also found variances in permission to access data across sites. Again, this was not related to the service model typology. To illustrate, some sites accepted the approvals as an indication to allow open access to all data areas, whereas others required individual written permission from local collaborators to collect information held within different systems. This was despite adherence to NHS guidelines, and highlights that individual trusts continue to have local guidelines that not only appear to duplicate work completed by a different department, but also operate to hinder the research process. In a time limited evaluation, this was a constant source of difficulty. The discussion in the follow-up process highlights that without this period of follow-up our data would not be of the standard reported here and this would be directly related to negotiating the individual, complex and often nonsensical procedures for accessing data that continues to operate at different trust sites.

Follow-up process

At the commencement of each evaluation at each site, discussions were held with local collaborators to ensure that a system was in place to retrieve discharge details of patients that were still in hospital at the end of the evaluation period. This would allow for accurate reporting on length of stay. However, it became apparent after the completion of 4 sites, a large amount of data was missing from data collection forms concerning important patient variables. Following further discussions with collaborators we approached the



Mental Health Research Network (MHRN) – a government funded research support stream with hubs nationwide. The service offers clinical studies officers to assist with mental health research locally. An application was made in January 2008 to be ‘adopted’ by the network and the study was adopted in April 2008. Several hubs were contacted and became involved in returning to sites to collate missing information. It is of interest that on this occasion, we met similar barriers to access to information to that seen previously in that honorary research contracts and negotiation with information gate-keepers was required at each site. In one site, the local R&D office commenced a screening process on the clinical studies officer including registration check and request for CRB clearance. This lack of understanding within the R&D Department reflects a lack of relationships with the local acute trusts and again may prevent other researchers from undertaking research within neighbouring trusts serving different purposes.

One research site was evaluated entirely by the MHRN. This was following several attempts to recruit staff. Once staff had been recruited, there was a lengthy delay in securing R&D approval as the hospital site had PCT beds and therefore necessitated 3 separate research governance applications (to the mental health trust, the acute trust and the primary care trust) for one site. There was lack of agreement about responsibility for the different trust beds and after several meetings and discussions, both fieldworkers recruited withdrew their interest immediately prior to the commencement of the evaluation. The MHRN in this area had the capacity at the time to collect patient data (albeit without including any assessments of patients mental health needs or symptom persistence). This process was facilitated by active engagement from the mental health service staff.

Three evaluation sites did not have any links with the MHRN. In these instances, we re-employed the original fieldworkers who collected data at these sites for brief periods (approx 20 hours in total per site) to collate the missing data. Due to limited availability, efforts were concentrated on variables where more than 10% of information was missing from patient data collected.

Variations in data collected

The nature of the data collected from all the evaluation sites was consistent, although the ability to complete all sections of the evaluation was influenced by the factors described in the previous section. Appendix 31 shows the number of participants included in different activities across the 11 sites.



4.3 Evaluation results The findings from the evaluation are presented in several sections; (5.3.1) evaluation site service descriptions; (5.3.2) analysis of referred and comparison patient cohorts per service model; (5.3.3) evaluation measures; (5.3.4) statistical inference-length of stay; (5.3.5) survival analysis; (5.3.6) discharge destination of referrals; (5.3.7) cost effectiveness analysis; (5.3.8) qualitative data analysis; (5.3.9) analysis of staff skills, knowledge and attitudes per service model. Results are reported for eleven sites, since after lengthy negotiations with a twelfth site that had originally expressed an interest in partaking in the evaluation it became evident that there was no mechanism for progressing the evaluation further as no local collaborator could be identified; this site was therefore dropped from the evaluation. This occurred late in the process, meaning that we were unable to identify a further evaluation site for the study. Further information on site selection and recruitment can be found in section 5.2.3 local collaborators.

4.3.1 Service characteristics

Table 251 shows characteristics of the eleven different service models included in the original evaluation sites and Table 26 shows staffing levels and composition of the ten different service models involved in the in-depth evaluation process. Figure 18.1 and 18.2 shows number of dedicated hours per week per profession for each of the services. Unsurprisingly, dedicated liaison services provide more dedicated time, both clinical and for administration, teaching and other tasks.

Figure 19.1 and 19.2 shows number of clinical hours per profession per week for each of the services.

1 TSM = Traditional Sector Model; LPN = Liaison Psychiatric Nurse(s); HMHTa = Hospital Mental Health Team consisting of not less than 2 different professionals and not more than 4; HMHTb = Hospital Mental Health Team consisting of more than 4 different professionals



Figure 18.1 Dedicated hours per week for different service models by

profession – medical staff

0

5

10

15

20

25

30

35

40

45

50

Num

ber o

f ded

icat

ed h

ours

Service model

ConsPsych

SpecReg

AssocSpec

OtherPsychMed

Figure 18.2 Dedicated hours per week for different service models by profession – nursing and other staff

0

20

40

60

80

100

120

140

160

Num

ber o

f ded

icat

ed h

ours

Service model

NurseBand7

NurseBand6

NurseBand5

OT

SuppWorker

Admin



Figure 19.1: Dedicated clinical hours per week for different service models by profession – medical staff

0

5

10

15

20

25

30

35

40

45

50

TSM1

TSM2

TSM3

LPN1

LPN2

LPN3

HMHT

a1

HMHT

a2

HMHT

b1

HMHT

b2

HMHT

b3

ConsPsychSpecRegAssocSpecOtherPsychMed

Figure 19.2: Dedicated clinical hours per week for different service models by profession – nursing and other staff

0

20

40

60

80

100

120

140

160 NurseBand7NurseBand6NurseBand5OTSuppWorker



Table 25. Service model characteristics

TSM LPN HMHT a HMHT b Service model

1 2 3 1 2 3 1 2 1 2 3

Characteristics

Funding source PCT None None Other PCT PCT Other Other PCT Other PCT

Age of service 3 yrs+ 3 yrs+ 2-3 yrs 1-2 yrs 2-3 yrs 2-3 yrs 2-3 yrs 3 yrs+ 3 yrs+ 3 yrs+ 3 yrs+

Based at general hospital

No No No Yes No Yes No No No Yes Yes

Access to hospital electronic records

No No No No No Yes No Yes Yes Yes Yes

Service database No Yes No No No No Yes Yes Yes Yes Yes



Table 26. Staffing levels of service models


1 2 3 1 2 3 1 1 2 3

Measures

Staffing level changes in past 6 mths No Yes No No Yes Yes Yes Yes No Yes

Staffing increase n/a No n/a n/a Yes No Yes Yes n/a No

Staffing decrease n/a No n/a n/a n/a Yes No n/a n/a Yes

Consultant Psychiatrist Yes Yes Yes No No No Yes Yes Yes Yes

Specialist Registrar No No No No No No No Yes Yes No

Other Psychiatric Medic No No No No No No Yes No Yes No

Mental Health Nurse Band 7 No No No Yes No Yes Yes Yes Yes Yes

Mental Health Nurse Band 6 No No No No Yes Yes No Yes Yes Yes

Mental Health Nurse Band 5 No No No No No Yes No No No No

Support Worker No No No No No No No No No Yes

Occupational Therapist No No No No No No No No Yes No

Admin Support No No No No No No Yes Yes Yes Yes



It is possible to see from this data, that there is wide variation in the characteristics and composition of similar service models, thus indicating that although services may align themselves with a particular model, development is highly individual, preventing direct comparisons across different models.

Descriptions of services demonstrate wide variations in service funding. Development is linked to securing funding outside of the PCT, primarily through short-term pilot projects. Hospital teams are often based off-site from the general hospital, which will have implications for access and timely liaison. There are also variations in the ability of services to access patient information and maintain electronic records for ease of administration and auditing purposes. This will have implications on their ability to monitor progress which seems to have a greater capacity in the more sophisticated liaison models.

There is wide variation within same service models on staffing levels and skill mix. Often, liaison nurse models have no medical support, and only hospital teams have some administrative support. Likewise, teams have higher numbers of clinical hours and ability to undertake other relevant professional activities i.e. auditing and training, when compared to less complex models.

Table 27 shows service activity for the ten evaluation sites.



Table 27. Service activity of evaluation sites

Activity data demonstrates that the number of referrals to services is related to model level. There are differences in the number of referrals as percentage of hospital admissions overall, however we cannot explore this further as we cannot assume that the patient caseload is the same across models. Referral rates are certainly higher in the more sophisticated models. However, smaller services may see fewer patients but these could be more complex cases. Capacity is however certainly higher with higher clinical availability. Speed of response to referrals does not show a consistent pattern across different models. The


1 2 3 1 2 3 1 1 2 3

Service activity

Number of referrals 12 mths prior to evaluation

90 62 67 360 375 300 242 264 859 1450

Number of referrals received during evaluation

29 16 37 20 75 74 59 66 174 207

Referrals as a % of admissions

0.5 0.3 1.2 0.4 2.7 1.9 2 0.9 3.6 1.6

Number of referrals seen

18 16 29 20 72 61 51 64 156 185

Average number of days between referral date and receipt

0 3.2 2.2 0.5 0.2 0.8 1 0.9 0.8 0.2

Average number of days between referral receipt and assessment date

4 7 6 3 4 2 3 2 6 1

Average number of reviews undertaken on –in patients

1 0 1 2.2 1.8 1.2 1.6 2.1 1.7 1.5

Evaluation start date 23/07/07 30/06/08 09/07/07 17/09/07 06/10/07 23/04/07 27/08/07 30/06/08 30/07/07 26/05/08

Evaluation end date 19/10/07 26/10/08 06/07/07 14/12/07 04/01/08 20/07/07 23/11/07 26/09/08 26/10/07 22/08/08



largest service does have the fastest response rate and the smallest services do have the slowest response rate, although there are clearly other intrinsic variables that affect capacity to respond quickly, most likely embedded within locally developed protocols on prioritisation.

Summary

Our findings reveal a wide variation in staffing levels across and within the different service models. Five were PCT commissioned and funded; most of the other services had obtained funding through short-term pilot projects. Almost all services we examined had been established for over three years. Six services did not routinely collect information on activity and other data. Larger teams tended to receive more referrals, but the size of the team did not appear to significantly affect response time.



4.3.2 Patient cohorts

Table 28 shows total number of patients and patient demographics included in the two patient cohorts (referred and comparison) by service typology. A total of 757 patients were included in the referred patients and 9752 patients in the comparison cohort. Difficulties with accessing hospital case notes (discussed previously) prevented inclusion of the target comparison group total in most services that were evaluated.

Table 28. Patient demographics by cohort

Service model

Measure Group

TSM LPN HMHTa HMHTb Total

Comparison 280

29%)

256

(26%)

102

(10%)

337

(35%)

975

(56%)

Number

Referred 82

(11%)

169

(22%)

59

(8%)

447

(59%)

757

(44%)

Comparison 300 300 100 300 1000 Target number

Referred 82 169 59 447 757

Comparison 138

(49%)

115

(45%)

48

(47%)

142

42%

443

(45%) Gender – Male

Referred 41

(50%)

60

(36%)

18

(31%)

154

(34%)

273

(36%)

Comparison 258

(92%)

232

(91%)

102

(100%)

297

(88%)

889

(91%) Ethnicity – White

Referred 75

(91%)

151

(59%)

55

(54%)

375

(84%)

656

(87%)

Comparison 80.4 79.6 79.6 81 80.2 Age at admission (mean) Referred 79 81.7 81.3 80.5 80.6

2 8 patients in the comparison cohort were subsequently referred to the services (TSM=4; HMHTa=2; HMHTb=2).



Table 28 demonstrates that the two patient cohorts have similar demographics. The following tables show measured variables for these two groups; residential status on admission; specialty admitted to; psychiatric history indicators; level of physical need; discharge destination and length of stay.

Residential status on admission

Table 29 shows residential status on admission for all patients by cohort and service typology.

Table 29. Residential status on admission

Service model

Residential

status Group


Com

par

ison

200

(29%)

71%

191

(27%)

75%

74

(11%)

72%

227

(33%)

67%

692

(71%) Living

independently

Ref

erre

d 56

(11%)

68%

128

(26%)

76%

40

(8%)

68%

266

(54%)

60%

490

(65%)

Com

par

ison

20

(26%)

7%

26

(33%)

10%

7

(9%)

7%

25

(32%)

7%

78

(8%)

Living with

relatives

Ref

erre

d 7

(11%)

9%

22

(34%)

13%

5

(8%)

8%

31

(48%)

7%

65

(9%)

Com

par

ison

22

(22%)

8%

21

(21%)

8%

10

(10%)

10%

46

(47%)

14%

99

(10%)

Non-NHS

residential care

Ref

erre

d 8

(8%)

10%

10

(10%)

6%

8

(8%)

14%

74

(74%)

17%

100

(13%)



Com

par

ison

22

(31%)

8%

13

(18%)

5%

11

(15%)

11%

26

(36%)

8%

72

(8%)

NHS residential

care

Ref

erre

d 8

(17%)

10%

5

(10%)

3%

3

(6%)

5%

32

(67%)

7%

48

(6%) Com

par

ison

16

(47%)

6%

5

(15%)

2%

0

13

(38%)

4%

34

(3%)

Missing data

Ref

erre

d 3

(6%)

3%

4

(7%)

2%

3

(6%)

5%

44

(82%)

9%

54

(7%)

*Group proportions are shown in brackets and service model proportions are shown directly underneath.

Table 29 shows that the majority of patients in both the referred and comparison cohorts were living independently, although slightly more patients were in the comparison group.

Specialty admitted to

Table 30 shows the most common specialty admitted to for all patients by cohort and service typology.

Table 30. Specialty admitted to

Service model

Specialty Group


Comparison 18 9 0 12 39

(4%) Urology

Referred 3 2 0 0 5

(1%)

General

Surgery Comparison 30 27 8 14

79

(8%)



Referred 6 4 1 16 27

(4%)

Comparison 49 5 10 62

126

(13%

) General

Medicine

Referred 11 25 11 34

81

(11%

)


227

(23%

) Elderly Acute

Referred 2 15 11 141

169

(22%

)


157

(17%

) Acute

Medicine

Referred 25 25 4 14 68

(9%)


(5%) Orthopaedics


(5%)


(4%) Cardiology


(4%)


148

(15%

) Emergency

Admissions

Referred 6 59 14 139 218

(3%)




(2%) Respiratory

Referred 3 1 4 2 10

(1%)


(7%) Other

Referred 15 21 2 31 69

(9%)


(2%) Missing


(6%)

Table 30 shows wide variations in admitting specialities. The most common specialty is Elderly Acute and Acute Medicine.

Psychiatric history indicators

Table 31 shows the number and proportion of patients (as a percentage of the entire group) taking psychotropic medication on admission and with a previous psychiatric history noted in their general hospital notes.



Table 31. Psychiatric history indicators

Indicator Group TSM LPN HMHTa HMHTb Total

Comparison 70

(25%)

66

(26%)

27

(26%)

96

(28%)

259

(27%) Psychotropic

medication

on admission

Referred 33

(40%)

64

(38%)

30

(51%)

198

(44%)

325

(43%)

Comparison 3 2 0 11 16 Missing

Referred 5 10 1 38 54

Comparison 78

(28%)

44

(17%)

29

(28%)

80

(24%)

231

(24%)

Previous

psychiatric

history noted

in general

hospital

notes Referred

40

(49%)

92

(54%)

29

(49%)

250

(56%)

411

(54%)

Comparison 5 4 0 18 27 Missing


Table 31 demonstrates that higher proportions of referred patients are receiving psychotropic medications prior to admission and have a previous psychiatric history noted compared to the comparison group patients.

Level of physical need

In order to compare groups of patients by their level of physical need, the Charlson index was recorded for each patient included in our samples. Table 32 shows mean weighted Charlson index for different groups of patients by service typology. Higher scores indicate higher levels of need.



Table 32. Charlson Index: Level of physical need

Service model

Indicator Group

TSM LPN HMHTa HMHTb

Comparison 1.1 1 2.6 1.9 Weighted index CCI

Referred 0.9 1.1 2.2 1.5

Comparison 4.7 4.5 6.1 5 Age combined index CCI

Referred 4.3 4.8 5.8 5.1

Comparison 38.2 42 25.4 25.6 10 year survival CCI

Referred 45.5 33.5 21.5 32.4

Table 32 demonstrates that patients included in the sample from services with hospital mental health teams have higher levels of physical need compared to those in other service models. These patients also have lower 10 year survival expectancies. Patients in the comparison group tend to have higher levels of physical need overall compared to those in the referred cohort. Referred patients from TSM services tend to have higher rates of life expectancy than patients in referred into other service models and all comparison cohort patients. Patients referred into the smaller hospital mental health teams have the lowest rate of life expectancy overall.

Discharge destination

Table 33 shows discharge destination for different groups of patients by service typology.



Table 33. Discharge destination

Service model

Discharge

destination Gro

up TSM LPN HMHTa HMHTb Total

Com

par

ison

157

29%)

153

(29%)

53

(10%)

170

(32%)

533

(55%) Home

(independent

living)

Ref

erre

d

24

(9%)

54

(20%)

20

(7%)

172

(64%)

270

(36%)

Com

par

ison

73

(25%)

77

(26%)

25

(9%)

116

(40%)

291

(30%) Other

(dependent

living)

Ref

erre

d

36

(11%)

74

(21%)

23

(7%)

207

(61%)

340

(45%)

Com

par

ison

38

(35%)

21

(19%)

20

(19%)

29

(27%)

108

(11%)

RIP

Ref

erre

d

13

(14%)

20

(22%)

12

(13%)

46

(51%)

91

(12%)

Com

par

ison

12

(28%)

5

(12%)

4

(9%)

22

(51%)

43

(4%)

Missing

Ref

erre

d

9

(16%)

21

(38%)

4

(7%)

22

(39%)

56

(7%)



Higher proportions of patients are discharged to independent living in the comparison cohort compared to referred patients, who have higher rates of discharge to dependent living.

Length of stay

Table 34 shows length of stay for different groups of patients by service typology.

Table 34. Length of stay

Service model

Variable Group

TSM LPN HMHTa HMHTb

Comparison 272 249 98 318 Number

Referred 70 145 54 433

Comparison 20.7 12.2 22.1 20.8 Mean

Referred 57.1 40.2 53.6 36.7

Comparison 23.8 19.6 28.8 29.8 Std Deviation

Referred 50.5 27.9 40.3 31.3

Comparison 1.4 1.2 2.9 1.7 Std Error of the mean

Referred 6 2.3 5.5 1.5

Table 34 demonstrates that referred patients have a longer length of stay, and that patients referred to TSM services have the longest length of stay. The relationship between length of stay and service model is explored further in the statistical inference section of this report.

Summary

Referred and comparison patients showed little difference in age, gender or ethnicity, Most patients in both the cohorts were living independently. All hospital specialities were well represented in both cohorts, with elderly acute and acute medicine the commonest referrers to mental health services. A higher proportion of referred patients were prescribed psychotropic medication on admission and had a history of mental health problems. Referred patients appear to have lower levels of physical care needs than the comparison cohort. Referred patients had higher rates of institutionalisation and longer lengths of hospital stay.



4.3.3 Referred patient variables

Referral process

This section describes what happens when a patient is referred to the services by service typologies and key variables; profession of referrer; initial actions taken by mental health services; assessor profession; assessment outcome; use of other services; discharge from mental health service arrangements; mental health diagnosis.

Profession of referrer

Table 35 shows profession of referrers by service typology.



Table 35. Profession of referrer

Table 35 shows variances in profession of referrers by service model, with Doctors being the most frequent in TSM and large HMHT’s. Nurses refer to nurses in LPN models, and Occupational Therapists (OT) to OT in the small HMHT, demonstrating evidence of profession to profession referral.

Profession TSM LPN HMHTa HMHTb Total

Nurse

5

(6%)

107

(63%)

28

(48%)

17

(4%)

157

(21%)

Doctor

54

(66%)

30

(18%)

5

(9%)

372

(83%)

461

(61%)

Consultant

14

(17%)

2

(1%)

0

26

(6%)

42

(6%)

Surgeon

1

(1%)

0

0

3

(1%)

4

(1%)

Occupational

Therapist

0

2

(1%)

19

(32%)

2

23

(3%)

Support

Worker

0

2

(1%)

0

0

2

Social Worker

0

2

(1%)

1

(2%)

0

3

Medical

Student

0

1

(1%)

0

0

1

Missing

8

(10%)

23

(14%)

6

(10%)

27

(6%)

64

(9%)

Total 82 169 6 27 757



Initial actions taken by mental health services

Table 36 shows the initial actions taken by service typology.

Table 36. Initial actions taken

The majority of referrals received result in an assessment being arranged, although just over 20% of referrals to TSM request further information before action. Telephone advice is offered in 7-8% of referrals received by HMHTs. TSM rarely offer telephone advice.

Assessor profession

Table 37 shows the profession of assessors by service typology.

Initial action TSM LPN HMHTa HMHTb Total

Assessment

arranged

65

(9%)

156

(22%)

52

(8%)

421

(61%)

694

(92%)

Telephone advice

given

1

(2%)

10

(20%)

5

(10%)

35

(68%)

51

(7%)

Other

18

(25%)

19

(26%)

1

(1%)

34

(47%)

72

(10%)

None as patient

discharged

1

(5%)

5

(25%)

4

(20%)

10

(50%)

20

(3%)



Table 37. Assessor profession

Nurses undertake around half of all initial assessments in HMHTs and the majority in LPN models. Around 20% of assessments arranged in TSM models do not occur due to patients being discharged before appointments.

Assessment outcome

Table 38 shows the outcome of assessment by service typology. Liaison services seem to recommend medication in a lower proportion of their referred patients, although this may not be the case when absolute numbers are considered, since liaison service see a higher proportion of the hospital population.


Nurse

0

131

(78%)

29

(49%)

227

(51%)

387

(51%)

Doctor

32

(39%)

0

14

(24%)

143

(32%)

189

(25%)

Consultant

27

(33%)

0

6

(10%)

13

(3%)

46

(6%)

Occupational

Therapist

1

(1%)

0

0

29

(7%)

30

(4%)

Team Leader

0

9

(5%)

0

0

9

(1%)

Missing

5

(6%)

16

(10%)

3

(5%)

24

(5%)

48

(6%)

Not applicable

17

(21%)

13

(8%)

7

12%)

11

(3%)

48

(6%)

Total 82 169 59 447 757



Table 38. Outcome of assessment

TSM models tend to recommend medications to a greater extent compared to other services. Nurses tend to recommend nurse management plans in LPN models moreso than other models. There is a greater varation in outcomes for HMHTs, particularly with reviewing patients, where these are arranged in 28% of instances.

Use of other services

Table 39 shows where patients were referred on to as a consequence of mental health service assessment by service typology.

Outcome TSM LPN HMHTa HMHTb Total

Behavioural

management plan

2

(2%)

13

(6%)

2

(3%)

12

(2%)

29

(3%)

Nurse

management plan

8

(9%)

52

(24%)

10

(16%)

35

(7%)

105

(12%)

Medication

recommended

34

(37%)

34

(16%)

11

(18%)

80

(16%)

159

(19%)

Review

arranged

10

(11%)

39

(18%)

15

(24%)

138

(28%)

202

(24%)

Referred

elsewhere

19

(20%)

40

(19%)

10

(16%)

114

(23%)

183

(21%)

Other

20

(22%)

36

(17%)

14

(23%)

111

(23%)

181

(21%)



Table 39. Use of other services

Where referred TSM LPN HMHTa HMHTb Total

Consultant

Psychiatrist

4

(5%)

5

(3%)

0

3

(1%)

12

(2%)

District Nurse

1

(1%)

0

0

1

2

Mental Health

Capacity Advocates

2

(2%)

0

0

2

4

(1%)

Occupational

Therapist

1

(1%)

5

(3%)

0

13

(3%)

19

(3%)

Social Services

4

(5%)

21

(12%)

4

(7%)

30

(7%)

59

(8%)

Speech/Language

Therapist

1

(1%)

0

0

0

1

Psychology

1

(1%)

0

0

1

2

CMHT

2

(2%)

7

(4%)

5

(9%)

33

(7%)

47

(6%)

Memory Clinic

1

(1%)

0

0

11

(3%)

12

(2%)

Psychiatry

In-patient

0

0

0

5

(1%)

5

(1%)

Different ward

2

(2%)

0

0

2

4

(1%)

Out patients

0

1

(1%)

0

7

(2%)

8

(1%)

Intermediate

Care

0

0

1

(2%)

1

2

Missing

3

(4%)

7

(4%)

3

(5%)

44

(10%)

57

(8%)

Total 82 169 59 447 757



Services tend to refer onto community services, particularly HMHTs, although LPN models tend to refer greater numbers to social services compared to other models.

Discharge from mental health services arrangements

Table 40 shows where discharge arrangements from mental health services by service typology. Data was missing for 99 patients.

Table 40. Discharge arrangements from mental health services

High levels of missing data in discharge arrangements reflects the model’s capacity to record it and the likely closure of the referral. This suggests that some patients may have no follow-up from admission. Discharge to CMHTs is common. Large HMHTs tend to follow-up to GPs in approximately a third of cases.

Mental health diagnoses

Table 41 shows mental health diagnoses by service topology.

Discharge arrangements TSM LPN HMHTa HMHTb Total

Transfer hospital

5

(6%)

8

(11%)

6

(8%)

57

(75%)

76

(10%)

CMHT

12

(7%)

38

(22%)

19

(11%)

105

(60%)

174

(23%)

Out-patients

appointment

5

(26%)

4

(21%)

0

10

(53%)

19

(3%)

GP

2

(1%)

13

(8%)

2

(1%)

139

(89%)

156

(21%)

Other

19

(10%)

50

(26%)

8

(4%)

118

(61%)

195

(26%)

Missing

16

(20%)

32

(19%)

3

(5%)

48

(11%)

99

(17%)

Total 82 169 59 447 757



Table 41. Mental health diagnoses

Mental health diagnosis TSM LPN HMHTa HMHTb Total

Schizophrenia/ delusional disorder

7

(9%)

6

(3%)

1

(1%)

22

(5%)

36

(4%)

Dementia

11

(14%)

45

(26%)

11

(15%)

133

(27%)

200

(24%)

Delirium

5

(6%)

11

(6%)

8

(11%)

50

(10%)

74

(9%)

Delirium with dementia

2

(3%)

7

(4%)

0

16

(3%)

25

(3%)

Alcohol related

4

(5%)

3

(2%)

0

10

(2%)

17

(2%)

Depression/low mood

23

(30%)

55

(31%)

16

(22%)

124

(25%)

218

(27%)

Anxiety

8

(10%)

8

(5%)

7

(10%)

16

(3%)

39

(5%)

Drug related

0

0

1

(1%)

0

1

(1%)

Required capacity assessment

5

(6%)

18

(10%)

0

13

(2%)

36

(4%)

Cognitive impairment

7

(9%)

7

(4%)

20

(28%)

12

(2%)

46

(6%)

Other

6

(8%)

9

(5%)

4

(6%)

35

(7%)

54

(7%)

Missing

0

7

(4%)

4

(6%)

63

(13%)

74

(9%)

Total 78 176 72 494 820



The most common diagnoses is depression/low mood in TSM and LPN models. Delirium is more common in HMHT suggesting that it is detected more frequently in specialist models. Around half to a third of referrals assessed have depression/low mood. LPN and large HMHTs see dementia with delirium more frequently compared to other models.

Summary

We found that the different service models unsurprisingly had different rates of assessment by different professionals, with the multidisciplinary teams able to offer a wider range of professional backgrounds more in keeping with other mental health care settings. Different models types received referrals from a different range of professional from the general hospital, reflecting team composition (nurses more likely to refer to teams comprised of nurses for example) and local custom and practice. After assessment, the traditional sector model advice (almost exclusively provided by doctors) was to recommend medication more often than other models, and the hospital mental health team was more likely to follow up the patient on the ward. All models employed a range of follow-up options on discharge, with low levels of transfer to psychiatric wards. Follow up by the patient’s general practitioner, social services and community mental health teams were the commonest arrangements. In terms of casemix, depression, dementia and delirium predominate in all models, with the traditional sector model and liaison nurse models seeing relatively more depression and hospital mental health teams seeing relatively more delirium.

4.3.4 Statistical inference - Length of stay

The principle outcome for the evaluation is length of stay. The data were examined for variables that have previously been related to length of stay (see literature review section): gender; psychotropic medication prescription; previous psychiatric history; admitting specialty; age and level of physical need (Charlson index). Table 42 shows number of patients for which length of stay data was available.



Table 42. Length of stay data numbers

Figures 20.1 and 20.2 shows boxplot results for this data.

Cases Group TSM LPN HMHTa HMHTb

Comparison

272

(97%)

249

(97%)

98

(96%)

318

(94%) Valid

Referred

70

(85%)

145

(86%)

54

(92%)

433

(97%)

Comparison

8

(3%)

7

(3%)

4

(4%)

19

(6%) Missing

Referred

12

(15%)

24

(14%)

5

(8%)

14

(3%)

Comparison 280 256 102 337 All

Referred 82 169 59 447



Figure 20.1 Boxplot results for length of stay by patient group and service model

HMHTbHMHTaLPNTSM

Service Model

400

200

0

LO

S (

days)

ReferredComparisonGroupBoxplot for Length of Stay



Figure 20.2 Boxplot results for length of stay by patient group and service model – Log LOS

HMHTbHMHTaLPNTSM

Service Model

6.00

5.00

4.00

3.00

2.00

1.00

0.00

Lo

g L

OS

(d

ay

s)

ReferredComparisonGroupBoxplot for Log Length of Stay



ANOVA results used to test whether differences in mean length of stay and log LOS for referred patients only, across the service models were statistically significant or just down to random chance, are shown in Table 43.

Table 43. ANOVA for service model

From the one-way ANOVA it can be seen that there were significant differences in length of stay and log length of stay between the four service models for the referred patients, both with p values <0.001. Table 44 shows the least significant difference (LSD) multiple comparisons of all possible comparisons between the means.

Length of Stay (LOS) Sum of Squares

df Mean Square

F Sig.

Between Groups

34885.288 3 11628.429

Within Groups

797657.9 698 1142.776 LOS

Total 832543.2 701

10.176 .000

Between Groups

22.926 3 7.642

Within Groups

563.601 698 .807

Log

LOS

Total 586.528 701

9.464 .000



Table 44. LSD Multiple comparisons

* the mean difference is significant at the .05 level; ≠95% confidence interval

Var

iable

model

model

Mean

D

iffe

ren

ce

Std

. E

rro

r

Sig

.

≠Lo

wer

Bo

un

d

≠U

pp

er

Bo

un

d

LPN

-16.915* 4.920 .001 -26.58 -7.26

HM

HTa

-3.532 6.123 .564 -15.55 8.49

TSM

HM

HTb

-20.443* 4.355 .000 -28.99 -11.89

TSM

16.915* 4.920 .001 7.26 26.58

HM

HTa

13.384* 5.389 .013 2.80 23.96

LPN

HM

HTb

-3.528 3.244 .277 -9.90 2.84

TSM

3.532 6.123 .564 -8.49 15.55

LPN

-13.384* 5.389 .013 -23.96 -2.80

HM

HTa

HM

HTb

-16.911* 4.879 .001 -26.49 -7.33

TSM

20.443* 4.355 .000 11.89 28.99

LPN

3.528 3.244 .277 -2.84 9.90

LOS

HM

HTb

HM

HTa

16.911* 4.879 .001 7.33 26.49



LSD Multiple Comparisons (contd)

* the mean difference is significant at the .05 level; ≠95% confidence interval

Var

iable

model

model

Mean

D

iffe

ren

ce

Std

. E

rro

r

Sig

.

≠Lo

wer

Bo

un

d

≠U

pp

er

Bo

un

d

LPN

-.27305* .13078 .037 -.5298 -.0163

HM

HTa

-.05822 .16275 .721 -.3778 .2613

TSM

HM

HTb

-.49478* .11576 .000 -.7221 .2675

TSM

.27305* .13078 .037 .0163 .5298

HM

HTa

.21483 .14325 .134 -.0664 .4961

LPN

HM

HTb

-.22173* .08622 .010 -.3910 .0525

TSM

.05822 .16275 .721 -.2613 .3778

LPN

-.21483 .14325 .134 -.4961 .0664

HM

HTa

HM

HTb

-.43656* .12968 .001 -.6912 -.1819

TSM

.49478* .11576 .000 .2675 .7221

LPN

.22173 .08622 .010 .0525 .3910

LogLO

S

HM

HTb

HM

HTa

.43656* .12968 .001 .1819 .6912



Length of stay data (LSD) comparisons reveal that referred patients in a TSM have a significantly longer length of stay than patients in both LPN (p=0.001) and HMHTb (p=<0.001) service models. Referred patients in a LPN have a significantly shorter length of stay than patients in a HMHTa (p=0.13). Referred patients in a HMHTa service have a significantly longer length of hospital than patients in a HMHTb (p=0.001). The biggest difference appears to be between patients in a TSM and those in a HMHTb. These differences can be clearly seen in the graph depicting the mean length of stay of each of the four service model groups, shown in Figure 21.

Figure 21. Means Plot for length of stay(days) by service model

HMHTbHMHTaLPNTSM

Service Model

60

55

50

45

40

35

Mea

n o

f le

ng

th o

f st

ay

The following tables (45-50) show descriptive statistics for each nominal variable which is thought to influence the length of stay of referred patients: gender; psychotropic medication on admission and previous psychiatric history. Results are presented by both length of stay and log length of stay as the length of stay data in its raw form is significantly skewed, as can be seen in Figure 20.1. A t-test was then performed to test whether the differences in mean length of stay and mean log LOS between the groups were statistically significant or just down to random chance. The Levene’s test is performed first and tests one of the assumptions of the t-test i.e. that the variance in the two groups are equal. When this assumption of homogeneity of variances is not satisfied, then the t-statistic is based upon an adjusted degrees of freedom which takes into account the unequal variances in the two groups.



Gender Table 45. Length of stay summary statistics for gender

Table 46. Independent samples test for gender

Levene’s test for equality of variances produces a p value of 0.006 for LOS which demonstrates that the assumption of equal variances is not valid. Subsequently taking the log of the length of stay data, Levene’s test for equality of variances produces a p value of 0.243 and thus equal variances can be assumed in this case. The mean difference in length of stay between referred males and females is 4.6 days (95% CI -1.10 to 10.29) suggesting that on average referred males tend to spend longer time in hospital than referred females. However this difference between male and female length of stay times could be as little as one day less or up to ten days more and there is no evidence of a significant difference between the length of stay times for male and females (p=0.113).

Variable Gender N Mean Std. Deviation Std. Error Mean

Male 253 43.77 39.643 2.492

LOS

Female 446 39.17 31.149 1.475

Male 253 3.4225 .95553 .06007

LogLOS

Female 446 3.3683 .89164 .04222

Levene’s Test for Equality of Variances Variable

F Sig. t df

LOS Equal variances not assumed

7.727 .006 1.587 429.586

LogLOS Equal variances assumed 1.365 .243 .752 697

t-test for Equality of Means

Variable

Sig

.

(2

-ta

iled

)

Mean

D

iffe

ren

ce.

Std

. Err

or

Dif

fere

nce

95

%

Co

nfi

den

ce

inte

rval

Lo

wer

95

%

Co

nfi

den

ce

inte

rval

Up

per


.113 4.596 2.896 -1.096 10.289

LogLOS Equal variances assumed .452 .5420 .0720 -.8724 .19563



The mean difference in log (length of stay) between referred males and females is -0.072 (95% CI -0.087 to 0.196). This suggests that again there is no statistical evidence of a significant difference between the log length of stay times for referred male and females (p=0.452).

Psychotropic medication

Table 47. Length of stay summary statistics for psychotropic medication at admission

Table 48. Independent samples test for psychotropic medication

When examining patients on psychotropic medication on admission compared to those not taking this type of medication, Levene’s test for equality of variances produces p values of 0.783 and 0.118 for LOS and LogLOS respectively which establishes that the assumption of equal variances is valid. With p value 0.095, there is no statistical evidence of a significant difference between the length of stay times for referred patients on psychotropic

Variable Psychotropic medication

N Mean Std. Deviation

Std. Error Mean

Yes 299 38.88 35.772 2.069

LOS

No 357 43.39 33.315 1.763

Yes 299 3.3181 .93127 .5386

LogLOS

No 357 3.4944 .84375 .04466


F Sig. t df


.076 .783 -1.671 654

LogLOS Equal variances assumed 2.448 .118 -2.542 654


Variable

Sig

.

(2

-ta

iled

)

Mean

D

iffe

ren

ce.

Std

. Err

or

Dif

fere

nce

95

%

Co

nfi

den

ce

inte

rval

Lo

wer

95

%

Co

nfi

den

ce

inte

rval

Up

per


-.095 -4.513 2.701 -9.817 .791

LogLOS Equal variances assumed .011 -.17629 .0693 -.31248 -.04011



medication at admission, and those that are not. The mean difference in length of stay between the two groups is -4.5 days (95% CI -9.81 to 0.79) indicating that referred patients on psychotropic medication at admission on average are spending less time in hospital than those that are not. There is evidence of a significant difference between the logged length of stay times for referred patients on psychotropic medication at admission, and those that are not (p=0.011). LogLOS is an improvement on LOS at explaining the variation in the data. The mean difference in log (length of stay) between the two groups is -0.176 (95% CI -0.312 to -0.040). This suggests that patients who are already receiving an intervention for mental health needs prior to admission are likely to have a shorter length of stay in hospital compared to those with a mental health need that is recognised during their current hospital admission. Previous psychiatric history

Table 49. Length of stay summary statistics for previous psychiatric history

Table 50. Independent samples test for previous psychiatric history

Variable Psychiatric history

N Mean Std. Deviation

Std. Error Mean

Yes 383 38.88 32.413 1.656

LOS

No 272 45.21 37.941 2.300

Yes 383 3.3474 .90927 .04646

LogLOS

No 272 3.4992 .88752 .05381


F Sig. t df

LOS Equal variances not assumed 3.037 .082 -2.293 653

LogLOS Equal variances assumed .037 .847 -2.127 653

t-test for Equality of Means Variable

LOS Equal variances not assumed .022 -6.331

2.760 -11.751

-.910

LogLOS Equal variances assumed

.034 =.151

8 .071

3 -.29206

-.01170



Levene’s test for equality of variances produces a p value of 0.082 and 0.847 for LOS and Log LOS respectively which establishes that the assumption of equal variances is valid. With p value 0.022, there is evidence of a significant difference between the length of stay times for referred patients with previous psychiatric history noted, and those with no previous history noted. The mean difference in length of stay between these two groups is -6.33 days (95% CI -11.75 to -0.91), with patients with previous psychiatric history noted on average spending less time in hospital than those with no history noted. There’s evidence of a significant difference between the logged length of stay times for referred patients with previous psychiatric history noted, and those with no history (p=0.034). The mean difference in log (length of stay) between the two groups is -0.152 (95% CI -0.292 to -0.012). These findings are similar (and significant) to those reported for use of psychotropic medication prior to current hospital episode. This suggests that knowledge of, and possibly established care pathways with mental health services from previous admissions, are related to shorter lengths of stay with these patients. Admitting specialty categories A one-way ANOVA was used to test whether differences in mean length of stay and log LOS among admitting speciality categories were statistically significant or just down to random chance, using the referred patient data only. Table 51 shows the summary statistics for the categories and Table 52 shows the ANOVA results.



Table 51. Length of stay summary statistics for admitting specialty

Admitting specialty

LOS N Mean Std. Deviation

Std. Error Mean

LOS 5 39.20 27.716 12.395 Urology(U)

LogLOS 5 3.4671 .79976 .35766

LOS 23 42.39 39.572 8.251 General Surgery(GS)

LogLOS 23 3.4048 .89863 .18738

LOS 75 42.69 30.730 3.548 General Medicine(GM)

LogLOS 75 3.5198 .78881 .09108

LOS 165 32.91 27.669 2.154 Elderly Acute(EA)

LogLOS 165 3.1581 .94889 .07387

LOS 61 52.61 48.120 6.161 Acute Medicine(AM)

LogLOS 61 3.5998 .98378 .12596

LOS 33 42.15 27.804 4.840 Orthopaedics(O)

LogLOS 33 3.5079 .81768 .14234

LOS 27 36.63 34.763 6.690 Cardiology(C)

LogLOS 27 3.2546 .91691 .17646

LOS 200 40.42 32.289 2.283 Emergency Admissions(EmA)

LogLOS 200 3.3994 .90421 .06394

LOS 9 48.89 30.048 10.016 Respiratory(R)

LogLOS 9 3.7803 .52378 .17459

LOS 69 46.67 40.810 4.913 Other

LogLOS 69 3.5602 .80672 .09712

LOS 667 40.68 34.192 1.324 Total

LogLOS 67 3.3936 .90186 .3492



Table 52. ANOVA for admitting specialty

From the one-way ANOVA it can be seen that there were significant differences in length of stay and log length of stay between the 10 admitting speciality groups, with p values 0.021 and 0.011 respectively. A least significant difference (LSD) multiple comparisons of all possible comparisons between the means was performed in order to see where these significant differences lie. Table 53 below shows comparisons which yielded significant differences.

Length of Stay (LOS) Sum of Squares

df Mean Square

F Sig.

Between Groups

22630.352 9 2514.484

Within Groups

756005.9 657 1150.694 LOS

Total 778636.3 666

2.185 .02

Between Groups

17.190 9 1.910

Within Groups

524.505 657 .798 LogLOS

Total 541.695 666

2.393 .01



Table 53. Multiple comparisons showing significant differences by admitting

specialty

* the mean difference is significant ath the .05 level; ≠95% confidence interval

Var

iable

spec

ialty

spec

ialty

Mean

D

iffe

ren

ce

Std

. E

rro

r

Sig

.

≠Lo

wer

Bo

un

d

≠U

pp

er

Bo

un

d

GM

EA

9.784* 4.724 .039 .51 19.06 G

M

-9.784* 4.724 .039 -19.06 -.51

AM

-19.697* 5.083 .000 -29.68 -9.72

Em

A

-7.511* 3.568 .036 -14.52 -.51

EA

Oth

er

-13.758* 4.863 .005 -23.31 -4.21

EA

19.697* 5.083 .000 9.72 29.68

C

15.977* 7.841 .042 .58 31.37 AM

Em

A

12.187* 4.962 .014 -21.93 21.93

C

AM

-15.977* 7.841 .042 -31.37 -.58

EA

7.511* 3.568 .036 .51 14.52

Em

A

AM

-12.187* 4.962 .014 -21.93 -2.44

LOS

Oth

er

EA

13.758* 4.863 .005 4.21 23.31



Multiple comparisons showing significant differences by admitting specialty (contd)

* the mean difference is significant ath the .05 level; ≠95% confidence interval

Var

iable

spec

ialty

spec

ialty

Mean

D

iffe

ren

ce

Std

. E

rro

r

Sig

.

≠Lo

wer

Bo

un

d

≠U

pp

er

Bo

un

d

GM

EA

.362171* .12443 .004 .1174 .6060 G

M

-.36171* .12443 004 -6060 -.1174

AM

-.44169* .13389 .001 -.7046 -.1788

O

-.34981* .17038 .040 -.6844 -.0153

Em

A

-.24124* .09387 .010 -.4258 -.0567

R

-.62221* .30585 .042 -1.2228 -.0217

EA

Oth

er

-.40210* .12810 .002 -.6536 -.1506

AM

EA

.44169* .13389 .001 .1788 .7046

O

EA

.34981* .17038 .040 .0153 .6844

Em

A

EA

.24124* .09397 .010 .0567 .4258

R

EA

.62221* .30585 .042 .0217 1.2228

LogLO

S

R

EA

.40210* .12810 .002 .1506 .6536



LSD comparisons reveal that referred patients in general medicine have a significantly longer length of stay than patients in elderly acute (p=0.039). Referred patients in elderly acute have a significantly shorter length of stay than patients in acute medicine (p=<0.001), emergency admissions (p=0.36) and other (p=0.005). Finally referred patients in acute medicine have a significantly longer mean length of stay than patients in cardiology (p=0.042) and emergency admissions (p=0.014). This suggests that services specifically specialising in elderly care are related to shorter lengths of stay when compared to general care areas.These differences can be clearly seen in Figure 22 which depicts the mean length of stay of each of the ten admitting specialties.

Figure 22. Means Plot for mean length of stay by admitting specialty

RespiratoryOtherEmergency admissions

CardiologyOrthopaedicsAcute Medicine

Elderly AcuteGeneral Medicine

General Surgery

Urology

Admitting specialty category

55

50

45

40

35

30

Mea

n o

f le

ng

th o

f st

ay

Relationship between age and level of physical need A correlation matrix was produced in order to determine the relationship between two continuous variables (Age; Weighted index CCI; Age combined CCI and 10 year survival CCI). Pearson’s correlation coefficient (r) is the statistic used to determine to what degree and in which direction this relationship exists. This is shown in Table 54.



Table 54. Correlations between continuous variables

Var

iable

Pear

son’s

st

atist

ic

LO

S

Lo

gLO

S

Ag

e a

t ad

mis

sio

n

Weig

hte

d

ind

ex C

CI

Ag

e

com

bin

ed

in

dex C

CI

10

year

surv

ival

CC

I

Correlation 1 .846 -.024 .054 .037 -.025

Sig. (2-tailed)

.000 .523 .162 .340 .522 LOS

N 702 702 699 662 662 662

Correlation .846 1 .043 .047 .056 -.062

Sig. (2-tailed)

.000 .257 .231 .149 .110

LogLO

S

N 702 702 699 662 662 662

Correlation -.024 .043 1 -.106 .308 -.433

Sig. (2-tailed)

.523 .257 .005 .000 .000

Age

at a

dm

issi

on

N 699 699 751 707 707 707

Correlation .054 .047 1 -.106 .308 -.433

Sig. (2-tailed)

.162 .231 .005 .000 .000

Wei

ghte

d index

CCI

N 662 662 707 708 708 708

Correlation .037 .056 .308 .882 1 -.865

Sig. (2-tailed)

.340 .149 .000 .000 .000

Age

com

bin

ed

index

CCI

N 662 662 707 708 708 708

Correlation -.025 -.062 -.433 -.667 -.865 1

Sig. (2-tailed)

.522 .110 .000 .000 .000

10 y

ear

surv

ival

CCI

N 662 662 707 708 708 708



There are no statistically significant relationships between either LOS or LogLOS and the four continuous variables.

Linear Regression A linear regression model was used to model the relationship between log length of stay and various categorical and continuous variables, thought to influence a referred patient’s length of stay in hospital. This is shown in Table 55.

Table 55. Model coefficients

The model suggests that previous psychiatric history and unit specific service model are both significant predictors of length of stay (log) for referred patients, with p values 0.019 and <0.001 respectively. However, with adjusted R square 0.031, only 3.1% of the variance in the log length of stay data is explained by the variables in the model. A summary of the model is shown in Table 56.

Table 56. Model summary

a. Predictors: (Constant), Previous psychiatric history notes in acute hospital trust notes b. Predictors: (Constant), Previous psychiatric history notes in acute hospital trust notes, Unit

Specific Service Model

Unstandardised Coefficients

Standardised Coefficients

Model

B Std. Error

Beta

t Sig.

1

(Constant)

Previous psychiatric history noted in acute hospital trust notes

3.159

.186

.108

.072

.105

29.32

2.591

.000

.010

2

(Constant)

Previous psychiatric history noted in acute hospital trust notes

Unit Specific Service Model

3.550

.168

-.045

.148

.071

.012

-.095

-.153

23.96

2.350

-3.79

.000

.019

.000

Model

R

R S

qu

are

Ad

just

ed

R

Sq

uare

Std

. Err

or

of

the

Est

imate

R S

qu

are

C

han

ge

F C

han

ge

df1

df2

Sig

. F

Ch

an

ge

1

.105a .011 .009 .8702 .011 6.713 1 601 .010

2

.185b .034 .031 .8507 .023 14.43 1 600 .000



Summary

The mean length of stay of referred patients was 41 days. We found significant differences between the service models, with the traditional sector model and small multidisciplinary teams having longer stays for referred patients than the nursing or large multidisciplinary team models. These are not like-for like comparisons however. No significant difference in length of stay was found for males or females. Referred patients on psychotropic medication on admission or with a history of mental health problems had lower lengths of stay than those without. The referring speciality appeared to influence length of stay, with elderly acute referrals having the lowest length of stay, perhaps reflecting skills in complex discharges.

4.3.5 Survival analysis The following section presents univariate summaries of various categorical and continuous variables by survival status, using all patient data. Subsequent to this are results from numerous chi-square tests which were used to measure the association between survival status (referred to in the tables as death status), and each categorical variable. Table 57 shows the survival status by service model.

Table 57. Survival status by service model

There is a significant relationship between service model and survival status. Pearson Chi-Square statistic of 17.608 (N=1633) and p value 0.001 (2-sided), shows that the liaison psychiatry nurse and large hospital mental health team are related to increased survival (although this may of course be an erroneous assumption given baseline differences in those referred to different

Survival status

Service model

Yes No Missing

Total

TSM 290

(80%)

51

(14%)

21

(6%) 362

LPN 358

(84%)

41

(10%)

26

(6%) 425

HMHTa 121

(75%)

32

(20%)

8

(5%) 161

HMHTb 665

(85%)

75

(10%)

44

(6%) 784

Total 1434

(82%)

199

(12%)

99

(6%) 1732



services).Table 58 shows survival status on the referred and comparison groups.

Table 58. Survival status by patient group

Pearson Chi-Square statistic of 0.726 (N=1633) and p value 0.401 (2-sided), shows that there is no significant relationship between referral group, and survival status. Table 59 shows survival status by gender.

Table 59. Survival status by gender

Pearson Chi-Square statistic of 1.594 (N=1.594) and p value 0.220 (2-sided), shows that there is no significant relationship between gender and survival status. Table 60 shows the survival status related to psychotropic drug prescription on admission.

Survival status

Group

Yes No Missing

Total

Comparison 824

(85%)

108

(11%)

43

(4%) 975

Referred 610

(81%)

91

(12%)

56

(7%) 757

Total 1434

(82%)

199

(12%)

99

(6%) 1732

Survival status

Group

Yes No Missing

Total

Male 587

(82%)

91

(13%)

38

(5%) 716

Female 844

(84%)

108

(11%)

59

(6%) 1011

Missing 3 0 2 5

Total 1434

(82%)

199

(12%)

99

(6%) 1732



Table 60. Survival status for psychotropic medication at admission

With a Pearson Chi-Square statistic of 0.677 (N=1578) and p value 0.420 (2-sided), there is no significant relationship between whether or not patients were on psychotropic medication at admission, and survival status. Table 61 shows the survival status for previous psychiatric history.

Table 61. Survival status for previous psychiatric history noted in acute hospital

trust notes

With a Pearson Chi-Square statistic of 0.909 and p value 0.382 (2-sided), there is no significant relationship between whether or not patients had previous psychiatric history noted in acute hospital trust notes, and survival status. Table 62 shows information on age and level of physical need by survival status.

Survival status Psychotropic medication on admission

Yes No Missing

Total

Yes 475

(81%)

72

(12%)

37

(6%) 584

No 910

(84%)

121

(11%)

47

(4%) 1078

Missing 49 6 15 70

Total 1434

(82%)

199

(12%)

99

(6%) 1732

Survival status Previous psychiatric history noted

Yes No Missing

Total

Yes 535

(83%)

67

(10%)

41

(6%) 643

No 842

(84%)

123

(12%)

42

(4%) 1007

Missing 57 9 16 82

Total 1434

(82%)

199

(12%)

99

(6%) 1732



Table 62. Continuous variable statistics by survival status

Variable Survival status

N Mean Std. Deviatio

n

Std. Error Mean

Yes 1431 80.24 7.864 .208

Age at admission

No 199 81.89 8.299 .588

Yes 1363 1.40 1.650 .045 Weighted index CCI

No 193 2.08 2.334 .168

Yes 1363 4.96 1.817 .049 Age combined index CCI

No 193 5.76 2.426 .175

Yes 1363 34.35 29.499 .799 10 year survival CCI

No 193 26.60 28.599 2.059


F Sig. t df

Age at admission

(Equal variances assumed) .007 .934 -2.761 1628

Weighted index CCI

(Equal variances not assumed) 33.07 .000 -3.904 219.9

Age combined index CCI

(Equal variances not assumed) 27.00 .000 -4.401 223.5

10 year survival CCI

(Equal variances assumed) 2.061 .151 3.426 1554



Continuous variable statistics by survival status (continued)

When investigating patients with various ages and Charlson scores, Levene’s test for equality of variances produces a p value of 0.934 for age at admission which establishes that the assumption of equal variances is valid. Equal variances can also be assumed for the variable 10 year survival CCI with p value 0.151, but for weighted index CCI and age combined index CCI equal variances cannot be assumed both with p values <0.001. The mean difference for age at admission between patients who died in hospital and those that didn’t is -1.65 years (95% CI -2.83 to -0.48), indicating that on average patients who subsequently died in hospital, were older on admission. This difference is statistically significant with p value 0.006. The mean difference in weighted index CCI between patients who died in hospital and those that didn’t is -0.68 (95% CI -1.02 to -0.34), indicating that on average patients who subsequently died in hospital, had a larger weighted index CCI. This difference is significant with p value <0.001. The mean difference in age combined index CCI between patients who died in hospital and those that didn’t is -0.80 (95% CI -1.16 to -0.44), indicating that on average patients who subsequently died in hospital, had a larger age combined index CCI. This difference is significant with p value <0.001. Finally the mean difference in 10 year survival CCI between patients who died in hospital and those that did not is 7.75 (95% CI 3.31 to 12.18), indicating that on average patients who subsequently died in hospital, had a smaller 10 year survival CCI. Table 63 shows the effect of admitting speciality on survival status.


Variable

Sig

.

(2

-ta

iled

)

Mean

D

iffe

ren

ce.

Std

. Err

or

Dif

fere

nce

95

%

Co

nfi

den

ce

inte

rval

Lo

wer

95

%

Co

nfi

den

ce

inte

rval

Up

per

Age at admission

(Equal variances assumed) .006 -1.654 .599 -2.829 -.479

Weighted index CCI

(Equal variances not assumed) .000 -.679 .174 -1.021 -.336


(Equal variances not assumed) .000 -.798 .181 -1.156 -.441


(Equal variances assumed) .001 7.745 2.260 3.311 12.178



Table 63. Admitting speciality category by survival status

A one-way ANOVA was used to test whether the differences in survival status among admitting speciality categories were statistically significant or just down to random chance. It can be seen that there were statistically significant differences in survival status between the ten admitting speciality groups (F=2.256, df=1571, p =0.017).

Survival status

Admitting specialty

Yes No Missing

Total

Urology(U)

40

(91%)

2

(5%)

2

(4%) 44

General Surgery(GS)

92

(87%)

7

(7%)

7

(6%) 106

General Medicine(GM)

162

(78%)

33

(16%)

12

(6%) 207

Elderly Acute(EA)

335

(85%)

45

(11%)

16

(4%) 396

Acute Medicine(AM) 185

(82%)

29

(13%)

11

(5%) 225

Orthopaedics(O)

81

(94%)

4

(5%)

1

(1%) 86

Cardiology(C)

61

(86%)

6

(9%)

4

(5%) 71

Emergency Admissions(EmA)

301

(82%)

36

(10%)

29

(8%) 366

Respiratory(R)

27

(82%)

5

(15%)

1

(3%) 33

Other

106

(80%)

24

(18%)

3

(2%) 133

Missing 44 8 15 65

Total

1434

(83%)

199

(12%)

99

(5%) 1732



A multivariate logistic regression model was used to predict a patient’s survival status, based on the numerous categorical and continuous variables (univariate summaries of which are presented in Figures 56-62). The factors in the model were unable to predict patients survival status from the variables measured. This may due to the low event rate of service, and lack of measurement of related variables.

Summary

Our findings suggest that two service models (liaison nursing and the large hospital mental health team) have a positive effect on survival for those patients referred to them. However, this may well be a result of differences in casemix of those referred rather than a direct effect of the service model in place. There was no difference in mortality between the referred and comparision cohorts, and gender, psychotropic medication on admission and history of mental health problems had no effect on mortaility of those referred. Increased age had ann adverse effect on survival.



4.3.6 Discharge destination for referrals

Table 64 shows how many patients underwent a change in accommodation on discharge form hospital. Approximately half of all patients admitted from independent living required some form of supported accommodation on discharge.

Table 64. Discharge destination by residential status on admission

a. Patient passed away in hospital b. Includes: Nursing home, residential home, transfer to another hospital, intermediate care,

psychiatric in-patient, sheltered accommodation and living with relatives

Table 65 shows the discharge destination of patients by service model.

Residential status on admission

Discharge destination

Liv

ing

in

dep

en

den

tly

Liv

ing

wit

h

rela

tives

No

n N

HS

re

sid

en

tial

care

NH

S

resi

den

tial

care

Mis

sin

g

To

tal

Home (independent living)

244

(50%)

1

(2%)

2

(2%)

1

(2%)

22

(41%)

270

(36%)

Other (dependent living)b

146

(30%)

55

(85%)

84

(84%)

37

(77%)

18

(33%

340

(45%)

NAa

60

(12%)

7

(11%)

10

(10%)

7

(15%)

7

(13%)

91

(12%)

Missing

40

(8%)

2

(3%)

4

(4%)

3

(6%)

7

(13%)

56

(7%)

Total 490 65 100 48 54 757



Table 65. Discharge destination by service model

This suggests that patients discharged from hospital operating with less specialised models proportionally have higher levels of community care packages compared to those discharged from liaison team services. However, none of these findings were significant (Chi=6.577,p>.05). Tables 66-69 shows the relationship between categorical and continuous variables measured, and discharge destination.

Table 66. Discharge destination by gender

Discharge

destination


Home

(independent living)

24

(29%)

54

(32%)

20

(34%)

172

(39%)

270

(36%)

Other

(dependent living)b

36

(44%)

74

(44%)

23

(39%)

207

(46%)

340

(45%)

NAa

13

(16%)

20

(12%)

12

(20%)

46

(10%)

91

(12%)

Missing

9

(11%)

21

(12%)

4

(7%)

22

(5%)

56

(7%)

Total 82 169 59 447 757

Discharge

destination

Male Female Missing Total

Home


95

(35%)

173

(36%)

2

(40%)

270

(36%)

Other

(dependent living)b

123

(45%)

216

(45%)

1

(20%)

340

(45%)

NAa

38

(14%)

53

(11%)

0

91

(12%)

Missing

17

(6%)

37

(8%)

2

(40%)

56

(7%)

Total 273 479 5 757



Table 67. Discharge destination by psychotropic medication at admission

Table 68. Discharge destination by previous psychiatric history noted in acute

hospital trust notes

Discharge

destination

Yes No Missing Total

Home


107

(33%)

145

(38%)

18

(33%)

270

(36%)

Other

(dependent living)b

156

(48%)

161

(43%)

23

(43%)

340

(45%)

NAa

34

(11%)

52

(14%)

5

(9%)

91

(12%)

Missing

28

(8%)

20

(5%)

8

(15%)

56

(7%)

Total 325 378 54 757

Discharge

destination

Yes No Missing Total

Home


134

(33%)

115

(40%)

21

(38%)

270

(36%)

Other

(dependent living)b

210

(51%)

113

(39%)

17

(30%)

340

(45%)

NAa

35

(9%)

47

(16%)

9

(16%)

91

(12%)

Missing

32

(8%)

15

(5%)

9

(16%)

56

(7%)

Total 411 290 56 757



Table 69. Summary statistics for continuous variables by discharge to

dependent living with independent samples test

Variable Discharged to

dependent living

N Mean Std. Deviatio

n

Std. Error Mean

No 268 79.82 7.531 .460

Age at admission

Yes 339 80.96 7.836 .426

No 251 1.31 1.564 .099 Weighted index CCI

Yes 323 1.32 1.527 .085

No 251 4.85 1.674 .106 Age combined index CCI

Yes 323 4.95 1.625 .090

No 251 35.65 28.718 1.813 10 year survival CCI

Yes 323 33.29 28.121 1.565


F Sig. t df

Age at admission

(Equal variances assumed) .217 .642 -1.817 605

Weighted index CCI

(Equal variances not assumed) .057 .811 -.086 572


(Equal variances not assumed) .060 .806 -.758 572


(Equal variances assumed) .241 .623 .989 572



Summary statistics for continuous variables by discharge to dependent living with independent samples test (continued)

The mean difference in years for age at admission between patients who were discharged to dependent living and those that weren’t is -1.14 years (95% CI -2.38 to 0.09), indicating that on average patients who were discharged to dependent living, were older on admission. However, this difference is insignificant with p value 0.070. The mean difference in weighted index CCI between patients who were discharged to dependent living and those that were not is -0.01 (95% CI -0.27 to 2.44), indicating that on average patients who were discharged to dependent living, had a larger weighted index CCI. This difference however is insignificant with p value 0.931. The mean difference in age combined index CCI between patients who were discharged to dependent living and those that were not is -0.105 (95% CI -0.377 to 0.167), indicating that on average patients who were discharged to dependent living, had a larger age combined index CCI. This difference however is insignificant with p value 0.449. Finally the mean difference in 10 year survival CCI between patients who were discharged to dependent living and those that weren’t is 2.361 (95% CI -2.329 to 7.052), indicating that on average patients who subsequently were discharged to dependent living, had a smaller 10 year survival CCI. A multivariate logistic regression model was used to predict a patient’s discharge destination, based on numerous categorical and continuous variables (univariate summaries of which are shown in Figures 68-70). However, most of the variation in the data has not been explained by the factors in the model. It cannot predict discharge destination from the variables measured, however this may be related to the large amount of missing data observed.

Summary

We found no significant difference in institutionalisation rates with difference liaison service models. Other factors measured were similarly unable to predict institutionalisation.


Variable

Sig

.

(2

-ta

iled

)

Mean

D

iffe

ren

ce.

Std

. Err

or

Dif

fere

nce

95

%

Co

nfi

den

ce

inte

rval

Lo

wer

95

%

Co

nfi

den

ce

inte

rval

Up

per

Age at admission

(Equal variances assumed) .070 -1.144 .630 -2.380 .093

Weighted index CCI

(Equal variances not assumed) .931 -.011 .130 -.266 .244


(Equal variances not assumed) .449 -.105 .139 -.377 .167


(Equal variances assumed) .323 2.361 2.388 -2.239 7.052



4.3.7 Prospective study cost analysis Introduction

Tabulation of length of stay by specialty (Table 70) revealed that patients receiving liaison service referral (intervention) had an average 22 days longer length of stay although this varied between specialties from an average of 14 to 38 days. Tabulation of length of stay by hospital (Table 71) revealed similar variation. Length of stay varied in comparison patients by hospital from 9 to 29 days, in hospitals providing substantial data. In liaison referral patients, length of stay varied from 24 days to 44 days.

Table 70. Length of stay (days) by admitting specialty and intervention

Comparison Referred Admitting specialty

N Mean SD N Mean SD

Urology 38 13.8 17.8 5 39.2 27.7

General Surgery 75 13.6 20.7 23 42.4 39.6

General Medicine 120 21.3 39.6 75 42.7 30.7

Elderly Acute 214 19.0 21.5 165 32.9 27.7

Acute Medicine 153 18.2 22.3 61 52.6 48.1

Orthopaedics 51 17.8 21.3 33 42.2 27.8

Cardiology 41 18.5 30.8 27 36.6 34.8

Emergency admissions 143 21.3 28.4 200 40.4 32.3

Other 64 19.0 21.2 69 46.7 40.8

Respiratory 23 10.6 10.3 9 48.9 38.0

Overall 937 18.6 25.8 702 40.8 34.5



Table 71. Length of stay (days) service model and hospital site between

referred and comparison patients.

Comparison Referred Service model (hospital)

N Mean SD N Mean SD

LPN 1 66 13.7 22.5 59 42.4 26.1

LPN 2 94 12.1 17.5 59 38.1 25.9

TSM 1 92 28.7 32.0 22 43.8 37.1

LPN 3 72 12.5 21.1 18 43.5 39.2

TSM 2 76 19.8 21.7 34 72.2 57.5

HMHTb1 30 8.8 9.5 92 36.5 27.4

HMHTb1 62 18.2 49.7 48 35.1 25.3

TSM 3 95 14.4 11.6 11 23.9 14.2

HMHTb2 88 26.2 25.0 171 39.6 36.1

HMHTb2 7 36.0 28.4 0 . .

HMHTa 98 22.1 28.8 52 55.0 40.4

HMHTa 43 21.9 24.6 28 44.0 26.0

HMHTa 59 20.5 20.3 31 39.5 30.1

HMHTa 3 41.7 36.9 1 43.0 .

HMHTa 1 26.0 . 1 66.0 .

Overall 937 18.6 25.8 702 40.8 34.5

Simple tabulations provide useful descriptions of the sample population but may not provide robust comparisons on intervention and comparison length of stay because of potential confounding from other measured variables.

Length of Stay (LOS)

Data were selected for inclusion in primary analyses with respect to hospital, ethnicity, and place of residence at admission to remove small numbers of patients providing an inadequate comparison of liaison intervention or comparison (less than 5 patients in either intervention or comparison groups). This reduced the number of patients contributing length of stay data from 1639 to 1515. The mean length of stay for all subjects was 29 days (range 0 to 395), and featured a right-skewed distribution. To facilitate valid OLS regression estimation, length of stay (LOS) was transformed onto the natural log scale as LLOS=ln (LOS + 1). This means that estimates of length of stay in days need to obtained from regression models using the formula LOS = exp(α + βix + δi) - 1, where α, β and δ are respectively the intercept, slope and dummy variable coefficients from models of LLOS. Use of this transformation means that absolute values in models correspond more closely to medians than means, and comparisons of intervention and control populations differences



approximate to differences in medians. Models presented, were tested for omitted variables and functional form. Models 1 to 3 assume that liaison service intervention has a constant ‘treatment’ effect: this assumption is explored within model 4. Univariate analysis of length of stay (Model 1) is provided to compare the difference in length of stay estimated from the linear and log-scaled data.

Model 1: Univariate effect of intervention on length of stay

Dependent variable: log(LOS+1)

B SE p

(Constant) 2.491 .031 .000

referral to liaison .969 .049 .000

Thus comparison and intervention lengths of stay are respectively exp(2.491) = 11 days and exp(2.492+.969) = 31 days, a 20 day difference. While means and medians may be quite different within skewed data, differences in means and medians may be reasonably similar when the degree of skew is similar. However one simple bivariate model (Model 2) featured consistently within more complex multivariate models. Both referral to liaison psychiatry and discharge delay due to non-medical need were consistently associated with longer length of stay, in this model each adding about 13 days to length of stay.

Model 2: Bivariate effect of intervention and discharge delay on length of stay


B SE p

(Constant) 2.439 .039 .000


discharge delay due to non-medical need .779 .084 .000

Multivariate modeling using forward conditional variable selection was conducted (Model 3). The selection rule used was by F-test: p=0.025 to enter and p=0.05 to remove variables. It became apparent that there were extensive interactions between variables and the effect of liaison intervention upon length of stay so all potential interactions with intervention were made available for selection within multivariate models. When all variables potentially predictive of length of stay were available to the model, then statistically significant variables were fitted for residence at admission, hospital, intervention, specialty, and destination as well as recorded non-medical delays at discharge (Model 3). The selected model shows that referral to liaison mental health increased length of stay for liaison mental health for most hospitals by 11 days. With respect to residence on admission and hospital, differences in length of stay are fairly constant once the additive effect of interactions is included. An important explanatory variable for increased length of stay was the presence of discharge delays: this variable did not interact significantly with interventional status.



The model predicted a different pattern of behaviour for 14% of patients who were discharged to nursing homes and 3% who were discharged to psychiatric care. These patients had longer than average lengths of stay and a small reduction in length of stay due to liaison intervention was estimated: 1 day for patients discharged to nursing homes and 4 days for patients discharged to psychiatric care.

Model 3: Multivariate analysis of length of stay


B SE P

(Constant) 2.542 .048 .000


adm.liaison: sheltered accom -.325 .144 .025

adm: nursing home -.664 .164 .000

adm.liaison: nursing home .536 .267 .045

hosp: LPN2 -.489 .079 .000

hosp: LPN3 -.727 .111 .000

hosp.liaison: HMHTa .709 .240 .003

hosp: LPN1 -.718 .112 .000

hosp.liaison: LPN1 .829 .172 .000

spec: General Surgery -.238 .102 .020


dest: nursing home .911 .136 .000

dest.liaison: nursing home -.704 .175 .000

dest: residential home .487 .123 .000

dest.liaison: psychiatric in-patient -.884 .194 .000

dest: mortality .771 .086 .000

Model 3 assumes a constant effect of liaison service referral but the content of interventions and service configuration was known to vary between hospitals. It is not possible to explore, in a robust manner, the influence of service configuration upon changes in length of stay since there were only eleven geographical sites and a number of levels to service configuration, i.e. models cannot differentiate well between geographic location and service levels because of inadequate replication in these parameters. Consequently model 3 was re-evaluated with hospital sites removed and liaison service parameters introduced. The general form of the new model is similar and provides some evidence that some service parameters have a modest impact upon length of stay although these differences may simply reflect differences in geographical location.



Model 4: Multivariate analysis of length of stay exploring service characteristics


B SE P

(Constant) 2.015 .054 .000


adm.liaison: sheltered accom -.477 .156 .002

adm: nursing home -.432 .142 .002

Consultant Psychiatrist .264 .060 .000

Age of service>3years .211 .063 .001

Referrals in year prior to evaluation<100 .221 .070 .002

spec: General Surgery -.231 .105 .027


discharge delay.liaison -.403 .166 .015

dest: nursing home .803 .134 .000

dest.liaison: nursing home -.517 .172 .003

dest: residential home .532 .125 .000

dest.liaison: psychiatric in-patient -.941 .203 .000

dest: died .819 .092 .000

Summary

We attempted to establish cost-effectiveness of different service models thought their impact on length of hospital stay. Referred patients had a greater length of stay than the comparison cohort, but we were unable to confidently attribute any contribution to alterations in length of stay from the liaison service model in place.

4.3.8 Staff skills questionnaire

Description and Overview of Units and Respondents

This section of the report describes responses received from general hospital staff to the questionnaire designed specifically to measure skills and attitudes. The nature of data collection for this part of the study (described in more detail in the method section) prevents comparing response rates across sites. A total of 817 questionnaires were returned. Table 72 shows response rates from different service typology sites and professions.



Table 72. Response rates by service typology and profession


Nurse 157

(35%)

159

(35%)

54

(12%)

82

(18%)

452

(55%)

Sister 7

(29%)

11

(45%)

3

(13%)

3

(13%)

24

(3%)

Support worker 18

(11%)

72

(43%)

42

(25%)

37

(22%)

169

(21%)

Missing 28

(16%)

92

(53%)

7

(4%)

45

(27%)

172

(21%)

Total 210

(26%)

334

(41%)

106

(13%)

167

(20%) 817

The majority of responses were received from ward based nurses. Profession is missing from one fifth of all responses. The highest proportion of responses were received from hospitals with LPN services.

Questionnaire responses

The questionnaire was presented in 8 parts, responses are reported below. Part 1: Assessing respondent’s attitudes towards older patients with mental health needs Tables 73-77 summarise responses designed to measure attitudes of general hospital staff to older people with mental health problems. Table 72 shows the proportion of agreement with different choices of responses received per service typology to the question: (1) Do you think that older people with mental health needs get a bad deal when compared to younger adults with mental health needs when admitted to a general hospital?



Table 73. Responses given to question 1

Responses TSM LPN HMHTa HMHTb Total

Strongly disagree

10

(5%)

6

(2%)

54

(12%)

5

(3%)

24

(3%)

Disagree

27

(13%)

56

(17%)

15

(14%)

26

(16%)

124

(15%)

Neutral

30

(14%)

64

(19%)

10

(9%)

23

(14%)

127

(15%)

Agree

98

(47%)

138

(41%)

47

(44%)

64

(38%)

347

(43%)

Strongly agree

30

(14%)

40

(12%)

21

(20%)

33

(20%)

124

(15%)

Don’t know

11

(5%)

27

(8%)

6

(6%)

11

(7%)

55

(7%)

Missing

4

(2%)

3

(1%)

4

(4%)

5

(3%)

16

(2%)

Table 74 shows typical reasons indicated as having a relationship with why older people get a bad deal.



Table 74. Reasons for bad deal for older people

Reason TSM LPN HMHTa HMHTb Total

Amount of information given to

patients

51

(10%)

87

(11%)

20

(9%)

32

(8%)

190

(10%)

Level of involvement in decision

about care

72

(14%)

111

(14%)

27

(12%)

51

(13%)

261

(14%)

Lack of recognition about longer

rehabilitation / recuperation period

48

(9%)

106

(14%)

25

(11%)

51

(13%)

230

(12%)

Amount of training available to staff 108

(21%)

150

(19%)

57

(25%)

84

(21%)

399

(21%)

Level of staffing needed

118

(23%)

195

(25%)

65

(28%)

100

(25%)

478

(25%)

Support from other

agencies/professionals

84

(17%)

112

(14%)

34

(14%)

67

(17%)

297

(15%)

Other

27

(5%)

18

(2%)

5

(2%)

21

(5%)

71

(4%)

Total 508 779 233 406 1926

A high proportion of respondents (63%) agree that older people get a poor deal. A range of factors are identified that contribute to this including; deficits in training, staffing levels being too low and a lack of availability of information and professional advice from mental health colleagues. Table 75 shows responses to questions: (2) Do you think that patients with mental health needs should be admitted to a general hospital ward? (3) Do you think that older patients with mental health needs should be admitted to a ward that you work on?



Table 75. Responses to questions 2 and 3


Q2. Yes

83

(40%)

110

(33%)

39

(37%)

62

(37%)

294

(36%)

Q2. No

93

(44%)

177

(53%)

53

(50%)

82

(49%)

405

(50%)

Q2. Don’t know

30

(14%)

37

(11%)

9

(9%)

18

(11%)

94

(11%)

Q2. Missing

4

(2%)

10

(3%)

5

(5%)

5

(3%)

24

(3%)

Q3. Yes

92

(44%)

120

(36%)

42

(40%)

79

(47%)

333

(41%)

Q3. No

86

(41%)

155

(46%)

40

(38%)

66

(40%)

347

(43%)

Q3. Don’t know

26

(12%)

52

(16%)

19

(18%)

18

(11%)

115

(14%)

Q3. Missing

6

(3%)

7

(2%)

5

(5%)

4

(2%)

22

(3%)

Half of all respondents felt that older people with mental health problems should not be admitted to general hospital wards.

Part 2 – Assessing the extent and coverage of protocols/guidelines/NHS documents in place in general hospital wards in reference to older people with mental health problems Table 76 shows the availability of protocols for the management of common mental health problems and what the protocols available refer to. Five respondents did not indicate what the available protocols referred to.



Table 76. The presence of protocols or guidelines to manage older patients with mental health needs

Protocols/guidelines TSM LPN HMHTa HMHTb Total

Available

39

(19%)

67

(20%)

38

(36%)

50

(30%)

194

(24%)

Not available

94

(45%)

124

(37%)

27

(26%)

43

(26%)

288

(35%)

Don’t know

73

(35%)

139

(42%)

38

(36%)

66

(40%)

316

(39%)

Missing

4

(2%)

4

(1%)

3

(3%)

8

(5%)

19

(2%)

Delirium (referral) 11 30 16 30 87

Delirium (diagnosis) 8 14 15 23 60

Delirium (treatment) 9 13 17 20 59

Dementia (referral) 31 47 22 39 139

Dementia (diagnosis) 22 28 17 29 96

Dementia (treatment) 21 23 18 26 88

Depression (referral) 28 49 20 35 132

Depression (diagnosis) 21 28 14 25 88

Depression (treatment) 23 28 20 24 95

The high percentage (39%) of ‘don’t know’ responses is interesting, and may well reflect that protocols may well be in place, but staff members do not know about them. The availability of protocols for the three common conditions indicates that where protocols are available, they are for depression and dementia, with delirium less often covered.



Respondents were also asked about the availability of key policy documents in their work place. Table 77 shows affirmative responses to the main three policy documents at the time of data collection.

Table 77. Availability of key policy documents

Policy documents TSM LPN HMHTa HMHTb Total

NSF for Older People 120 195 53 115 483

NICE guidelines on Dementia 84 100 24 73 281

NICE guidelines on Depression 71 83 20 58 232

This demonstrates that although the NSFOP is available in two-thirds of workplaces, the availability of NICE guidance is much lower. Part 3 – Evaluating the extent of mental health needs amongst older people admitted to general hospital wards

Respondents were asked to estimate the proportion of patients admitted to general hospital wards with mental health needs. A summary of responses is shown in Table 78.



Table 78. Estimates of the level of mental health need in general hospital settings

Percentage with mental health

needs TSM LPN HMHTa HMHTb Total

< 10% 34

(16%)

30

(9%)

13

(12%)

19

(11%)

96

(12%)

10-20% 51

(24%)

54

(16%)

19

(18%)

23

(14%)

147

(18%)

20-30% 30

(14%)

63

(19%)

10

(9%)

22

(13%)

125

(15%)

30-40% 28

(13%)

49

(15%)

10

(9%)

28

(17%)

115

(14%)

40-50% 26

(12%)

37

(11%)

11

(10%)

17

(10%)

91

(11%)

50-60% 11

(5%)

24

(7%)

8

(8%)

19

(11%)

62

(8%)

60-70% 10

(5%)

26

(8%)

15

(14%)

12

(7%)

63

(8%)

70-80% 10

(5%)

22

(7%)

12

(11%)

6

(4%)

50

(6%)

80-90% 4

(2%)

20

(6%)

6

(6%)

15

(9%)

45

(6%)

>90% 0

2

(1%)

2

(2%)

3

(2%)

7

(1%)

Missing 6

(3%)

7

(2%)

0

3

(2%)

16

(2%)

Total 210 334 106 167 817

Wide variation in perception of need is seen across all service model types. The actual level is somewhere between 50-60%. High numbers of respondents underestimate level of mental health, independent of service typology. Part 4 – Assessing respondent’s perceptions on what should take place when older patients are admitted to their general hospital ward



These questions attempted to explore respondents ideas on the routine assessment and management of common mental health needs should occur when an older person was admitted to a general hospital ward. They were asked: (4) Do you think routine mental health assessments should be conducted on admission? (5) Do you have adequate training to conduct mental health assessments? (6) Do you have adequate training to care for older people with common mental health needs? Table 79 to 81 shows a summary of responses to these questions.

Table 79. Routine mental health assessments (Question 4)

Routine mental health

assessments on admission TSM LPN HMHTa HMHTb Total

Strongly disagree

21

(10%)

29

(9%)

5

(5%)

14

(8%)

69

(8%)

Disagree

50

(24%)

64

(19%)

13

(12%)

29

(17%)

156

(19%)

Neutral

32

(15%)

65

(20%)

14

(13%)

23

(14%)

134

(16%)

Agree

64

(31%)

105

(31%)

45

(43%)

51

(31%)

265

(32%)

Strongly agree

32

(15%)

50

(15%)

24

(23%)

40

(24%)

146

(18%)

Missing

11

(5%)

21

(6%)

5

(5%)

10

(6%)

47

(6%)

Total 210 334 106 167 817



Table 80. Adequacy of training in mental health assessment (Question 5)

Adequate training to conduct

mental health assessments TSM LPN HMHTa HMHTb Total

Strongly disagree

17

(8%)

33

(10%)

7

(7%)

14

(8%)

71

(9%)

Disagree

23

(11%)

29

(9%)

7

(7%)

14

(8%)

73

(9%)

Neutral

30

(14%)

41

(12%)

9

(9%)

20

(12%)

100

(12%)

Agree

73

(35%)

122

(37%)

42

(40%)

57

(35%)

24

(36%)

Strongly agree

58

(28%)

93

(28%)

37

(35%)

56

(34%)

244

(30%)

Missing

9

(4%)

16

(5%)

4

(4%)

6

(4%)

35

(4%)

Total 210 334 106 167 817



Table 81. Adequacy of training in mental health management (Question 6)

Adequate training to care for

older people with common

mental health needs


Strongly disagree

12

(6%)

21

(6%)

5

(5%)

12

(7%)

50

(6%)

Disagree

8

(4%)

9

(3%)

4

(4%)

2

(1%)

23

(3%)

Neutral

15

(7%)

30

(9%)

9

(9%)

4

(2%)

58

(7%)

Agree

78

(37%)

127

(38%)

38

(36%)

66

(40%)

309

(38%)

Strongly agree

86

(41%)

134

(40%)

48

(45%)

78

(47%)

346

(42%)

Missing

11

(4%)

13

(4%)

2

(2%)

5

(3%)

31

(4%)

Total 210 334 106 167 817

This demonstrates that over half of respondents who have a liaison team service think that assessment should be part of admitting routine. Well over half of all staff believe that they are adequately trained to conduct assessments and manage care for common mental health needs. Part 5 – Assessing respondent’s knowledge and subsequent conduct when older patients are admitted to their general hospital ward This part of the questionnaire attempted to establish the processes carried out by respondents in dealing with mental health problems in older people. Respondents were asked: (7) Do you assess patients for mental health needs? (8) Do you know how to assess patients for mental health needs? (9) How do you assess patients – do you use history taking? (10) How do you assess patients – do you use assessment tools?



Table 82 shows a summary of responses to these questions. Responses were missing from 6 respondents to these questions and 152 respondents were not expected to answer questions 8-10, given their response to question 7.

Table 82. Summary of responses to questions 7-10


Q7. Yes

99

(47%)

145

(43%)

46

(43%)

114

(68%)

404

(49%)

Q7. No

93

(44%)

164

(49%)

52

(49%)

48

(29%)

357

(44%)

Q7. Don’t know 15

(7%)

23

(7%)

6

(6%)

5

(3%)

49

(6%)

Q8. Yes

44

(21%)

52

(16%)

15

(14%)

4

(2%)

115

(14%)

Q8. No

137

(65%)

227

(68%)

59

(56%)

121

(73%)

544

(67%)

Q9. Yes

125

(60%)

191

(57%)

45

(43%)

99

(59%)

460

(56%)

Q9. No

56

(27%)

88

(26%)

29

(27%)

26

(16%)

199

(24%)

Q10. Yes

60

(29%)

134

(40%)

50

(47%)

74

(44%)

318

(39%)

Q10. No

121

(58%)

145

(43%)

24

(23%)

51

(31%)

341

(42%)

This shows that only a small proportion of respondents admitted to knowing how to conduct a mental health assessment (n=115). There are large variances across all models, although the variances in response rates may



account for this. A higher proportion of staff report using assessment tools in liaison models, although responses to knowledge on how to conduct assessments suggests that staff are not confident in using and interpreting the results of assessment tools. Part 6 – Evaluating respondent’s level of comfort when assessing older patients for mental health needs This part of the questionnaire attempted to establish how comfortable staff felt when assessing older people with different mental health problems. Results from this are shown in Table 83-87.

Table 83. Levels of comfort reported when assessing older patients for low mood

Comfort when assessing older

patients for low mood TSM LPN HMHTa HMHTb Total

Strongly disagree

12

(6%)

23

(7%)

7

(7%)

9

(5%)

51

(6%)

Disagree

41

(20%)

58

(17%)

17

(16%)

26

(16%)

142

(17%)

Neutral

35

(17%)

83

(25%)

25

(24%)

32

(19%)

175

(21%)

Agree

93

(44%)

101

(30%)

32

(30%)

70

(42%)

296

(36%)

Strongly agree

12

(6%)

22

(7%)

8

(8%)

19

(11%)

61

(8%)

Missing

10

(5%)

7

(2%)

5

(5%)

5

(3%)

27

(3%)

Not applicable

7

(3%)

40

(12%)

12

(11%)

6

(4%)

65

(8%)

Total 210 334 106 167 817



Table 84. Levels of comfort reported when assessing older patients for confusion


patients for confusion TSM LPN HMHTa HMHTb Total

Strongly disagree

11

(5%)

21

(6%)

6

(6%)

8

(5%)

46

(6%)

Disagree

23

(11%)

56

(17%)

15

(14%)

24

(14%)

118

(14%)

Neutral

44

(21%)

60

(18%)

15

(14%)

24

(14%)

147

(18%)

Agree

90

(43%)

118

(35%)

45

(43%)

74

(44%)

327

(40%)

Strongly agree

29

(14%)

35

(11%)

6

(6%)

24

(14%)

94

(12%)

Missing

6

(3%)

4

(1%)

4

(4%)

6

(4%)

20

(2%)

Not applicable

7

(3%)

40

(12%)

12

(11%)

6

(4%)

65

(8%)

Total 210 334 106 167 817



Table 85. Levels of comfort when assessing older patients for self-harm


patients for self-harm TSM LPN HMHTa HMHTb Total

Strongly disagree

42

(20%)

75

(23%)

21

(20%)

37

(22%)

175

(21%)

Disagree

74

(35%)

110

(33%)

33

(31%)

5

(33%)

272

(33%)

Neutral

51

(35%)

66

(20%)

20

(19%)

34

(20%)

171

(21%)

Agree

23

(11%)

28

(8%)

14

(13%)

21

(13%)

86

(11%)

Strongly agree

4

(2%)

7

(2%)

1

(1%)

7

(4%)

19

(2%)

Missing

6

(4%)

8

(2%)

5

(5%)

7

(4%)

29

(4%)

Not applicable

7

(3%)

40

(12%)

12

(11%)

6

(4%)

65

(8%)

Total 210 334 106 167 817



Table 86. Levels of comfort when assessing older patients for suicidal

ideation


patients for suicidal ideation TSM LPN HMHTa HMHTb Total

Strongly disagree

75

(36%)

103

(31%)

32

(30%)

47

(28%)

257

(32%)

Disagree

59

(28%)

99

(30%)

25

(24%)

48

(29%)

231

(29%)

Neutral

32

(15%)

58

(17%)

18

(17%)

34

(20%)

142

(17%)

Agree

20

(10%)

20

(6%)

12

(11%)

19

(11%)

71

(9%)

Strongly agree

7

(3%)

6

(2%)

2

(2%)

6

(4%)

21

(3%)

Missing

10

(5%)

8

(2%)

5

(5%)

7

(4%)

30

(4%)

Not applicable

7

(3%)

40

(12%)

12

(11%)

6

(4%)

65

(8%)

Total 210 334 106 167 817



Table 87. Levels of comfort when assessing older patients for capacity


patients for capacity TSM LPN HMHTa HMHTb Total

Strongly disagree

31

(15%)

37

(11%)

13

(12%)

14

(8%)

95

(12%)

Disagree

57

(27%)

64

(19%)

21

(20%)

34

(20%)

176

(22%)

Neutral

42

(20%)

88

(26%)

21

(20%)

32

(19%)

183

(22%)

Agree

50

(24%)

60

(18%)

19

(18%)

45

(27%)

174

(21%)

Strongly agree

4

(2%)

12

(4%)

3

(3%)

15

(9%)

34

(4%)

Missing

19

(9%)

32

(10%)

17

(16%)

21

(13%)

8

(11%)

Not applicable

7

(3%)

40

(12%)

12

(11%)

6

(4%)

65

(8%)

Total 210 334 106 167 817

Responses to these series of questions suggest that higher proportions of staff are comfortable assessing for low mood and confusion compared to other mental health needs. Part 7 – Assessing the level of support/training given to general hospital staff in terms of caring for older patients with mental health needs This section of the questionnaire attempted to determine the levels of mental health training and support that exist for older people with mental health needs in the general hospital setting. These responses are summarised in Tables 88 to 92.



Table 88. Adequacy of training in assessment of older people’s mental health needs

Adequate training for performing

a mental health assessment TSM LPN HMHTa HMHTb Total

Strongly disagree

58

(28%)

100

(30%)

26

(25%)

32

(19%)

216

(26%)

Disagree

93

(44%)

128

(38%)

39

(37%)

60

(36%)

320

(39%)

Neutral

29

(14%)

44

(13%)

17

(16%)

32

(19%)

122

(15%)

Agree

17

(8%)

27

(8%)

10

(9%)

28

(17%)

82

(10%)

Strongly agree

3

(1%)

8

(2%)

3

(3%)

8

(5%)

22

(3%)

Missing

10

(5%)

27

(8%)

11

(10%)

7

(4%)

55

(7%)

Total 210 334 106 167 817



Table 89. Adequacy of training in management of older people’s mental

health needs

Adequate training for caring for

older patients with mental

health needs


Strongly disagree

49

(23%)

69

(21%)

23

(22%)

31

(19%)

172

(21%)

Disagree

73

(36%)

120

(36%)

38

(36%)

51

(31%)

285

(35%)

Neutral

39

(19%)

63

(19%)

15

(14%)

32

(19%)

149

(18%)

Agree

33

(16%)

50

(15%)

16

(15%)

39

(23%)

138

(17%)

Strongly agree

4

(2%)

6

(2%)

5

(5%)

7

(4%)

22

(3%)

Missing

9

(4%)

26

(8%)

9

(9%)

7

(4%)

51

(6%)

Total 210 334 106 167 817



Table 90. Availability of mental health services for older people in the

general hospital setting

Know what psychiatric service is

available in hospital TSM LPN HMHTa HMHTb Total

Strongly disagree

35

(17%)

34

(10%)

14

(13%)

18

(11%)

101

(12%)

Disagree

61

(29%)

63

(19%)

19

(18%)

16

(10%)

159

(20%)

Neutral

39

(19%)

60

(18%)

20

(19%)

34

(20%)

153

(19%)

Agree

53

(25%)

136

(41%)

35

(33%)

76

(46%)

300

(37%)

Strongly agree

13

(6%)

18

(5%)

8

(8%)

15

(9%)

54

(7%)

Missing

9

(4%)

23

(7%)

10

(9%)

8

(5%)

50

(6%)

Total 210 334 106 167 817



Table 91. Ability to contact the mental health service to request their

input

Ability to contact mental health

services to request input TSM LPN HMHTa HMHTb Total

Strongly disagree

40

(19%)

45

(14%)

16

(15%)

27

(16%)

128

(16%)

Disagree

55

(26%)

56

(17%)

23

(22%)

32

(19%)

166

(20%)

Neutral

37

(18%)

49

(15%)

15

(14%)

23

(14%)

124

(15%)

Agree

60

(29%)

130

(3%)

35

(33%)

58

(35%)

283

(35%)

Strongly agree

8

(4%)

28

(8%)

6

(6%)

19

(11%)

61

(8%)

Missing

10

(5%)

26

(8%)

11

(10%)

7

(4%)

54

(7%)

Total 210 334 106 167 817



Table 92. Knowledge of referral process for mental health input

Know how to refer patients for

mental health input TSM LPN HMHTa HMHTb Total

Strongly disagree

34

(16%)

41

(12%)

17

(16%)

24

(14%)

116

(14%)

Disagree

62

(30%)

60

(18%)

24

(23%)

18

(11%)

164

(20%)

Neutral

28

(13%)

52

(16%)

15

(14%)

22

(13%)

117

(14%)

Agree

70

(33%)

130

(39%)

34

(32%)

72

(43%)

306

(38%)

Strongly agree

7

(3%)

25

(8%)

5

(5%)

23

(14%)

60

(7%)

Missing

9

(4%)

2

(8%)

11

(10%)

7

(4%)

52

(6%)

Total 210 334 106 167 817

Responses to these questions suggest that the presence of a specialist liaison service, and in particular a large team, increases the perceived adequacy of training and knowledge of mental health service availability. However, this is far from universal. High proportions of staff feel that they are not adequately trained to perform mental health assessments (65%), although higher proportions of staff who have access to liaison services report adequate training compared to non-liaison services. More than half of all staff do not know what services are available to them or how to contact and refer patients to liaison services. Respondents were asked two questions in an attempt to determine perceptions of the impact of mental health problems on discharge and management. Questions and responses are shown in Tables 93 and 94.



Table 93. Perceptions of mental ill health as a reason for delayed

discharge of medically fit patients

Perception of mental ill health as

a common reason for delayed

discharge


Strongly disagree

10

(5%)

16

(5%)

2

(2%)

8

(5%)

36

(4%)

Disagree

30

(14%)

29

(9%)

7

(7%)

13

(8%)

79

(10%)

Neutral

31

(14%)

57

(17%)

21

(20%)

38

(23%)

147

(18%)

Agree

67

(32%)

107

(32%)

44

(42%)

53

(32%)

271

(33%)

Strongly agree

63

(30%)

103

(31%)

22

(21%)

47

(28%)

23

(29%)

Missing

9

(4%)

21

(6%)

10

(9%)

8

(5%)

48

(6%)

Total 210 334 106 167 817



Table 94. Adequacy of management of mental health problems in older

people

Believe mental ill health in older

people is adequately managed TSM LPN HMHTa HMHTb Total

Strongly disagree

28

(13%)

44

(13%)

14

(13%)

20

(12%)

106

(13%)

Disagree

72

(34%)

85

(25%)

26

(25%)

43

(26%)

226

(28%)

Neutral

71

(34%)

118

(35%)

37

(35%)

55

(33%)

281

(34%)

Agree

18

(9%)

50

(15%)

15

(14%)

34

(20%)

117

(14%)

Strongly agree

6

(3%)

12

(4%)

1

(1%)

6

(4%)

25

(3%)

Missing

15

(7%)

24

(7%)

13

(12%)

9

(5%)

61

(8%)

Total 210 334 106 167 817

A relatively small proportion of staff believe that mental health in older patients is adequately managed (17%), and there is a larger proportion of staff in liaison models who believe this, compared to non-liaison services.

Respondents were asked for feedback about their use of mental health services. These two questions, and responses received are shown in Table 95 and 96.



Table 95. Requests for help from mental health services

Requested help from the mental

health services TSM LPN HMHTa HMHTb Total

Yes

135

(64%)

213

(64%)

49

(46%)

112

(67%)

509

(62%)

No

61

(29%)

91

(27%)

42

(40%)

39

(23%)

233

(30%)

Don’t know

10

(5%)

18

(5%)

12

(11%)

7

(4%)

47

(6%)

Missing

4

(2%)

12

(4%)

3

(3%)

9

(5%)

28

(3%)

Total 210 334 106 167 817



Table 96. Usefulness of advice from mental health services

Usefulness of service TSM LPN HMHTa HMHTb Total

Strongly disagree

15

(7%)

11

(3%)

1

(1%)

2

(1%)

29

(4%)

Disagree

33

(16%)

45

(14%)

2

(2%)

17

(10%)

97

(12%)

Neutral

29

(14%)

60

(18%)

12

(11%)

23

(14%)

124

(15%)

Agree

59

(28%)

92

(28%)

31

(29%)

60

(36%)

242

(30%)

Strongly agree

6

(3%)

11

(3%)

7

(7%)

10

(6%)

54

(4%)

Missing

5

(2%)

16

(5%)

3

(3%)

8

(5%)

32

(4%)

Not applicable

48

(23%)

74

(22%)

44

(42%)

39

(23%)

205

(25%)

Total 210 334 106 167 817

A high proportion of respondents have requested help at some stage. Higher proportions of staff agree that the service has proved useful (37%), compared to disagree (15%), although there is a lot of variance in response to the question about usefulness, and a high proportion of neutral/don’t know responses (22%). Part 8 – Determining whether or not further training should be provided with regards to dealing with older patients with mental health needs, the type of training preferred and in which specific areas. This final part of the questionnaire attempted to determine the training needs of respondents. Over 85% of all respondents said that they required further



training in the assessment and management of older people with mental health needs, with little variance across service typologies. Responses to the training needs question are shown in Table 97.

Table 97. Training needs of respondents

Further training required TSM LPN HMHTa HMHTb Total

Yes

180

(86%)

269

(81%)

95

(90%)

151

(90%)

695

(85%)

No

10

(5%)

30

(9%)

8

(8%)

9

(5%)

57

(7%)

Don’t know

14

(7%)

20

(6%)

2

(2%)

4

(2%)

40

(5%)

Missing

6

(3%)

15

(5%)

1

(1%)

3

(2%)

25

(3%)

Total 210 334 106 167 817

Respondents were asked a series of questions about the content of training they require. The most frequent requests for training were for the care of wandering patients (35%), refusal to take medications (33%), aggression (32%) and agitation (31%). The is a preference for group training sessions and half/one day course over other modes of training although large HMHTs also favour lectures more so than other models. This may be because they are based in large teaching hospitals and therefore this is the norm, thus indicating that training needs to be tailored to local staff needs. Summary Overall, findings from this questionnaire may need to be interpreted with caution. Response rates were relatively low, and there is the obvious potential for bias, with those holding more extreme views being more likely to respond. Particular responses may depend on the presence or absence of a liaison mental health service, and the presence of an effective liaison service may influence responses by making people aware of mental health as a significant issue. The use on a non-validated questionnaire to measure attitudes is a contentious area. Nevertheless, several key findings suggest that general hospital staff underestimate the size of the problem and there is a willingness to engage in training specifically tailored to meeting the needs of older people with mental health needs.



4.3.9 Qualitative data analysis

Semi-structured interviews (n=9), informal interviews (i.e. field notes, n=5) and, focus groups with different service personnel (mixture of hospital and mental health liaison staff grades, n=5) were conducted across several hospital districts. A number of main and sub themes emerged from the data which gave an insight into the development of psychiatric liaison services, perceptions about the services available to elderly patients with mental health needs, perceptions about how services impacted on the care of such patients, and preferred changes to current services. Main themes are indicated at the beginning of each paragraph, and sub-themes indicated by lettered sub-headings with examples of supporting quotes provided in each section. This section summarises by drawing together the findings from this part of qualitative work at a conceptual level.

Establishment of services

Responding to questions about the development of psychiatric liaison services, clinicians from one hospital commented on the need to incorporate a more formal and accessible psychiatric service, one that would have a focus on the specialised care and discharge needs of elderly patients. a) Function of service introduction What was the service established to provide? “A link between mental health services and acute general services where a psychiatric “opinion” is required. This is in the context of an apparent lack of capacity from the Old Age Psychiatrists who do not have the time available to visit acute general wards on a daily basis” (int04)

b) Motivation for service introduction Why was the psychiatric liaison team established? “To improve the care of patients with mental health problems who are admitted to acute general wards – care of the elderly or otherwise. Also, to facilitate discharge to more appropriate care settings where necessary.”(int09)

Drivers of service development

A formal, consistent, and centralised agenda for the development of old age psychiatric liaison services across the hospitals we encountered was not apparent from our interviews. Rather, service development appeared to be individualised and ad-hoc, relying instead on evolving needs informing practice, which in turn was reliant on complex negotiations with several trusts to secure funding for these new services. For example:



“…the service has sort of evolved…there was actually one nurse with…no dedicated medical time, so it has evolved to how it is now over a number of years…the initial funding for the nurse came from the Care Trust out of intermediate care monies…and then a couple of years ago we actually managed to get a sort of tripartite arrangement…to bring some extra funding and then we employed the additional nurses…funding actually came partly from the Mental Heath Trust, the Care Trust and the Acute Trust… so it was a three way split…”. (int04) “So it was opportunistic really (yeah ” (int07)

Once a service had been introduced, the drivers for further development appeared to centre on three key themes: (a) a recognition of the need for service development due to the prevalence of elderly patients with mental health needs; (b) clinicians’ desire to form a closer working relationship with liaison psychiatry and; (c) clinicians’ personal interest (rather than managerial input) in developing a much-needed service. a) Recognition of need “…recognising the large prevalence of older people with mental health problems and so wishing to invest in the service.” (int01) “…there are the hidden drivers…which is the 60% or so of acute hospital beds being occupied by older people, and they’ll be 60% of those having mental health problems…so if anything should drive an interest from an acute trust, those large numbers should…in developing liaison services.”(int02)

b) Desire for good working relations …”we are enthusiastic…about a better working relationship…improving upon what we perceive to be already good working relationship with older people’s mental health services…so there is a driver from us to improve the service.” (int01)

c) Clinicians’ personal interest Interviewer “I mean I’ve got quite a clear picture of how the service has developed…over the last three to four years and how it’s been operating…and it seems that a lot of that has been driven by…clinicians’ personal interest…would you say that?” Interviewee “Yeah definitely…I mean I’ve had a sort of personal interest in it and the…geriatricians have all been very supportive, particularly Dr C….because nobody else took a particular interest really… so it certainly wasn’t driven by managers at all…it was just sort of personal interest and…the feeling that there was a huge un-met need…”(int04)

Barriers to service development

While there appeared to be a clear desire from hospital clinicians to develop a good, complementary liaison psychiatry service, one main theme that emerged from the data centred on some of the barriers to that goal. Such barriers appeared to include: (a) a conflict of interest between the improvement of acute hospital services and the improvement of liaison psychiatry services; (b) funding and financial restrictions on service development; (c) geographical separation of the hospital(s) and the liaison psychiatry service; (d) administrative separation of the hospital(s) and the liaison psychiatry service, with the possibility of conflicting agendas, staff loyalty complications, and inefficient working hours and; (e) lack of trained staff and opportunities for educating them on mental health issues.



a) Conflict of interest “…improving upon what we perceive to be already good working relationship with older people’s mental health services…so there is a driver from us to improve the service…but, of course, that runs into a conflict if there is also a driver within our department to improve our own service.” (int07)

b) Financial considerations “I think that the agendas for both organisations, ‘A’ hospital and the mental health trust, are financially driven and it’s not clear that the patients at the interface, who are currently within the district hospital, are a priority and aren’t necessarily going to generate income.” (int08) “…we invited all the commissioners for all the local PCTs to a day and they were very enthusiastic and seem to understand all the key points and we thought that was rather splendid and a year and a half later they still think it is splendid and they are still not doing anything specific about it because I think it probably because its not actually its performance target is it and they don’t have any money.” (int04)

c) Geographical separation “I would see a barrier being having the liaison mental health team offsite, irrespective of whether they are in a different trust.” (int02)

d) Administrative separation “I would see the main barriers being…the separation between an acute trust and the mental health trust; so they have different agendas.” (int09) Interviewee “Well you’ve probably gathered it’s very complicated in (this area)… so the consultant psychiatrist – that’s me, and the other medics in the team are managed by the Mental Health Trust…while the nurses are currently managed by the…Care Trust…” Interviewer “… I would imagine that that causes quite a lot of difficulties?” Interviewee “Yeah it does make things very complicated and the…nurses are currently sort of sitting within the CMHTs and… not one CMHT, but two different ones… two of the nurses are in the ‘A’ CMHT and two are in the ‘B’ CMHT.” “… well I still think that the way it’s sort of managed is a barrier…you know because - the nurses are managed by somebody else and they have to do all the things that care managers in the CMHTs have to do like, you know, putting all their information onto the team’s IT system… which doesn’t talk to our trust’s IT system…so just generally it’s just extra work for them which could be used a lot more profitably elsewhere…I think it has been quite a barrier really. (int02)

e) Staff education and training “In terms of how it’s developing, I think you know education is a huge part of it and again they’ve not done a lot of that, but that’s sort of starting to come together, well I think, particularly for nursing staff, and…trying to work out how best to do that because it’s so difficult to get nurses off wards.” (int04)

Perceptions of liaison psychiatry services

Both general hospital staff and liaison psychiatry staff brought up issues surrounding the effectiveness and efficiency of liaison psychiatry services. Most respondents appeared to be frustrated and/or concerned with what they felt were the main shortcomings in the service: (a) staff shortages; (b) delays in response to referrals; (c) quality of input/advice from liaison service; (d) low staff morale of liaison psychiatry; (e) ignorance of function of liaison psychiatry services. Nonetheless, embedded in a number of comments are suggestions



that any limitations in the liaison service are the result of poor resources and management communication, rather than staff negligence. a) Staff shortages General hospital staff comments “…clearly there’s quite a lot of concern from…very senior medical people within (the hospital)… that…the service isn’t up-to-scratch… could do a lot better….they do believe that more staff as apart of the team would be beneficial.” (int06) “The real issue is that because the older people’s liaison mental health team is under resourced in terms of human bodies, there are often issues about people being sick, or people being on leave, or too many people being at a conference.” (int05) “…services are under-resourced, because it’s a big, big hospital….And, you know, one nurse and a mini amount of medical time isn’t really enough so ideally it would be a…medical team psychology support, social worker support…”(int03) “She did say that it needed more of the liaison team…she was only aware that actually there was one person involved in the team and that’s the liaison mental health nurse. She didn’t understand that there was more staff, including doctors that did this job. She was very clearly advising that there was more liaison nurses needed…for the service to be effective.” (int08)

Psychiatric liaison staff comments “The team explained that they are working at 50% and have been for the last 6 months, due to staff sickness, study leave, holidays and annual leave. This means that on average there have been 2 WTE covering two hospital sites.” (Field notes 3)

b) Referral response time “I think that the mental health team do their best to try and support but I know that they are under a lot of pressure here so it is very difficult for them to come when we need them they do tend to come fairly quickly if you ask them to come but I don’t think I’m satisfied no, no I don’t think so.” (int03) “…one perceives an excessive delay, simply because there aren’t bodies there to take referrals. The other perceived problem, which may not be a problem, is that sometimes, even when we believe that everyone is around….the review of a referred patient doesn’t appear to be as swift as we would like it to be.” (int05) “Yes, sometimes, I perceive that the service is slow, not as responsive as I’d like it to be. I’m adult enough to know that there are maybe…there are reasons why that might happen…and my guess is that sometimes it really is as slow as I think it is, but it’s probably not as slow as often as I think it is….if that makes sense?” (int07)

c) Input/advice from liaison service “People are generally assessed but often no clear plans or advice are given to the ward staff. And indeed, no input, physically, is given to patients on the ward. So, for instance, if a chap was particularly unsettled, suffering from dementia, then I think the staff unrealistically believe that the liaison team would support them actually in person, on a daily or every other day basis” (int04). “…(there is a) lack of advice regarding effective anti-psychotic or sedative medication, particularly with people with dementia.” (int01) Voice 1 “Sometimes they just refuse to eat and say they want to die, sometimes they forget ought, forget that you tell them to swallow and they’ll do it, they don’t get referred” Interviewer “Do you think they should be referred people who are experiencing those…” Voice 1 “Yes I do, yes I do” Interviewer “So the liaison team…you think that they should perhaps pick up situations where someone (is) physically declining because of their mental state…, they may not have a defined mental health problem but they are just not quite right?” Voice 1 “Yeah.”(fg2)



d) Low staff morale in liaison psychiatry “The team are extremely de-motivated and do not like or enjoy their job. They don’t feel like they have any support from managers and that they are not appreciated by ward staff.” (int04) “One of the band six nurses explained that she had sent an email to the team leader in June explaining her frustration and acknowledging the need for the team to establish proper documentation, patient pathways, and boundaries for the team, but that she received no response.” (int07) “They feel like the expectations are above what they can currently deliver, both from management and ward staff. They feel that they have become an outlet that is abused by staff, some of which refer six patients in a short period of time to the team and expect them to be able to do something with the patient or get them ‘moved’. They feel like they lack clear boundaries and guidance from management and that at the moment all they can do is quantity not quality.” (int09)

e) Ignorance of function of liaison psychiatry services “She was a senior staff nurse, she wasn’t a sister or a supervisory role…she was…aware that there is a service within the hospital, of mental health service, could not tell me how to access it, assumed that this was…instigated by medics or consultants specifically, and that she has never taken part in a referral process to liaison mental health. And that if she had concerns regarding one of the patients she was looking after, she would pass it onto the nurse in charge or the ward sister, who would then effect some kind of communication with the doctor or consultant in charge….Said she couldn’t really comment on how useful she found it, didn’t really think it affected her practice…at all.” (Field notes 2) Interviewer “…what support is there for you, do you see that there is any support for any services in the hospital in terms of mental health?” Voice 1 “I’m not too sure, I know they have referred them…” Interviewer “…from your view point you feel that there is more that you could do to…” Voice 1 “I’m sure there is Interviewer “…To tap into.” Voice 1 “Yeah I’m sure there must be but we don’t know what there is…”(int04) Interviewer “…do you feel you are able to comment on the strengths and the weaknesses of the mental health service really that you as a ward receive?” Voice 1 “I don’t really know that we receive much really… no I don’t think we do…If there is, I don’t know about it…Maybe there is, I don’t know…We have struggled with a lot of patients in the past and I’ve not been aware of anything that we could have...done.” (int06) Interviewer “…the mental health liaison team….what sort of problems should be referred to that team?” Voice 1 I don’t, I don’t really know I think we’ve only referred when we’ve not been able to cope I don’t know quite what should be referred to them… I, I’m not sort of up on all the conditions…. …. You know so I don’t really know what they would be…I know we refer if we’ve got a real problem with aggression….That’s the only reason I know.” (int05)

Perceptions of general hospital services

Many interviewees recognised the additional and specialised care needs of those with mental health needs but expressed concern that such needs were not being met by current general hospital services. Most responses centred on themes of the suitability and manageability of such patients on general hospital wards due to a number of issues: (a) staff shortages; (b) staff safety and



wellbeing; (c) inappropriate environment and; (d) lack of mental health training. a) Staff shortages “…took 2 staff to sit with her because we couldn’t actually manage with one so it left one nurse on the ward and they wouldn’t give us anybody to help us and she was frightened and upset it was very difficult to actually nurse her and she got this illness on top of everything else” Voice 3 “That is deplorable, short staffed not enough staff and its frustrating it is.” Interviewer “It is when the staff are there are trying to dealt with it isn’t it?” Voice 2 “It is.” Voice 3 “Because they need 1 to 1 but we can’t give them that 1 to 1.” (fg2) “…the nurses… I know they really, really struggle… “(int04) “…because everyone is so busy… we are so short staffed that we’ve tried to do things at lunchtimes, things that people can’t get to…”(int02)

b) Staff wellbeing Interviewer “So they are, try to be sort of violent towards you?” Voice 1 “Yeah” Interviewer “Do they really?” Voice 1 “Oh yeah…we do deal with it, I’m not on about occasionally I’m on about regularly.” (int04) “I mean once this man wanted to leave the ward and you obviously can’t let him leave the ward so he grabbed me by the throat and he was waltzing around the men, round the men’s and the poor patients are saying ‘leave her alone, leave her alone’ and they couldn’t do nought.” (int02) “I’ve been not so much punched but I’ve had my hair pulled and scratched and hit and you know, and you brush it aside because they are what they are and they can’t help it but it doesn’t solve the problem does it…”(int05) “…they go out of there (hospital ward) much worse than when (they) came in… to me that’s mad there must be something that we can... be doing with them but I don’t know what and not a lot of my colleagues do either… so I think that where we feel we are letting them down…it is the system yeah but you feel it personally… because if you have somebody that you’ve looked after and they leave you much worse than when they came in you…we can only try our best.” (int09) “…sometimes we do feel a bit powerless don’t we… don’t know what to (do), yeah, don’t know.” (int05)

c) Inappropriate environment Interviewer “Thinking about your service, your services and the liaison service in relation to your wards do you think that the environment if you see what other people…” Voice 1 “No, not always no, they can upset the other patient.” Voice 2 “And the other patients can upset them.” Voice 1 “Yes they can.” Voice 2 “Because they are in a bay aren’t they with strangers?” Voice 1 “Strangers yes, at the moment we have 2 confused one at this side and one at that and I wont mention name but this one has come across pinching her slipper and you know your to diffuse it this ones saying to the next bed you’ve got my glass and that all glasses are the same you



see and even one of the visitors got upset because shed been at it, I thought ah oh I need to go and diffuse it, its not your glass love your is here and all glasses are the same and but even the visitor was upset and she came can you come and sort you know…” Voice 2 “Cos’ one of our patients tried to get in bed with another patient.” Voice 1 “That’s terrible… its frightening for them isn’t it?” Voice 2 “Yeah but you’ve got somebody who is confused and disorientated they don’t even know where they are and yet there are all these people around and there is all sorts of people coming and going people asking them what they want to eat and have you taken your medicine and its your physio and now its time to get washed and dressed…” (fg2) Voice 3 “…it must be horrible, we’ve got one man at the moment he’s in a side room and I was feel so sorry for him, because he just sits in that chair day in day out.” Voice 1 “There is no stimulation is there…?” Voice 2 “Because he’s got learning difficulties…” Voice 3 “Yeah its horrible for him he just sits there, doesn’t see nobody.” Interviewer “So the environment we’ve established isn’t ideal.?” Voice 3 “No.” (fg2) “…we’ll get somebody in with dementia… we’ve just had a lady now who we’ve had for weeks and weeks and weeks who’s been waiting for a placement and its what do we do with this lady in the mean time, she’s been like(a) prisoner… that’s what we were treating her as… yeah its been quite sad she’s gone really, really down hill while she’s been with us both mentally and physically and I think its sad really because we don’t…(Know)…what to do with her… we can treat her physical need if she’ll let us…” (int04) Interviewer “…how equipped would you say the ward is to deal with mental health patients?” Voice 1 “Not very well at all… for a kick off we are not secure… I mean this particular lady that was one of the big problems she was everyday not even just once a day all day trying to get out.” (int06)

d) Lack of mental health training “Well at the moment we struggle is the best way of putting it in that the identification of mental health needs in the hands of the admitting physicians and or the nurses that end up looking after them and there is a varied amount of training between the personnel so there are a few geriatricians that do the medical take, there are some general physicians from that view point and likewise amongst the nursing staff on the wards once that help need has been identified just suspect it means a lot of things aren’t identified.” (int04) “…we’ll end up with someone (with dementia) on our ward and I mean none of us are mental health trained…”(int05) “Mental health needs of patients within the general hospital are poor. Nursing staff have poor training with regard to mental health, therefore lack in knowledge and confidence to treat this client group. A&E provide an excellent service and use a screening tool to assess suicide/self-harm. All nurses have completed STORM training, which manage and assess risk in relation to suicide. Other wards need to follow A&E lead. As a profession, we neglect to address MH needs. (int01) “I’m not a mental health nurse so its difficult for us if somebody’s to know because we haven’t got the training anyway its only through experience its not actually mental health training.” (int04) “I don’t know if we need some training in how to deal with them, I don’t know if whether they treat them differently on the mental health wards… I’d perhaps like to do a bit of shadowing… on the mental health wards and see whether I could pick up some ideas… I think that there is a few of us that think we need so training really… so learn to interact.” (int08) “I think that is, that is something that is really important to capture in this research that, that at the moment the physical need over rides that mental health need if you like and you know you are on a ward where there doesn’t tend to be anybody with mental health training you are very lucky if there is.” (int03)



Interviewer “…how well equipped do you feel yourself to recognise if a patient has got a mental health need? “ Voice 1 “I’m not always sure, sometimes its not all that evident is it… and it doesn’t always come out straight away… yeah obviously the notes will tell you but sometimes its not even in the notes and it’ll become apparent, or it could early cases of dementia so I, only through experience really…yeah.” (fg1) Interviewer “…are you aware of any sort of trust or national guidelines or policies that have been developed to help yourself or therapists or nurses cope with these patients?” Voice 1 “No.” (fg2) Voice 1 “Its like the ones we have that are really, really demented and they are wanting their mum or their dad I don’t know quite what to say to them. Do you say, ‘ well, your mum and dad are dead’ or do you go along with it, I’m never sure which is the right way to go… its really difficult… I find it the hardest part of my…” Interviewer “…Job.” (fg2)

Impact of services on patients

Inevitably, the quality, quantity, and management of mental health services will impact on patient care and several participants raised concerns about this issue. The main themes being: (a) health and safety of patients, with and without mental health problems; (b) unclear care pathways and; (c) early hospital discharge. a) Health and safety of patients Voice 3 “Because they need 1 to 1 but we can’t give them that 1 to 1” Interviewer “Do you think that they are then at risk if you can’t do?” Voice 2 “If we hadn’t have stayed with this lady she have been on the floor and she also with all her IVs and stuff you know she’d got drips and bags going everywhere and confused and disorientated on top of that and it did take two staff, she was quite strong.” Voice 3 “She has actually broke her hip so we had to send her off to another ward she had to go down to theatre for an operation.” (fg1) “It’s like when the kitchen staff come up and take the food orders… they don’t always give them time to eat it on a weekend, the young they want it to be off and get it all away you know, and you are thinking you’ve got to put down that its eaten and they’ve done you know, kind of thing, its difficult.” (int08) “…we’ll end up with someone on our ward and I mean none of us are mental health trained… so we’ll get somebody in with dementia who’s probably waiting for a EMI ward and there aren’t that many places available so we end up with them for a long time … we’ve just had a lady now who we’ve had for weeks and weeks and weeks who’s been waiting for a placement and its what do we do with this lady in the mean time, she’s been like prisoner… that’s what we were treating her as… yeah its been quite sad she’s gone really, really down hill while she’s been with us both mentally and physically and I think its sad really because we don’t (know) what to do with her… we can treat her physical need if she’ll let us.” (fg3) “Yeah I do feel that sometimes we (get) people in who are perhaps that bad when we get them but because there is no where for them to go we end up with the(m) a long time and they leave us much worse then they came in .. mentally wise because there is nothing to stimulate them what can we do with them… they are sat in a room sometimes we have to put them in a side room for the safety of the other patients because they can’t be in a 4 bedded room and they are stuck in there and they feel like they are in a prison cell and they go out of there much worse than when came in… to me that’s mad there must be something that we can... be doing with them but I don’t know what and not a lot of my colleagues do either… so I think that where we feel we are letting them down. Now what they do with them on mental wards I



don’t know…” (fg3) “…had spent so much time with this other lady we hadn’t spent time with any of our other patients who had to say were ok there were no problems with them but that’s not the point…”(fg1) “She (mentally ill patient) kept all the patients up all night…”(fg1)

b) Unclear care pathways Interviewer “If a patient has mental health issues but is also physically unwell, they tend to fall through a hole regarding who their care should be managed by, how is this situation dealt with?” Interviewee “This is very difficult....we have no facilities to look after physical ailments of the patient...No IVs, no equipment....the staff are not dual-trained anymore.” (int04) Interviewer “What happens at the moment when there is an older person on the ward/ A&E who you think may be experiencing mental health difficulties?” Interviewee “Usually mental health services will request medical clearance; this usually involves patients being admitted for a series of invasive/unnecessary procedures.” (int07) “…the pathway of a dementia patient is undesirable, that is, moved from A&E to MAU and then to the ward.” (int02) “… we are a rehab ward, they don’t get admitted on to our ward they get transferred so they sometimes have been in A&E they might go to MAU they might go to an acute ward by the time they get to us, we can sometimes be their third place they’ve been in and I think its very disorientating. Also what time they are transferred doesn’t seem to have any, it doesn’t seem to concern people you know the priority is the bed situation not the person in the bed so if we’ve got a lot of our patients can be quite confused or with dementia or things like that and it doesn’t seem to say well its not a good idea to move them and its doesn’t seem to hold, no, they just do it so you can appreciate that sometime you know we got people transferred to our ward at 11 o’clock at night even 10 o’clock at night when they ought to be in bed asleep and so it, it is very unsettling and they don’t know where they are, they didn’t know where the were to start with and they certainly don’t then so…” (fg1) “…we’ll get somebody in with dementia who’s probably waiting for a EMI ward and there aren’t that many places available so we end up with them for a long time … we’ve just had a lady now who we’ve had for weeks and weeks and weeks who’s been waiting for a placement…” (fg2)

c) Early hospital discharge “…you know the turnover in .... is-is very fast, so it’s too quick for peoples’ depression to be picked up really… they’re out before it’s detected.” (int08) Voice 2 “…she actually was discharged very soon the next day, I think it was felt that she was, you know, ok.” Voice 3 “She wasn’t.” Voice 2 “Actually she wasn’t, she was in for dehydration I remember now she was in for dehydration and they’d think that she’d got adequate hydration and sent her back partly I think coz nobody knew what to do with her.” (fg1)

Preferred changes to current services

When shortcomings in psychiatric services were highlighted by participants, often the interviewer would ask follow-up questions about how the staff would like the service to change. Two main issues about future service development emerged: (a) psychiatric service model and; (b) staff education and training (including barriers to). a) Psychiatric service model



Interviewer “Do you think it would be beneficial to have an on-site team?” Interviewee “It would be beneficial to have a liaison team - ideally, you know....a junior doctor and a senior consultant. But, some weeks....there are no referrals and then several come at once. So it's debatable whether there is enough work to warrant a full-time team...and there is the issue of funding...” (int04) “A liaison service would be helpful as I think (town) is probably one of the trusts within the (county) who do not provide such a service.” (int05) “I suppose our ideal model would be to have input from all the disciplines we would normally work with in mental health practice…”(int09) “I would like to see a better relationship between the acute trust and community mental health teams, so I think they should take referrals direct from the hospital much more easily.” (int01) “I would like to see greater cross-fertilisation between my (hospital) department and liaison old-age psychiatry…the bridge could be stronger.” (int03) “I would quite like to see some joint unit; there are pros and cons of those…but it might be that we could make better use, either of some beds within Medicine for the Elderly, with a psychiatric focus…or some better use of joint beds on (the hospital) ward.” (int05) Interviewer “What changes/developments would (name) like to see?” Interviewee “A seamless service between acute and mental health staff. It’s the patient we’re there to look after.” (int04) “I would like to see the acute unit…invest in a bigger and better liaison psychiatry service for older people.” (int08) “If you’re trying to provide a service for the people who are your main customers and your main customers are old and, many of your main customers have mental health problems, it seems reasonable that you ought to invest in a decent service for the…that to me would be just so obvious that I don’t see why we don’t do it.” (int09)

b) Staff education and training “At the moment there is little formal education. There is a formal training session planned over the next few months. Informal training takes place on an ad hoc basis on the wards, however the team feel that often there is little take up of this or little attention paid to this, particularly by qualified nursing staff.” (int01) Interviewer “What steps could be taken to improve the service given to older people with mental health difficulties on the ward where they work?” Interviewee “Staff knowledge and skills, skills mix - RMN training (STORM training)” (int03) Interviewer “Would any type of training help you manage older people with mental health illness better than at present?” Interviewee “Any training would be beneficial as mental health in the elderly is a specialist area.” Interviewer What would this training look like, how can training needs be met?” Interviewee “Medical/nursing staff should be proactive in initiating own training, it does not always have to be formal, but time could be given to encourage staff to go to observational visits in MH areas and reading/internet exploration etc.” Interviewer “Are there any particular training priorities?” Interviewee “Self-harm is my priority. Historically, older adults were the high risk group.” Interviewer “What would help you put this training into practice once you are back on the ward?” Interviewee “Motivation of ward, managers and other multidisciplinary teams.” (int04) “I did the ‘sharing of the hurt’ course I thought that was absolutely fantastic but you can’t always put it all into practice … but that was an absolutely fantastic course that was, that really opened my eyes.” (fg1) “Training would be very useful… yeah because you know you might have done it a while ago but its not, it not as up to date training you need and especially about all the mental health



disorders you know to actually learn something about dementia and various impairments.” (fg1) “I don’t know if we need some training in how to deal with them, I don’t know if whether they treat them differently on the mental health wards… I’d perhaps like to do a bit of shadowing… on the mental health wards and see whether I could pick up some ideas… I think that there is a few of us that think we need so training really… so learn to interact.” (fg2) “… I’d like to know sometimes how to deal with the relatives as well because that’s awful as well, what do you say to them… they find it so difficult don’t they? Yeah I’d like to know how to talk to them….”(int04) Interviewer “Do you think there are many barriers to acting on what you will have learned through training and development?” Interviewee “Yes. Time, other people's beliefs and prejudices.” (int07) Interviewer “Do you think that there are any barriers to acting to what you will have learnt through training and development, I know you kind of mentioned its difficult to put it into practice, what is the actual difficulty with putting the training then into practice, can you pin point?” Voice 3 “Time” Interviewer “Time you’re able to do even though should be done.” Voice 2 “Cost comes into it, to it sometimes.” (fg3)

Summary The function of a liaison service is clearly about access to a psychiatric opinion and facilitating access to appropriate and timely discharge packages. Drivers to development are embedded within individual clinicians’ personal interest and their investment in time and effort to secure contemporary funding sources. Barriers to development are the competing interests of ‘own’ services and the agenda of the hospital; it is unclear who should pay for the service, manage it and has responsibility for it; proximity of liaison services is seen as a barrier to successful integration with other general hospital based services. Perception of liaison services General hospital staff who have access to liaison services report barriers to effective care including; availability of liaison staff and lack of advice on basic nursing management for patients which is embedded within a belief that liaison staff should provide basic nursing care daily. Perception of general hospital services Liaison staff report barriers to effective ward based care as; lack of staff available to help manage the care of patients, a sense that staff feel they are unsafe and at risk from older patients with mental health needs, an inappropriate environment to care and lack of mental health training and skill mix. Impact on patients Stakeholders report that the health and safety of patients are at risk, there are increasingly complex and indecipherable care pathways and that patients are being discharged prematurely.



5 Discussion and conclusions This section draws together the findings of the three phases of our study at a conceptual level. An examination of the limitations of the study and considerations for the future direction of liaison mental health services for older people in general hospital settings is also offered.

5.1 Phase 1: Literature review. We carried out a systematic and comprehensive search of healthcare literature databases, together with a wide range of other potential sources of information, in order to identify relevant literature that provided descriptions of the structure, processes and effectiveness of liaison mental health services for older people. This included peer-reviewed and non-peer-reviewed sources.

A total of 484 potentially relevant articles were identified that met predefined inclusion criteria. Of these, 372 articles were rejected due to lack of relevance to the review question and a further four were rejected due to poor methodology. Studies were subsequently categorised according to the population served (defined by age), the service model described, and the study methodology (e.g. descriptive study audit or randomised controlled trial).

Examination of this literature revealed one meta-analysis, four systematic reviews, eight randomised controlled trials, ten non-randomised evaluative studies, two evaluations of an educational intervention, and two cost-effectiveness analyses with the remainder being descriptive studies of service models and activity, or audits. There was little literature of high quality, and much of the higher quality literature originates from North America, so may not be fully relevant or applicable to the United Kingdom setting.

The meta-analysis suggested that in the presence of a liaison mental health service, treatment outcomes for depression tended to be better, length of stay tended to be lower and physical functioning was slightly improved. The systematic reviews suggest that liaison mental health services have the potential to improve outcomes. Of the randomised studies, only one suggests that liaison mental health services are beneficial for outcomes including length of hospital stay, physical functioning and institutionalisation on discharge. Some non-randomised studies show a beneficial effect, including reduced length of stay, but these have to be interpreted with caution. The descriptive studies do not report information on outcomes, although they do provide valuable information on service evolution, structure or processes.

We used recognised methods of searching the English language literature, and are confident that we have identified most if not all of the relevant literature. Given the potential importance of liaison mental health services to the healthcare system, it is highly likely that relevant publications will appear in indexed peer reviewed journals and so will have been detected by our searches. Our exclusion of non-English language articles may have lead to some literature not being examined, although several European authors have published in the English language literature.



One significant flaw found in most of the evaluation studies was the use of randomisation at the level of the individual patient. This is a problem because an effective liaison service will have a direct treatment effect – assessing patients and providing direct care and advise to general hospital colleagues – but will also have an indirect effect, through education and training of general hospital staff in order to improve detection and management of mental health problems. These improved knowledge and skills cannot be turned on and off by staff, who in any case should be blinded to the allocation group. This will lead to contamination in the non-intervention group, who will receive some of the intervention, and may be one of the reasons why the literature we identified is often inconclusive.

Another problem with the literature we identified is that the intervention (a liaison mental health service) is not well described. As has become apparent from phases 2 and 3 of this study, the term liaison means different things to different people, and services that look the same on paper can have very different clinical and educational activity. The lack of detail about what the intervention actually was means that it is difficult to generalise and reproduce the study findings in another setting. These liaison services are complex interventions with many components, each of which alone may have little effect but where the sum is greater than that of the individual parts.

Our knowledge of the management of mental health problems in older people in general hospital settings is not as good as it could be. We know that mental health problems, and in particular dementia, delirium and depression, are very common in the general hospital population, and there is also convincing evidence that outcomes are badly affected by the presence of a mental health problem. Despite this, we have revealed a lack of good evidence for the effectiveness of mental health services in the general hospital setting. The implications for future research are summarised at the end of this discussion.

5.2 Phase 2: Service mapping We have built on previous work in 2002 to provide an up-to-date map of liaison mental health services for older people across the UK, together with a description of service changes in the intervening period. We carried out a two-stage survey. The first stage was carried out to determine what liaison services were in existence (if any), with the second stage a more extended survey of existing specialist liaison services to provide more in-depth information.

Our mapping revealed that the majority of old age mental health service provision into general hospitals is the traditional sector-based consultation model. This is closely followed by the liaison psychiatry nursing model, with the hospital mental health team the next most frequent model in use.

This reveals a clear change from service provision in 2002, which was much more dominated by the traditional sector model. In the intervening period there has been a clear shift away from the traditional sector model towards specialist liaison models, with increases in both liaison psychiatry nursing models and in hospital mental health teams.

Our survey response rates were not 100%; we obtained a response rate of 73% to the initial questionnaire from mental health clinicians and a much lower response rate of 17% from geriatrician colleagues. We used NHS service



mapping data to fill in the gaps our incomplete response left us with. Scrutiny of this data suggests that it does not identify the subtypes of liaison services that we and others have used, but that it appears reasonably accurate in identifying the presence or absence of a liaison service of any kind. It is also likely that the areas where we were unable to get a response had no dedicated liaison service that could provide a response; a lack of response is probably indicative of a lack of a liaison service. We believe our findings reflect the true state of liaison mental health services for older people at the time of the survey.

The extended survey that we carried out provided more detail about individual liaison mental health services for older people. We identified several important areas of concern. Many services, whilst attempting to help general hospital colleagues, had little or no support from the general hospital trust they were working in and providing a service to. This ranged from a lack of general hospital-based accommodation, through insecure or short-term funding to a lack of clarity about managerial arrangements. It seems that general hospital trusts see liaison mental health services as being mental health business, whereas mental health providers see no benefit in a service that works entirely in another NHS organisation and brings in no activity-related income to its own coffers. This lack of ownership and responsibility is a significant barrier to service development. It is in the face of recommendations by various policy documents and other relevant documents that liaison mental health services should be provided in all general hospitals (Department of Health and Care Services Improvement 2005; Department of Health 2009).

Where liaison services are in existence, they have usually developed due to the interest of an individual clinician rather than in any strategic way. This is confirmed both by our extended survey and by the sporadic distribution of liaison services across the country. It seems that until recently there has been little provision of strategic direction for old age liaison mental health services, despite their potential importance to providers of mental health care, physical health care and social care. This is in the context of the large number of older people with mental health problems that use general hospital services, and the adverse outcomes they endure.

One striking finding was the response to our question about which service model respondents would prefer. This reveals a great preference for liaison models, with the hospital mental health team a clear favourite, and only three respondents preferring the traditional sector model. This preference is clearly at odds with the current models of service provision, and reflects the multi-disciplinary nature of mental health care, together with dissatisfaction about the prevalent service model provision. We had a different constituency of individual respondents compared to our original survey in 2002, and there is likely to be a degree of response bias, but we had similar geographical coverage in both surveys.

One thing that becomes quickly apparent when looking at different services is the wide range in skill-mix, staff numbers and clinical and educational activity between services. Accessing liaison services, processing referrals, note-keeping, activity recording and interfaces with other services all can differ considerably. This is not just between the different service model typologies we have examined, but within service models as well. This variation means that it is difficult to carry out a like-for-like comparison between services that appear on the face of it to be using the same service model. This relates back



to one of the observations from the literature review; that services are often poorly described and therefore difficult to reproduce. Some services appear quite large, but on closer inspection are actually providing to more than one general hospital site, thus diluting the service; this means that a simple head-count is less helpful when determining the level of service provided.

We found no reporting of the involvement of clinical psychology staff in the delivery of liaison mental health services for older people. Clinical psychology services exist in general hospitals, but mental health services do not appear to see them as part of a mental health service provision for older people.

We found differences in the level of administrative support, including services that had little or no support of this kind. It seems that in these services, clinicians themselves would carry out administrative tasks such as database entry or letter-writing, or that these tasks simply did not happen.

Examination of reported activity from the extended survey revealed that use of a liaison model appears to allow for a more broad spread of activities; not just mental health assessment and review, but also education, audit, administration and research. This broader range of activities allows for a degree of service audit and evaluation in an ongoing way, providing prospective evidence of process measures such as speed of response, to feed back both to referrers to and funders of the service. Where this does not take place, services may have little evidence to present at arenas where service planning and financial decisions are made.

The presence of a liaison model rather than the traditional sector model input seems to bring increased referral rates, both in overall numbers and as a proportion of the population of older people in hospital. The highest numbers and proportions seen are with the larger hospital mental health teams. When reporting changes in clinical activity, almost all services reported referral rates that were rising, which has clear implications for service capacity to respond in a timely and appropriate manner. It seems that the presence of a liaison service acts to raise awareness about older people’s mental health amongst general hospital colleagues, who then recognise problems and refer for help when they would not have previously done so. There are also other potential drivers of referrals, such as concerns about mental capacity to make decisions, and deprivation of liberty issues.

These increased rates of referral improve access to specialist mental health assessment, and by implication improves access to community and other mental health services for those who did not previously have a diagnosed mental disorder. Since general hospitals admit high numbers of older people, many of whom have a mental health problem but are unknown to mental health services, it seems that general hospitals are a good place to detect and signpost people to appropriate services, and that liaison mental health services can play a key role in this process by helping to develop both screening protocols and care pathways into specialist services such as memory clinics. This screening is a relatively low cost option, since the people to be screened are sat in NHS beds rather than being out in the community. If we are to close the diagnostic gap for dementia as the National Dementia Strategy requires (Department of Health 2009), then the presence of a liaison mental health service for older people is clearly part of the solution.



At the same time, we asked respondents about prioritisation of referrals, since our previous survey in 2002 revealed that many clinicians prioritised community referrals over general hospital referrals, with the latter were seen as being in a place of safety, a questionable assumption. Our findings here suggest that opinion has changed, with most giving equal priority to community and hospital assessments. Risks in these different setting may be different. For example, someone with dementia at home may be at risk of hypothermia due to leaving their home at an unsuitable hour, inappropriately attired for the weather, whereas in a general hospital ward, similar behaviour may bring the risk of falls due to inappropriate medication being administered. That being in a general hospital ward does not necessarily mean that someone is in a place of safety is a message that seems to be getting through.

Our findings suggest that not all parts of the hospital access mental health services to the same degree. Some speciality areas (such as paediatrics and obstetrics) will naturally have no older people, but there are specialities such as general surgery and orthopaedics that refer to mental health services infrequently, despite good evidence that mental health problems are no less common on these wards than elsewhere in the hospital. This information may be helpful in targeting particular interventions such as training events. The content of these training events may need to be tailored to the needs of individual specialities; for example, the management of post-operative delirium after hip fracture, depression after stroke, or alcohol withdrawal after an elective surgical procedure.

One final finding from our extended survey was about the use of protocols. The English National Service Framework for Older People (Department of Health 2001) requires protocols for the management of depression and dementia in all care settings, yet we have found that this is far from universal in the general hospital setting. Liaison mental health services can act to develop protocols with general hospital colleagues so that they are tailored to their particular care setting; this involvement of ward staff in the customisation of a protocol can bring increased ownership by ward staff and may mean better use of and adherence to the protocols in day-to-day clinical care.

5.3 Phase 3: In-depth evaluation We selected a sample of each common service model in order to provide a more detailed in-depth evaluation of each service. The models chosen were the traditional sector model, the liaison psychiatry nurse and the hospital mental health team. The latter were divided into small and large teams for the purpose of evaluation, since we believed that there would be differences in activity and outcomes between these two sub-types. These particular models were chosen since they represented the most common services, and each had seen a change in prevalence since our survey in 2002, with a reduction in the traditional sector model and increases in liaison mental health nursing and hospital mental health teams.

At the time of sampling strategies in which we determined which service we would evaluate, the heterogeneity within our service model typology revealed by our extended survey was not apparent to us. However, the time-frame of the research programme did not allow for us to wait until the information from the extended survey was available. Our initial plan was to evaluate 12 services. This proved problematic; some sites that we identified as potential



collaborators showed initial enthusiasm to take part, but this enthusiasm waned once a more firm commitment was sought. After a year of attempting to negotiate with one site where clinicians from the mental health trust had expressed a great deal of interest, we eventually had to abandon this site as no local collaborator from the general hospital trust could be identified. This happened too late in the research programme to allow us to identify and recruit a replacement site, meaning that the in-depth evaluation occurred in only 11 sites. Sites with very new liaison services were interested in having these new services evaluated by an external agency, but these services did not meet our inclusion criteria as they were not well established and therefore would not be achieving their maximum potential benefits. There were also significant difficulties encountered in working across mental health trusts and providers, general hospital trusts and commissioning bodies in primary care trusts, which are discussed in more detail below.

The process of seeking approval to carry out our in-depth evaluation varied a lot between different sites. Ethical approval was not a particular issue here; ethical approval for the overall study was obtained from one of the Leeds research ethics committees, and site-specific assessments were obtained for the individual sites taking part in this phase of the research. More problematic were research governance approval, access to data and the recruitment of fieldworkers who then needed honorary contracts with two or sometimes three different NHS organisations. This seems to be as a consequence of carrying out research that cuts across different NHS trusts, each of which has different agendas, governance structures and levels of administrative support for the approval process. Even within individual general hospital trusts there could be little consistency between different departments, meaning that high-level approval to carry out our research still meant considerable blockages, for instance in relation to accessing Patient Administration System data. Although the use of research passports would have eased some of our problems, the different structures for research governance in different trusts seems to suggest that in order to stick to our planned timetable of a staged series of evaluations there should have been more time dedicated both to setting up the study at each individual site and to overseeing and troubleshooting the early stages of each evaluation.

We also experienced problems in recruitment and deployment of fieldworkers. Our original plan was to use the networks established by the Personal and Social Services Research Unit (based in Manchester, Canterbury and London). However, our service mapping and subsequent sampling resulted in a poor geographical alignment to these three sites, and our plans were revised to include a mixture of short-time research contracts with the University of Leeds, and local secondments of existing staff with recharging of salary and other costs. We discovered that in many places NHS staff were reluctant to consider such a short-term secondment; it seems that at a time of great pressure within the NHS, staff feel that their posts may be at risk if they take on such short-term positions. One of the results of these problems was a wider than anticipated variation in the background and experience of our fieldworkers; although we provided all with what we felt to be suitable training, the unanticipated relative inexperience of some staff we appointed may have meant that this training was insufficient to enable them to carry out collection of a full dataset.



One of the consequences of the problems highlighted above was levels of missing data, which were higher than we expected in some (though not all) sites. We have used statistical techniques to allow for this where possible, but it means that some results must be interpreted with caution. In one site, levels of missing data for some domains meant that this site was excluded from parts of the analysis. We were able to gain the help of the Mental Health Research Network, who provided additional support at some of the sites where data collection had been incomplete. This support appears to be extremely helpful in carrying out this type of multi-centre study.

5.4 Characteristics of service models The service models we evaluated proved to have diverse characteristics, even within the same model type. Source of funding and managerial responsibility varied, and seems to reflect the lack of ownership and responsibility that was apparent from our extended mapping survey. Most services were well-established, with none having been in existence for less than a year. This means that the indirect impact of education and training of general hospital staff in the identification and management of mental health problems in older people would be expected to be evident. The more specialist liaison models had a tendency to have more of a presence within the general hospital, with accommodation and access to the general hospital patient administration database, but this finding was only weak and conclusions cannot be drawn.

Staffing skill-mix and numbers within the service models also showed differences both between and within model typologies. Two traditional sector models only had had input from a consultant psychiatrist, whereas by definition the liaison nurse model only had mental health nurses (at three different pay bands). Only the larger hospital mental health teams had an occupational therapist or support worker and only the hospital mental health team model had dedicated administrative support. The skill-mixes in the uni-disciplinary services do not seem to meet the complex needs of older people with both physical and mental health problems, where advice on behavioural management, psychotropic medication, mental capacity for decision-making, risk assessment, discharge planning, assessment of response to treatment strategies and psychological approaches may all be required in the same individual. Elsewhere in mental health it is the norm to work in multi-disciplinary teams, but in the general hospital this is much less common and the provision of holistic, multi-disciplinary input is relatively rare.

Working as a liaison mental health practitioner requires a certain set of knowledge, skills and attitudes. There is knowledge about the mental health problems encountered in the general hospital setting, the interaction with and effects of physical illness, medication effects and management, the availability of mental health and other services in the community. Skills required include the assessment of mental health problems in an environment that is often not conducive to this taking place, the ability to engage and teach general hospital colleagues, and the ability to use diplomacy when conflict arises. Attitudes need to be helpful and enabling. These attributes require training for practitioners to work at their best, yet our respondents revealed very little in the way of specialist liaison mental health training; most had an experiential training on the job. Liaison mental health work is often extremely complex, yet the workforce seems poorly prepared for the challenges ahead.



The amount of staff time available to the different service models also showed variation. The traditional sector model showed very low levels of input (two hours of consultant psychiatrist time at the most). This seems a grossly inadequate amount of time to deal with the complex problems that present in the general hospital setting. The amount of clinical time available also differs, with larger services being able to provide staff time for administrative tasks, teaching and training, audit and professional development.

The referral activity varied across and within models also. The specialist liaison models all received considerably more referrals than the traditional sector models, with a twenty-three-fold difference in referral numbers in the last year and a thirteen-fold difference during the evaluation period for the most extreme examples. This provides good evidence for the improvement of access to specialist mental health assessment that liaison models bring, and highlights the ability of a liaison service to detect previously unrecognised mental health problems and to signpost people to appropriate community mental health services. This is supported by our finding of increased referral rates to community mental health teams by liaison services.

Two other areas of difference were in speed of response and number of reviews undertaken. None of the three traditional sector models we evaluated responded on average in less than three working days; this response time was quicker for the specialist liaison models apart from one of the larger hospital mental health teams, which took more than three days to respond on average. One larger hospital mental health team was able to respond on average in less than one working day. The specialist liaison models all provided more reviews after assessment than the traditional sector models. Speed of response clearly has an impact on utility, and it seems intuitive that reducing the delay for a mental health assessment could make a difference to the length of stay of someone waiting for such an assessment. It is also clear that the traditional sector model is in no position whatsoever to provide input into fast-paced accident and emergency departments, and even the larger models we evaluated told us anecdotally that they could only offer this input during office hours.

Referred and comparison cohort characteristics

We collected information on those patients referred during the evaluation period at each site, and also examined a randomly-selected comparison cohort of older people admitted to the hospital during the evaluation period. This included elective and emergency admissions across all relevant specialities. We aimed for 100 patients in the comparison cohort at each site but issues of lack of consent, severity of physical illness and inability to access case-notes meant we were unable to achieve this across all of the sites. Differences in service activity mean that the ratio of referred to comparison patients varies across the service models.

We examined gender, ethnic mix and age of referred and comparison cohorts. Our findings suggest that women are more likely to be referred than men, a finding not accounted for by age alone. The ethnic mix was mainly White British, although with changing population demographics bringing an increasing ethnic mix to our older population this will likely change in time.

There was little apparent difference between service models for residential status on admission, with most people in both the referred and comparison



cohorts living independently. Speciality of admission was used as a proxy for the reason for hospital admission; this revealed low rates of referral from surgical areas across all models. This does not reflect truly the fact that older people often present with multiple physical problems, and is more an observation of referring behaviour of different specialities. A higher proportion of the referred cohort was prescribed psychotropic medication on admission, and also had a previous mental health history recorded in the general hospital notes. Levels of physical co-morbidity did not reveal any particular pattern across the different services.

Discharge destination was determined for the two cohorts. There was a trend towards liaison services increasing return to independent living, although this is influenced by a wide range of other factors. We came across anecdotal evidence of individual cases where institutionalisation had been avoided through the input of a liaison service and successful discharge home with an appropriate care package had been achieved. The possible benefits to not just the healthcare system but social care too are obvious, and a further example of the potential for whole-system impact of liaison mental health services for older people.

Service models had different rates of referrals from different professions. Most of the liaison models appear to open up referral routes for nursing staff, especially the liaison nursing model, and one model was commonly accessed by occupational therapists. The nature of this variation could be an inherent feature of the particular models, but is just as likely to reflect local custom and practice; for example, it may be a doctor’s job to access a mental health opinion, but a nurse’s job to refer to social services in a particular hospital. It seems likely though that the presence of a particular profession in a service may encourage or allow others of that same professional background to feel able to refer. Our determination of the profession of the person who makes the referral does not, of course, tell us who instigated the referral.

We attempted to determine actions taken after the initial assessment. Liaison services seem less likely to recommend medication (by proportion of people seen) and more likely to carry out reviews in hospital than the traditional sector models that we examined, although the much greater numbers seen by liaison services mean that the former may simply be an artefact; the effect disappears when whole numbers are considered. This acts as a reminder that in examining these services, and in particular the referred cohorts, we are not comparing like with like; liaison services see greater numbers of referred patients, many of whom would not have been referred to a traditional sector model service if it were in existence. This basic matter of fact is a key reason why comparisons are difficult to draw from this data.

We established the diagnostic case-mix of different service models. There was a broad spread of diagnoses, with dementia, delirium and depression the most common. This reflects the high prevalence of these problems in older people in general hospitals, but in terms of total numbers in each hospital, liaison teams are far from seeing everyone with a mental health problem. This is relevant if services are to be consistent with NICE guidance for the management of dementia (Excellence 2006), which recommend (amongst many other things) that all people with dementia in the general hospital should be seen by a liaison mental health service. However, further consideration of this reveals that this would greatly increase the clinical workload of liaison teams, when the emphasis should be on the liaison teams modelling good person-centred care,



and training and educating general hospital colleagues, so that the default position is to provide good holistic care for people with dementia without direct involvement of the liaison service. Indeed, if all people with dementia are seen by the liaison service, then this will only serve to encourage the attitude that dementia is not a problem for general hospital services but one for mental health services. The input of a liaison team should be required only when there is diagnostic uncertainty or when the case is more complex. Dementia needs to be jointly owned by both general hospital and mental health staff if it is to be successfully managed.

One of the outcomes of importance in the general hospital population is length of hospital stay. This outcome is influenced by many confounding factors, including (for the population we are interested in) the availability of community mental health resources such as intermediate mental health care teams and other discharge facilitators. When looking at the cohorts of patients referred for a mental health assessment, those referred to liaison nursing or the larger hospital mental health teams had a shorter length of stay than those referred to the traditional sector model. This difference was not apparent for the smaller hospital mental health teams, and may be a result of the differences in the referred populations for each service model. However, if this is a true reflection of the facts, the presence of a liaison mental health service may reduce length of stay for those people who are referred, although these form only a small proportion of the overall hospital population.

There were clear differences in length of stay between admitting hospital specialities for the referred cohorts. It is not clear whether these differences reflect case-mix, skill-mix or other factors. We carried out a linear regression, which suggested that the presence of previous mental health history and the liaison model in use may have an effect on length of stay, although the liaison model only accounted for a small proportion of the variance in length of stay.

We examined survival; we found a significant relationship between increased survival and service model, with the liaison nurse and larger hospital mental health team models both appearing to increase survival. If this is correct, then some liaison service models could make a difference to a very important outcome of interest to all stakeholders. We cannot draw such a conclusion from these data however; as there are differences between the referred populations in each service that preclude this. The interpretation of factors influencing survival was affected by the low event rate; most people who were referred for mental health assessment survived the encounter.

We attempted to establish predictors of discharge destination, but were unable to do so; this part of the dataset contained a large amount of missing data which means a conclusion cannot be drawn.

5.5 Cost effectiveness analysis Within the sampled population there were multiple determinants of length of stay including: age, referral to liaison psychiatry service, hospital site, ethnicity, place of residence on admission, admitting specialty, measures of co-morbidity, previous psychiatric history, delay to discharge, discharge destination and liaison service characteristic. Despite these multiple influences, liaison mental health service referral was seen to consistently increase length of stay.



Model parameterisation was sensitive to the probabilistic threshold for inclusion in forward conditional models although this did not qualitatively affect the main model finding.

A major limitation of a case-control epidemiological design is that matching is imprecise and unknown confounding variables may influence findings. Difficulties in achieving consistent sampling across all hospital sites may have limited the inferential value of findings. A further limitation with this research design is that it cannot establish the direction of causality. For example, although referral to a liaison service may seem to affect length of stay in patients discharged to nursing home care it is unclear whether the characteristics of the patient are influencing the decision to refer or referral is affecting the choice of, or time to, discharge destination.

Given that each hospital had to a lesser or greater extent its own service configuration there was little scope to reliably differentiate liaison service differences from other hospitals or geographical differences between sites. For example differences in hospital management practices may have confounded liaison service differences.

Consistent with the review of previously conducted research, the current analyses illustrates the problems of measuring cost-offset; patients, settings and services are highly heterogeneous. Notwithstanding these difficulties there appears to be a consistent picture that liaison services do not decrease but increase length of stay and a number of other resources could be expected to increase as well such as medication and subsequent cost of care at discharge. These changes are consistent with better care and patient outcomes although only a randomised controlled design will robustly estimate the net costs and benefits or liaison service intervention.

5.6 Staff skills, knowledge and attitudes We attempted to determine the knowledge, skills and attitudes of general hospital staff toward older people with mental health problems through questionnaires and focus groups. Although our dissemination of questionnaires was variable, consistent features included a lack of training in detecting and managing mental health problems in older people, and a lack of mental health input and advice. We also found many respondents who believed that older people with mental health problems should not be admitted to general hospital wards. The latter reveals one significant barrier to change; these attitudes are deeply stigmatising and must be challenged. The presence of a specialist liaison service provides a mechanism to provide clinical input, education and training and the championing of mental health issues in older people.

There is a clear and deep-seated problem with the training of many clinicians. Much of a general nurse’s time will be spent delivering care for older people with mental health problems, yet it is not addressed in the training curriculum and it is possible to train as a general nurse in the United Kingdom without undergoing a mental health placement. Similarly, many doctors receive only small amounts of mental health training and experience. These deficiencies are most prominently highlighted in the National Dementia Strategy for England (Department of Health, 2009) which identifies workforce training as an area for significant development. With an ageing population, this is a message we cannot ignore.



5.7 Strengths and limitations of the study

Phase 1

Our literature review utilised the help of colleagues skilled in the construction of comprehensive search strategies for the detection of appropriate literature from a wide range of sources. Our search strategy was a broad as possible in order to include relevant literature such as audits or descriptive studies. We excluded articles not written in English; we did not feel that this would affect our findings, since we were most interested in liaison mental health services in the context of the United Kingdom National Health Service. Some of the literature we found (mainly from North America) referred to services that were not specific to older people, and this made interpretation difficult. We believe that our finding of limited evidence for effectiveness of liaison mental health service for older people is valid, with methodological weaknesses in much of the literature we found that made any estimation of effectiveness difficult.

Phase 2

We built on a previously successful methodology in order to attempt to construct a map of liaison services across the United Kingdom. Our initial postal survey generated a response from 73% of sites, and we obtained further information from these sites for the second stage of our mapping. However, we did not receive responses from 27% of sites surveyed, and although we utilised National Health Service mapping data to fill in the gaps, we have no detailed information about services in these sites. We are confident that we have not missed any specialist liaison mental health services in our mapping and believe that a non-response was indicative of an absence of such a specialist service (or rather the presence of a traditional sector model). The information obtained from the second stage of the mapping proved extremely useful in describing services in more detail, and in determining services to be examined in the following phase of the study.

Phase 3

This phase of the study encountered several problems, detailed in the following section. We found that our service typology did not reflect the wide variations in services that we encountered. Services that appeared to be similar on paper were not so when examined in more detail. This means that a great deal of local knowledge is required in order to understand what each service actually does, in terms of processes and outcomes. Many services did not routinely collect data on their own activity and lacked structures to be able to do so even with external help. The heterogeneity encountered was not just of the liaison services themselves; there was wide variation in size and number of general hospitals that mental health services covered and in the availability of other mental health services such as intermediate mental health care that could act as discharge facilitators. This meant that most of the comparisons we have made are not like for like and some of our assumptions may not be valid. This is a problem that is inevitable when using the methodology of this study, and is difficult to overcome even in a trial setting. The large amount of missing data from some sites is a further weakness. We have been able to learn a great



deal despite these problems, particularly around the issues of working across several National Health Service organisations at one time.

5.8 Problems encountered We successfully carried out the first two phases of our project as planned. However, the third phase was less successful and we were unable to obtain much of the information we had originally planned, particularly around individual patient data. We encountered barriers at an organisational level which reflected the lack of ownership of liaison mental health services that is a recurrent theme in this project. We encountered difficulties in recruiting staff on short-term contracts, and we also found that secondment arrangements were not satisfactory in some sites, with a lack of clarity about management arrangements and responsibilities between local NHS managers and the project manager, despite such clarity being sought. There were significant delays in many sites in gaining the necessary Criminal Records Bureau clearance required to work in clinical settings, and in gaining honorary contracts for some organisations. These problems would be greatly aided by the widespread recognition of research passports across a range of NHS organisations. These delays are the main reason why some data we planned to collect was unavailable to us; time constraints meant that we had to prioritise data collection in certain areas that were likely to be most fruitful.

We also encountered difficulties in accessing data, individual patients and clinicians at some sites. Despite us having agreement from senior staff (clinical directors, senior nurse managers etc), ethical approval and approval for data access, our fieldworkers often found that when they attempted to obtain relevant data, identify staff members for interview, or examine case-notes and interview patients or carers, staff on the ground had no knowledge of the study and refused access. This problem seems more difficult to solve, and it may be that future work needs to concentrate on smaller parts of the general hospital and develop closer relationships with clinicians over a longer time-period rather than to attempt to engage the whole of the hospital at once.

The delays introduced by the above problems had a significant impact on project management. Whereas the original plan was to run three evaluation sites for three months at a time over a fourteen month period, many site evaluations did not occur at the time planned, and at one stage we were running seven sites at the same time. This stretched the project management time and meant that supervision of some staff was not as close as we would have liked. The delays also meant that data came in from sites later than we anticipated. We also found high levels of missing data from some sites that were only apparent once the evaluation at that site was complete. In these instances we were very grateful to colleagues in the Mental Health Research Network, who were able to provide project support.

5.9 Implications for practice Mental health problems are extremely common amongst older people in general hospitals, and bring poorer outcomes. Liaison mental health services



for older people have evolved in some localities in response to this, with the belief that they are beneficial. What evidence we have uncovered from the literature is not conclusive with regard to benefit, Our service evaluations are likewise inconclusive, but much of our evidence points towards these services being helpful. Our evaluation was hampered by a high degree of heterogeneity between services, and this would be reduced by guidance on what a liaison mental health service should look like and what it should do. This guidance is currently lacking. It is also apparent that being a liaison mental health practitioner is a complex role with many facets, and required training and supervision that is not widely available. Many practitioners have trained on the job, spending their initial time in post improving knowledge and skills, meaning that services often require time to bed in and become effective. The funding arrangements for many liaison services are frequently in the form of short-term pilot or pump-priming funding, and services can be evaluated and decisions made about sustainability before they have been given a chance to prove their full worth. The apparent lack of ownership in many places suggests a need for more joined-up working between commissioners and providers of general hospital and mental health care, in order to benefit all stakeholders.



6 Dissemination Our findings have broad implications across the health and social care economy. We will therefore disseminate the results to a wide audience in a variety of ways: The production of this formal report with executive summary for dissemination to relevant stakeholders, including chief executives, chairs and older peoples leads in primary care, acute and mental health trusts, strategic health authorities and social services; older peoples champions; consultants in old age psychiatry and geriatric medicine; Dementia Services Collaboratives and their equivalents; workforce development confederations; the ageing and mental health charities; users and carers involved in project design, steering and management; appropriate professional organisations such as the Royal College of Nursing, British Geriatrics Society, College of Occupational Therapists, British Association of Social Workers, the Royal College of Psychiatrists and NIMHE; and research funding bodies, including the commissioners of the project. We will also disseminate the report to all respondents to our mapping exercise. We will also disseminate through conferences, including our annual Leeds Liaison Psychiatry for Older People conference and Royal College of Psychiatrists, British Geriatrics Society and Royal College of Nursing meetings. We will seek publication in appropriate peer-reviewed journals for dissemination to the academic community.



7 Recommendations for future research We know that mental health problems are common in older people in general hospitals, and that outcomes are poor for this group. What is less clear is how these problems are best managed, and our project has identified significant gaps in our knowledge-base of liaison mental health services for older people. There is little evidence of any quality to guide commissioners and providers, and we have revealed considerable heterogeneity within existing service models. In order to proceed with service evaluation, it seems important to produce a standardised service model that can be successfully replicated in a range of general hospital settings and with specified activities (mental health assessment and reviews, education and training of general hospital colleagues, protocol development etc) Once such a service model is developed a formal evaluation will be more feasible. It is also evident that the conventional outcomes we attempted to measure are difficult to establish in a population with high levels of cognitive impairment and significant co-morbidity and frailty, and consideration needs to be given to the development of global outcomes rather than concentrating on condition-specific measures. This preparatory work will lay the foundations for a large, multi-centre, cluster-randomised trial that will answer the important question regarding the efficacy and effectiveness of liaison mental health services for older people.



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Appendices



Appendix 1: Literature review - Exact search strategies employed These search strategies were deliberately devised to be wide-ranging, in order to find articles on both liaison and non-liaison mental health services, for older people and non-age discriminatory services.

Ovid Databases (all OVID databases searched at the same time) AMED (1985-2006), British Nursing Index (1994-2006), British Nursing Index Archive (1985-1996), CAB Abstracts (1976-2006), CINAHL (1982-1976), EMBASE (1980-2006), Global Health (1976-2006), HMIC (1976-2006), MEDLINE (1976-2006) and PsycINFO (1976-2006).Exp consultation-liaison psychiatry/

Exp liaison psychiatry Consultation adj2 liaison Geriatric psychiat$ service$ Liaison adj2 psychiat$ Liaison adj2 mental Psychogeriatric service$ Psychogeriatric consultation$ Psychogeriatric referral$ Geropsychiat$ service$ Geropsychiat$ consultation$ Geropsychiat$ referral$ Old age psychiat$ service$ (Combine using ‘OR’) WEB OF SCIENCE (Advanced Search) TS = Consultation liaison TS = Liaison consultation TS = Geriatric psychiat* service* TS = Liaison psychiat* TS = Liaison mental TS = Psychogeriatric service* TS = Psychogeriatric consultation* TS = Psychogeriatric referral* TS = Geropsychiat* service* TS = Geropsychiat* consultation* TS = GEropsychiat* referral* TS = Old age psychiat* service* (Combine using ‘OR’; TS = “topic”)) Cochrane Library (All) Geriatric psychiatry (MeSH heading) Liaison psychiatry Liaison mental health Old age psychiatry Consultation-liaison (Combine using ‘OR’; “search all text”)



Appendix 2: Literature review – Data extraction form Literature summary

Category:

RM

no

Author/year Country Setting

Study question:

Subject of study/conditions examined

Depression Delirium Dementia Other – give details below

Other conditions:

Study population

Population size Sample size Mean age (yrs) Range Exclusion criteria

Additional demographics

Total population of area No of older people in area No of beds Previous admission rates Previous psychiatric

history

Study design and length:

Outcomes examined:

Outcome measures used:

Data collection

Method

Intervals

Analysis methods:



Key findings:

Service delivery

Service delivery model used:

Response times (urgent and routine):

Interventions offered:

Reviews:

Discharge planning:

Additional comments:

Guidelines for literature summaries

1. Descriptive studies: extract information on service model used (preferably categorising them using the 7 established models on the service mapping data)

2. Include any other information used to describe the structure and process of the service model in the comments section (i.e staff team delivering the service, staff activity etc)

3. Include any information on interventions offered by the service (medical and non-medical); reviews conducted and any involvement in discharge planning including information on care packages following discharge

4. Outcomes: main demonstrable measurements include length of stay, mortality and morbidity and institutionalisation rates (i.e transfer to psychiatric wards, returning home or moving into residential/nursing care home). Include comments on any other measurements that were used i.e. audit of activity, evaluation and/or feedback from other services and service users/carers



Appendix 3: Literature review - Means of searching grey literature This section describes the search strategies employed to search the grey literature. It contains the list of websites searched, as well as the other databases that were searched in addition to the bibliographic databases describes in Appendix 1. These sources were all searched in June and July 2006. All the websites and databases were searched using the following keywords (in the databases listed here, it was not possible to combine searches, in contrast to the bibliographic databases in Appendix 1, and consequently we had to use separate searches for all the keywords): Liaison psychiatry Consultation liaison psychiatry Liaison mental health Psychogeriatric Geropsychiatry General hospital psychiatry Three further points should be made here. Firstly, if searching using the above keywords yielded very few results, we widened the search by using more general terms, such as “psychiatry”. Secondly, some, but not all, of the databases listed here supported more advanced search options such as truncation. If this was the case, “psychiatry” was shortened to “psychiat*”. Thirdly, with regard to the website, two methods of searching were employed. The first was to enter the above keywords into the website’s search engine. The second was to methodically search all the sections of the website. Websites Academy of Psychosomatic Medicine (The Organization for Consultation and Liaison Psychiatry) www.apm.org American Psychiatric Association www.psych.org American Psychosomatic Society www.psychosomatic.org Canadian Psychiatric Association www.cpa-apc.org European Association for C-L Psychiatry and Psychosomatics www.eaclpp.org International Society of Psychiatric Consultation-Liaison Nurses http://www.ispn-psych.org/html/ispcln.html Royal Australian and New Zealand College of Psychiatrists www.ranzcp.org Royal College of Psychiatrists (UK) www.rcpsych.ac.uk World Psychiatric Association www.wpanet.org/home.html Department of Health (UK) www.dh.gov.uk National Institute of Clinical Excellence www.nice.org.uk NHS www.nhs.uk

o NHS Wales www.wales.nhs.uk o NHS Scotland www.show.scot.nhs.uk o NHS Northern Ireland www.healthandcareni.co.uk (NHS websites for different

regions in the UK searched separately, to allow for potential regional differences) Australia www.gov.au Eight state and territory governments, which all need to searched separately because of potential different policies on mental health (go to the health services sections on these websites):

o Australian Capital Territory www.act.gov.au o New South Wales www.nsw.gov.au o Northern Territory www.nt.gov.au



o Queensland www.qld.gov.au o South Australia www.sa.gov.au o Tasmania www.tas.gov.au o Victoria www.vic.gov.au o Western Australia www.onlinewa.com.au/enhanced

Ministry of Health, New Zealand www.moh.govt.nz Health Canada www.hc-sc.gc.ca United States Department of Health and Human Services www.hhs.gov Google www.google.co.uk (it was decided not to use other search engines such as Yahoo etc) Other databases African Trials Register www.mrc.ac.za/ATR/ Arab Psychiatric Literature www.arabpsynet.com/INDEX.ASP Australasian Medical Index www.nla.gov.au/ami/ Binleys Online www.binleysonline.com Center Watch www.centerwatch.com Chinese Academic Journals http://0-online.eastview.com/index.jsp Clinical Trials http://clinicaltrials.gov Cochrane Library Databases www.thecochranelibrary.com Conference Papers – ISI Proceedings http://portal.isiknowledge.com/portal.cgi?DestApp=ISIP&Func=Frame Controlled Trials www.controlled-trials.com COPAC http://copac.ac.uk/ DIMDI www.dimdi.de/dynamic/de/index.html Dissertations and Theses – Index to Theses (www.theses.com) and ProQuest (www.proquest.com) Eastern Mediterranean Literature (WHO) www.emro.who.int/ Egypt Literature http://search.sti.sci.eg/fillform.html ERIC www.eric.ed.gov FDA – drug approval packages (USA) www.fda.gov/cder/foi/nda/index.htm Google Scholar http://scholar.google.com/ GrayLit Network www.osti.gov/graylit Hungary http://sunyy.eski.hu:8080/cgi-bin/wi.sh India http://indmed.nic.in Integrated Catalogue of the British Library http://catalogue.bl.uk Iran www.parsmedline.net Japanese Science and Technology Databases www.jst.gp.jp/EN/ Korea www.koreamed.org/SearchBasic.php Latin America www.bireme.br/iah2/homepagei.htm National Electronic Library for Health www.nelh.nhs.uk/ National Library of Australia www.nla.gov.au National Research Register www.nrr.nhs.uk New York Academy of Medicine www.nyam.org OMNI www.OMNI.ac.uk Open Uni Links to Grey Literature http://library.open.ac.uk/resources/reports.html ReFeR www.refer.nhs.uk Scirus www.scirus.com Social Policy and Practice Database Trials Central www.trialscentral.org/ClinicalTrials.asp University of Leeds Library Catalogue http://lib.leeds.ac.uk WorldCat www.worldcat.org



Appendix 4: Literature review – Appraisal for study quality

Criteria Score

Design

Study described as randomised

Process of randomisation not described

Process of randomisation described and appropriate

If “randomisation” described but is inappropriate1

Add 1 point

Add 0 point

Add 1 point

Deduct 1 point

Control

Control group (including usual care)

Comparison group

Add 2 points

Add 1 point

Blindness

Study described as blind

Process of blinding not described

Process of blinding described and appropriate

Process of blinding described and inappropriate2

Add 1 point

Add 0 point

Add 1 point

Deduct 1 point

Withdrawals

Number of withdrawals and dropouts in each group stated

Intention-to-treat analysis performed

No withdrawals/dropouts are noted

Add 1 point

Add 1 point

Add 0 point

Others

Comparable groups at baseline

Add 1 point



Appendix 5: Literature review - Description of service models reproduced from Who Cares Wins

Standard Sector Model

This is the generalist service model, providing all mental health services for a defined population of older people who either reside within a particular

geographical area or are registered with a particular group of general practices. It is a specialist service only in that it specialises in the mental health

care of older people but not older people’s mental health in the general hospital. The standard sector model operates on a consultation basis, normally

provided by medical staff. Referral may not be straightforward. Referrers need to know which sector service to refer to and how to make contact.

Travelling to the hospital may create inefficient use of time but this model has the advantage of easy communication within the community team and

continuity of care. Response can be slow and referrals of people in the community may be prioritised, being perceived as more at risk. Where there are

several sector teams all providing input to the same general hospital, the individual providing advice will differ depending on the sector of residence and

the grade of that individual. For example, if a general hospital covers three mental health sectors and each sector community team has a consultant, a

specialist registrar and senior house officer, then nine different individuals may be offering advice for patients. This inconsistency may not be helpful.

Although this is not a liaison model, studies describing such a service were included in the review for comparison.


A community mental health team receives extra staff time (usually nursing) to provide input to the general hospital. Community staff provide in-reach to

general hospital wards. This creates opportunities for non-medical assessments and continuity of care. However, limitations of the standard sector model

apply. Both standard and enhanced sector models operate primarily consultation and the opportunities for education and training are limited.

Outreach from mental health wards

Staff from mental health wards visit general hospital wards to perform assessments. This is usually on a consultation basis, although there is potential for

training and education. This model is only practical when wards are on the same site, and depends on ward staff being available when needed. This

means that the response may be slow when an urgent assessment is necessary. With this model, staff have limited expertise working in the general

hospital environment.



The liaison mental health nurse

A mental health nurse is based in the general hospital with dedicated time to provide a liaison mental health service to general hospital wards. A liaison

mental health nurse will respond quickly to referrals. Some referrals seen by the nurse may need medical input (10-20% depending on the maturity of

the service). This model has greater potential for the introduction of teaching and training, genuine shared care and the development of treatment

protocols. These services may be oriented towards high-referring wards, especially medicine for older people, but can provide input throughout the

general hospital, limited only by the time available. A single liaison nurse working in isolation can rapidly become overwhelmed by increasing workload

and expectation. This allows no time for training. Liaison nurses must have support from a designated consultant psychiatrist who has dedicated time for

liaison. There is the potential for lack of continuity of care when community follow-up is required but good channels of communication can address this

problem.

The liaison psychiatrist

An old age psychiatrist has dedicated time for general hospital work. Activity is analogous to the liaison mental health nurse, with a similar rapid response

for advice and assessment, education and training. The greater understanding of complex medical problems brought by the psychiatrist’s medical training

is helpful, but may be countered by, for example, less expertise of the non-pharmacological management of behavioural disturbance. Again, good

communication with community services is necessary and low staffing levels can lead to burnout as the workload increases.

The shared care ward

Mental health and general nurses, psychiatrists, physicians and therapy staff work together delivering care in a ward where patients have complex

physical and mental health needs that cannot be met elsewhere. This ward should be on the general hospital site to facilitate access to specialist medical

treatment and investigations. This model can cope with complex care needs such as challenging behaviour in a patient with serious physical illness.

There is also the opportunity to care, for example, for people with severe depression and substantial physical illness. The high staffing levels and skill mix

on a shared care ward reflect the complex care needs of the patients. This model builds up the clinical skills of all staff working on the shared care ward.

Such a ward can act as a beacon of good practice and a valuable training resource for junior staff of all disciplines. There is also the potential for outreach

to other general hospital wards.



The hospital mental health team

A multidisciplinary team including psychiatrists, mental health nurses, occupational therapists, social workers and other disciplines work together to deliver

mental health care in the general hospital. The team operates a single point of access. Each team practitioner is able to build relationships with general

hospital disciplines and provide teaching, training and support, but can call on the specialist skills of other team members when needed. It is well suited

to a single assessment process. This model operates on a consultation and liaison basis. Referrals are received but also sought proactively through the

comprehensive induction of staff with ongoing training and supervision, in order to improve the detection and management of mental disorder co-

morbidity. The hospital mental health team relies on excellent channels of communication. Rapid electronic, written and telephone contact ensures that

community teams and services are kept informed when community follow-up is needed. It enables community mental health teams to easily request

assessments for older people on their caseload who are admitted to the general hospital.

The older persons’ liaison mental health outpatient clinic

Specialist liaison mental health clinics for adults of working age exist in many parts of the British Isles treating patients with complex co-morbid conditions

and somatic presentations of mental disorder. Older people also present with these conditions and a similar clinic for older people would allow the

specialist assessment of complex somatic presentations and short-term follow-up of self-limiting conditions such as delirium and adjustment disorders.



Appendix 6: Literature review – Hierarchy of Evidence from UK NHS Centre for Reviews and Dissemination

Level of

Evidence

Description

I Well-designed randomized controlled trials

II-1A Well-designed controlled trial with pseudo-randomization

II-IB Well-designed controlled trials with no randomization

II-2A Well-designed cohort (prospective) study with concurrent controls

II-2B Well-designed cohort (prospective) study with historical controls

II-2C Well-designed cohort (retrospective) study with concurrent controls

II-3 Well-designed case-control (retrospective) study

III Large differences from comparisons between times and/or places with and

without intervention(in some circumstances these may be equivalent to level II or

I)

IV Opinions of respected authorities based on clinical experience; descriptive

studies; reports of expert committees



Appendix 7a: Literature review – Randomised evaluative studies: Interventions and service make-up

Study Service Make-Up and Interventions

Kominski et

al. (2001)

o The Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) program provides individualised interdisciplinary mental

health treatment and care co-ordination to elderly veterans whose co-morbid depression, anxiety or alcohol abuse may result in the

overuse of inpatient services and the underuse of outpatient services.

o The two critical elements of UPBEAT care are “in-depth psychogeriatric assessment and proactive mental health care coordination by a

multidisciplinary team trained in psychogeriatrics, including nurses, psychiatrists, psychologists and social workers”. The intervention

consists of

o A comprehensive, individualised treatment strategy involving frequent contact between the patient and the assigned clinician, who liaises

with patients, relatives and primary care providers, and facilitates and monitors ambulatory resource linkages.

o Continuity of care

o Direct interventions e.g. educational, psychosocial, psychopharmacologic

o Treatment plans continuously reviewed

Cole et al.

(2006)

Systematic treatment for depression for a period of 24 weeks, assessment and treatment by a psychiatrist, follow-up by the research nurse

and follow-up by the general practitioner

Slaets et al.

(1997)

o Service model was liaison psychiatrist, working as part of a wider geriatric team.

o Patients assigned to receive the intervention were given multidisciplinary joint treatment by the geriatric team in addition to usual care.

o The geriatric team consisted of three medical professionals:

-Psychiatrist/geriatrician – assessing patients, drawing up treatment plans, planning and managing discharge, two hours per day in

direct contact with patient and their relatives.

-Physiotherapist – full-time on intervention ward. Assessing patients’ level of daily functioning and mobility, liaising with medical staff

and implementing procedures to prevent increasing disability and for rehabilitation therapy.

-Liaison nurse – part-time post. Communicate all the relevant information about patients to all medical staff involved, attend all shift

meetings of nurses on ward, communicate with primary health care system.

o Ward rounds, weekly multidisciplinary meeting

Cole et al. o Participants allocated to the intervention group received a geriatric psychiatry consultation, completed within two days of referral for



(1991) psychiatric consultation

o Consultation consists of interviews with the patient, relatives and medical staff to establish the patient’s past psychiatric and medical

history, history of the present illness, personal and family history and mental status

o Patients were then given a DSM-III diagnosis, and recommendations were made for appropriate treatments

o The results of the consultation were recorded in the regular hospital consultation form, and also discussed with other members of the MGT

o Patients were reassessed at least weekly for a minimum period of 8 weeks, with further findings or recommendations also written in the

progress notes

Baldwin et

al. (2004)

o Multi-faceted intervention from a registered mental health nurse, with three components: assessment, direct interventions, liaison support

o The nurse also discussed cases with the medical team

o Liaison support entailed “encouragement of person-centred care, education about mental disorder, nutrition and safety issues, and sign-

posting to relevant services”

o Interventions were specific to each patient, and lasted for 6 weeks.

Cullum

(2004)

o Patients were assessed by the liaison psychiatric nurse (LPN) within five days, and received a comprehensive care/treatment plan for their

depression prepared by the LPN, addressing patients’ psychological and social requirements, and need for antidepressant medication

o The LPN liaised with the medical team, primary care, social services and other agencies as well as informal carers, ensuring that the

appropriate treatment and management strategies were applied both in hospital and in the community after discharge

o Participants’ mood, mental state and response to treatment was examined by the LPN every 2-3 weeks for up to 12 weeks, after which

they were either discharged back to the sole care of the GP or to the Community Mental Health Team for Older People.

o Interventions included giving support, information and advice, education, facilitation of day care and community care, anxiety

management, behaviour therapy, referral to counselling or cognitive therapy, review pain control regime

Shah et al.

(2001)

Detailed formal psychogeriatric consultation from a psychogeriatrician within 24 hours of screening, which includes a full diagnostic work-up

and management advice to the medical staff. Sector model.

Levenson et

al. (1992)

o Patients who had high scores on the Medical Inpatient Screening test randomised to the experimental group, received the intervention

within 24 hours

o The intervention consisted of a psychiatric consultation, which included a chart review, patient interview and liaison with physicians, nurses

and patients’ relatives.



Appendix 7b: Literature review – Randomised evaluative studies: Methods, characteristics, outcomes and outcome measures (part 1 of 3)

Study Baldwin et al. (2004) UK Cole et al. (1991) Canada Cole et al. (2006) Canada

Service Model Old Age; Liaison Nursing Old Age; Liaison Psychiatrist Old Age; Multidisciplinary Team - depression

Level of Evidence II-IA II-IA II-IA

Study design Randomised Controlled Trial Randomised controlled trial Randomised controlled trial

Duration 15 months 8 weeks 3 years

Follow-up 6-8 weeks At least once a week for 8 weeks, post-treatment 3 and 6 months

Setting Four general medical wards in a district

general hospital aged 65 years or older

Older (aged 65+) medical and surgical inpatients

in a primary acute care hospital

Consecutive patients aged 65 or older

admitted to general medical

services in a primary acute care hospital

Sample Size 153 patients at baseline

77 in intervention group

76 in control group

Total participants = 80

Intervention group, N = 41

Control group, N = 39

Total - 157 participants


79 in control group

Number completed

study

120 completed study

59 in intervention group (18 lost to follow-up,

and excluded from study)

61 in control group (15 lost to follow-up and

excluded from study)

35 participants completed study from intervention

group

28 participants completed study from control

group

40.8% (N = 64) completed the follow-up to 6

months

N = 33 for intervention group

N = 31 for control group

Age Total - mean age 80.3 years (SD 7.3)

Intervention - mean age 80.6 years (SD 7.2)

Control – mean age 80.0 years (SD 7.5)

Mean age of total participants = 83 years

Mean age of intervention group = 83.3 years

Mean age of control group = 82.4 years

Mean age 77.9 years

Gender 64% female at baseline 72.2% female for total participants

71% female for intervention group

71% female for control group

69.2% female in intervention group

69.6% female in control group

Psychiatric morbidity All participants scored above the threshold for

depression and/or cognitive impairment

26% of intervention group vs. 21% of control

group had had contact with psychiatric

services in the past

After initial assessment,

o Mean GDS score for intervention group =

45.3

Mean GDS score for control group = 34.5

o Mean SPMSQ score for intervention group =

Intervention group: 14.5% with past history

of depression

Control group: 15.4% with past history of

depression



5.8

Mean SPMSQ score for control group = 6.9

For the intervention group (DSM-III criteria):

No psychiatric disorder, 14%; dementia (most

were Alzheimer’s disease) without behavioural or

emotional problems, 37%; delirium

(superimposed on dementia in seven cases),

34%; major depression, 9%; adjustment disorder

with depressed mood, 6%

Functional/health

status

Intervention group:

Cardiovascular (36.1%); respiratory (13.9%);

gastrointestinal (4.2%); central nervous

system (20.8%); genito-urinary (5.6%);

musculoskeletal (1.4%); endocrine/metabolic

(13.9%); infective (2.8%); other (1.4%).

Control group:

Cardiovascular (25%); respiratory (20.8%);

gastrointestinal (9.7%); central nervous

system (19.4%); genito-urinary (0%);

musculoskeletal (1.4%); endocrine/metabolic

(8.3%); infective (4.2%); other (11.1%).

No information Intervention group: mean severity-of-illness

score (SD) = 4.3 (0.9)

Control group: mean severity-of-illness score

(SD) = 4.2 (1.1)

Outcomes Length of Stay

Prescribed psychotropic medication on

discharge

Readmitted at 3 months

Death at 3 months

Length of Stay

Disposition

Compliance with recommendations

Mortality

Suicide and suicide attempts

Health services utilisation

Antidepressant use

Outcome measures Health of the Nation Outcome Scale for Older

People (HoNOS65+)

Geriatric Depression Scale

Standardised Mini Mental State Examination

Short Portable Mental Status Questionnaire

(SPMSQ)

Anxiety Status Inventory (ASI)

Geriatric Depression Scale (GDS)

1. Measures at baseline:

Clinical Severity of Illness

Charlson Comorbidity Index

Cage Questionnaire



(All three measures administered at baseline

and outcome)

Crichton Geriatric Behavioural Rating Scale

(CGBRS)

2. Measures at baseline and follow-up:

Diagnostic Interview Schedule

Hamilton Depression Rating Scale

Medical Outcomes Study 36-item Short

Form

Mini-Mental State Examination

Older Americans Resources and Services

Rating Scale for Side-Effects

(part 2 of 3) Study Cullum (2004) UK Kominski et al. (2001) USA Levenson et al. (1992) USA

Service Model Old Age; Liaison Nursing Old Age; Multidisciplinary Team Non-Age Discriminatory; Liaison

Psychiatrist

Level of Evidence II-IA II-IA II-IA

Study design Randomised controlled trial Randomised controlled trial Randomised double-controlled trial

Duration 12 weeks (total = 15 months) 45 months (in total) 21 months

Follow-up 16 weeks 12 months 3 months

Setting Consecutive acute medical inpatients aged 65+

admitted to medical wards of a district general

hospital

9 VA sites Consecutive admissions to general

medical teams at a university hospital

Sample Size N = 121, total participants

N = 62 in intervention group

N = 59 in control group

814 participants in intervention group

873 participants in control group

Baseline control group, N = 232

Experimental group, N = 256

Contemporaneous control group, N = 253

Number completed

study

86 participants completed study


45 in control group

No information Patients in experimental and

contemporaneous control groups

targeted for follow-up (telephone

interviews); 41% (N = 197) were

contacted

Age Mean age (SD) of completers (screen positive):

Intervention group = 78.4 years (7.84)

Participants aged 60 years or older Mean age (SD) for baseline period = 49.2

years (16.2)



Control group = 80.7 years (8.08) Mean age (SD) for psychiatric screening

trial = 47.0 years (16.8)

Gender Completers (screen positive):

Intervention group 59% female

Control group 71% female

96.7% male in intervention group

95.9% male in control group

49.6% female for baseline period

49.9% female for psychiatric screening

trial

Psychiatric morbidity o 19/41 (46%) of intervention group and 26/43

(60%) in the control group had depressive

disorder at follow-up

o In the subgroup with depression at baseline,

11/20 (55%) in the intervention group and

13/18 (72%) in the control group remained

depressed at follow-up

1. Intervention group

Anxiety alone (8.5%); depression alone (27.7%);

alcohol abuse alone (6.2%); anxiety and

depression (47.1%); anxiety and alcohol abuse

(1.5%); depression and alcohol abuse (2%);

anxiety, depression and alcohol abuse (7%)

2. Control group

Anxiety alone (9.2%); depression alone (23.9%);

alcohol abuse alone (5.7%); anxiety and

depression (49.1%); anxiety and alcohol abuse

(1%); depression and alcohol abuse (2.5%);

anxiety, depression and alcohol abuse (8.5%)

o Experimental consultations (N = 145)

Organic/cognitive mental disorders

(46%), substance abuse (37%),

adjustment disorders (15%), affective

disorders (10%), anxiety disorders (4%),

somatoform disorders (3%),

schizophrenia (1%), personality disorders

(15%), no psychiatric

diagnosis (18%)

o Naturalistic consultations (N = 30)

Organic/cognitive mental disorders

(13%), substance abuse (20%),

adjustment disorders (27%), affective

disorders (17%), anxiety disorders

(13%), somatoform disorders (10%),

schizophrenia (3%), personality disorders

(20%), no psychiatric

diagnosis (13%)

Functional/health

status

For trials entrants:

o Intervention group (N = 62): ischaemic heart

disease (32%), respiratory (16%), GI tract

(10%), neurological (including stroke) (11%),

musculo-skeletal (8%), other (22%)

o Control group (N = 59): ischaemic heart

disease (17%), respiratory (19%), GI tract

No information o Baseline period (N = 455)

Mean number of discharge diagnoses

(SD) = 5.82 (3.09)

o Psychiatric screening trial (N = 1,086)

Mean number of discharge diagnoses

(SD) = 5.62 (3.03)



(7%), neurological (including stroke) (14%),

musculo-skeletal (22%), other (22%)

Outcomes o Primary outcomes - presence of ICD-10

defined depressive disorder; change in GDS-15

score from baseline

o Secondary outcomes - difference in quality-

adjusted life weeks (QALWs); patient

satisfaction rating

Use of inpatient and outpatient services

Cost estimation

o Primary outcomes: length of stay,

hospital costs

o Secondary outcomes: post-hospital

health status, rehospitalisation rates,

use of outpatient medical care

Outcome measures The following measures used at baseline:

GDS-15 – assess patients for depression

ICD-10 depressive disorder

EuroQol – quality of life

Abbreviated Mental Test Score (AMTS) – cognitive

status

Cumulative Illness Rating Scale-Geriatric (CIRS-G)

– chronic physical morbidity

ADL score – disability

Self-rated previous history of depression

Alcohol Use Disorder Identification Test (AUDIT)

Anxiety and depression subscales of the Mental

Health Inventory (MHI)

36-Item Health Survey Short Form (SF-36) –

self-perceptions of physical and mental health

status

Medical Inpatient Screening Test

Hopkins Symptom Checklist

Mini-Mental Status Examination

Visual Analog Scales

DRG Weight

TOTSCALE score from the Disease

Staging System of SysteMetrics

(part 3 of 3) Study Shah et al. (2001) UK Slaets et al. (1997) Holland

Service Model Old Age; Sector Model – Depression Old Age; Liaison Psychiatrist as part of a team

Level of Evidence II-IA II-IA

Study design Single-blind randomised controlled trial Randomised controlled trial

Duration 7 months 12 months

Follow-up 10 weeks, 1 year 12 months

Setting Consecutive admissions under the two geriatricians on three acute

geriatric medicine wards at a district general hospital

Internal medicine department

Sample Size 47 participants in total


Total = 237 participants

140 participants in intervention group



28 in control group 97 participants in control group

Number completed

study

31 patients at 10-week follow-up

19 patients at 1-year follow-up

23 withdrawals (included in total sample size)

Age Median age - 85 years; age range 67-97 years Mean age for all participants (SD) = 82.8 years (5.0), range 75-96

Mean age in intervention group (SD) = 82.5 years (4.9), range 75-96

Mean age in control group (SD) = 83.2 years (5.1), range 75-94

Gender 57% female 70.5% female for all participants

67.1% female for intervention group

75.3% female for control group

Psychiatric morbidity All participants described as depressed for inclusion in study

Depression (all GDS ≥ 11, median 15); (all BAS-DEP ≥ 7, median 9)

1. Mean GDS (SE; range):

All participants = 2.9 (2.9; 0-13)

Intervention group = 2.5 (2.8; 0-13)

Control group = 3.4 (3.1; 0-13)

2. Mean MMSE (SE; range):

All participants = 23.5 (5.6; 5-30)

Intervention group = 23.4 (5.5; 5-30)

Control group = 23.6 (5.7; 7-30)

Functional/health

status

Median (range) Barthel Index score 17 (7-20) Intervention group

Cancer 10.7%, congestive heart failure (41.4%), chronic lung disease

(7%), pneumonia (12.1%), gastrointestinal disorders (20%),

endocrinological disorders (28.6%)

Control group

Cancer (14.4%), congestive heart failure (41.2%), chronic lung disease

(4.1%), pneumonia (10.3%), gastrointestinal disorders (16.5%),

endocrinological disorders (26.8%)

Outcomes Change in BAS-DEP cases for depression

Improvement in MADRS scores

Implementation of management advice

Patient compliance

Physical functioning, according to basic ADL functions

Length of stay

Nursing home placement within 12 months of discharge

Outcome measures Outcome measures at baseline: SIVIS Dependency Scales



Clinical Severity of Illness – measure of physical illness

Charlson Comorbidity Index – measure of physical illness

CAGE questionnaire – measure of alcohol abuse

Outcome measures at baseline and at 3- and 6-month follow-up:

Diagnostic Interview Schedule

21-Item Hamilton Depression Rating Scale (HAMD)

Medical Outcomes Study 36-Item Short Form (SF-36)

Mini-Mental State Examination (MMSE)

Older Americans Resources and Services (OARS) – assess basic and

instrumental activities of daily living

Rating Scale for Side Effects (RSSE)

Geriatric Depression Scale

Mini Mental Status Examination



Appendix 7c: Literature review – Randomised evaluative studies: Results Study Results

Kominski

et al.

(2001)

o Mental health and general health status scores improved equally from baseline to 12-month follow-up in both the intervention and usual care groups;

the extent of the change over time was not significantly different between the UPBEAT and usual care groups.

o UPBEAT care resulted in a statistically significant increase in outpatient costs of $1,171 (P < 0.001) per UPBEAT patient during the 12-month period

after enrolment compared with usual care.

o UPBEAT patients received more social work visits (2.25 vs. 0.31), more individual psychotherapy visits (2.33 vs. 0.17) and more psychiatric telephone

contacts (1.85 vs. 0.05).

o Increased outpatient costs were offset by statistically significant per-patient reductions in inpatient cost ($3,027; P = 0.017) during the 12-month period

after enrolment, for an overall savings of $1,856 (P = 0.156), and the reduction in inpatient costs was attributable to a significantly greater reduction in

inpatient bed days of care (3.30 days; P = 0.016) for UPBEAT patients compared with usual care patients.

Cole et al.

(2006)

o At 6 months, there were no statistically significant differences between the intervention and usual care groups in the primary outcomes (HAMD, SF-36

mental component, SF-36 physical component).

o There were no differences in the rates of improvement (≥ 50% decrease in HAMD scores) or in the rates of remission (HAMD score < 7) of depression.

o Secondary outcomes for intervention group vs. control group: median LOS 12 vs. 10 days; readmission to hospital 39.4% vs. 29%; Suicide or suicide

attempt 3.2% vs. 3.3%; any visit to emergency dept 45.5% vs. 41.9%; mortality at 6-month follow-up 23.1% vs. 22.8% (all not significant)

Slaets et

al. (1997)

o Mean total length of stay for the intervention group was 19.7 days versus 24.8 days for the usual care group – statistically significant, even after

controlling for baseline characteristics

o There were more readmissions to hospital in the usual care group (29.9%) compared with the intervention group (17.4%)

o The physical functioning of a larger proportion of patients assigned to the intervention group consistently improves or stays the same, and a smaller

number worsen in their physical functioning, compared to the usual care group, even after adjusting for baseline variables

o Disposition - 18% of the patients allocated to the intervention group were admitted to a nursing home within 1 year of discharge from hospital,

compared to 27% of the usual care group (P = 0.05). The probability of being placed in a nursing home within 12 months of discharge from the

hospital after usual care was 2.5 times greater than in the case of psychogeriatric liaison intervention

o The additional staff costs were $150,000 for the 140 patients allocated to the intervention group, and the benefit gained from shorter length of stays (in

days) after admission and readmission was $573,300 (9.1 days * $450 per day * 140 patients), which means that the difference totals $423,300.

Therefore, the net benefit was approximately $3,000 per patient admission

Cole et al.

(1991)

o Both the treatment and control groups appeared to improve over the study period, but no statistically significant differences were found between the

intervention and control groups according to a two-way analysis of variance. More intervention than control cases improved on all measures;



statistically significant for the Anxiety Status Inventory (P < 0.05) only. Improvements on all measures were most likely to occur in cases aged

between 75 and 84 years and when rates of compliance with the psychiatrist’s recommendations were high

o No significant differences between the intervention and control groups were found in terms of length of hospital stay during the trial (39.8 vs. 35 days)

o Significant differences (P < 0.01) in disposition at 4 and 8 weeks: in spite of the fact that more patients from the control group were discharged from

hospital at both 4 and 8 weeks, twice as many patients who received the intervention were discharged home rather than to foster homes or nursing

homes.

o Rates of full compliance with both initial and follow-up recommendations were similar and ranged from 33% for investigations to 79% for drug

prescriptions; the association between full compliance and drug prescription recommendations was statistically significant (P < 0.001).

Baldwin et

al. (2004)

o In terms of the primary outcomes, no significant differences were detected between the two groups on the HoNOS65+ or SMMSE scores, whereas the

mean 30-item GDS score of the intervention group was significantly lower than that for the control group.

o Using the threshold of 11 on the GDS-30, the percentage of cases of depression at follow-up amongst patients who received the intervention fell from

66% at baseline to 53% at follow-up, whilst amongst patients in the control group, it rose from 64% to 65%, but this was not statistically significant.

The proportion of cognitive impairment cases decreased between baseline and follow-up in both groups (from 77% to 61% in the intervention group,

and from 72% to 51% in the control group).

o In terms of the secondary outcomes, no significant differences were found between the intervention and control groups with regards to mean length of

stay (27.8 days vs. 29.5 days), the proportion prescribed psychotropic medication at discharge (44% vs. 42%), the proportion re-hospitalised within

three months of entering the trial (24.7% vs. 27.6%), or the proportion who died within three months (22.1% vs. 17.1%).

Cullum

(2004)

o No significant differences were found between the two groups when depressive disorder, depression rating and QALWs gained were concerned.

o 19/41 (46%) in the intervention group and 26/43 (60%) in the control group had depressive disorder at follow-up. In the subgroup with depression at

baseline, 11/20 (55%) in the intervention group and 13/18 (72%) in the control group remained depressed at follow-up. Both groups showed a

reduction in mean GDS-15 score (indicating improvement in mood) at follow-up. The difference in reduction of GDS-15 score was 1.0 in screen

positives and 2.1 in the subgroup with depressive disorder at baseline, but the 95% confidence intervals in both groups crossed unity.

o Participants in the intervention group had a mean of 9.9 QALWs over the 16-week study period, compared to a mean of 8.4 QALWs in the controls. In

the subgroup with depressive disorder at baseline, the intervention group had 8.6 QALWs compared to a mean of 5.9 QALWs in the controls.

o 93% of participants in the intervention group were “very satisfied” or “fairly satisfied” with the service they received compared to 67% of the

participants in the control group. Once again, the findings were greater in the subgroup with depressive disorder at baseline.

Shah et

al. (2001)

o There were no statistically significant differences between the intervention group and the control group with regard to improvement in BAS-DEP

depression caseness, MADRS scores, BAS-DEP scores, GDS scores, Barthel Index scores, Clinical Global Scale of Physical Illness scores, length of stay in

hospital and mortality between baseline and 10 weeks and 1 year follow-up.

o There were no differences between the intervention and the control group with regard to any of the intervention and treatment variables at the outset



and at follow-up.

o There was poor concordance between recommendations made during the psychogeriatric consultation and their implementation in the intervention

group.

Levenson

et al.

(1992)

o Patients randomised to the experimental group had longer length of stay, more medical procedures and higher hospital costs and charges than the

contemporaneous control subjects, but patients in the experimental group also had significantly more severe medical illness than the contemporaneous

control subjects. When severity of illness was partialed out, no statistically significant differences were found between the experimental and

contemporaneous control groups in any of the inpatient utilisation outcome variables.

o In terms of the effect of the intervention on post-hospital utilisation, for the study participants who were interviewed at follow-up, no statistically

significant differences were found between the contemporaneous control and experimental participants with regards to activities of daily living score,

emergency room visits, physician visits, number of medications or depression and anxiety scores.

o Contemporaneous control and experimental patients did not differ significantly on the number of readmissions to hospital, the cumulative length of stay,

cumulative number of procedures, or cumulative costs and charges. However, patients who received the intervention were more likely to be readmitted

to hospital sooner, but this difference disappeared after correction for disease severity.



Appendix 8a: Literature review – Non-randomised evaluative studies: Methods, characteristics, outcomes and outcome measures (part 1 of 3)

Study Baheerathan (1999)UK Camus et al. (2003)Switzerland de et al. (2003)Netherlands

Service Model Old Age; Liaison Psychiatrist Non-Age Discriminatory; Liaison Psychiatrist Non-Age Discriminatory; Multidisciplinary

Team

Level of Evidence II-2B II-2A II-2B

Study design Two changes in service delivery studied with a

retrospective design in an opportunistic and

naturalistic study divided into three phases

defined by the two changes in service delivery;

addition of a formal liaison component to a

consultation-only service

Prospective, pre- and post-intervention controlled

study

Prospective pre- and post-intervention

comparison

Duration 30 months 8 weeks each for baseline and intervention periods Six months for historic controls; 8 months for

intervention

Follow-up N/A – retrospective study Questionnaire sent to participants 3 weeks after

discharge

No information

Setting Older medically ill inpatients at a geriatric

psychiatry unit of a district general hospital

Medical inpatients, internal medicine division of a

university hospital

Two medical wards: nephrology and

gastroenterology, general internal medicine

Sample Size 161 referrals; complete datasets available for

155 referrals

78 (49%) referrals in phase 1

62 (39%) referrals in phase 2

20 (12.5%) referrals in phase 3

Intervention group, N = 95 (36 aged 65 or older)

Control group, N = 81 (49 aged 65 or older)

Intervention group, N = 100

Historic control group, N = 93

Number completed

study

N/A – retrospective study 129 (73.3%) answered questionnaire 193 alive at end of study

Age Median age 84 years

Age range 65–98 years

Mean age of intervention group (SD) = 60.0 years

(15.9)

Mean age of control group (SD) = 60.9 years

(17.4)

Mean age in intervention group (SD) = 69.7

years (17.6)

Mean age in historic controls (SD) = 61.9

years (17.7)

Gender 66% female 37% female 55% female in intervention group



54% female in historic control group

Psychiatric

morbidity

Delirium, 20%; dementia, 51%; depression,

19%; schizophrenia, 2.5%; anxiety, 1.3%; other

diagnoses, 6.3%

Early GHQ screening identified 59/176 included

patients (33%) as

suffering from emotional or mood disorders

GHQ score of ≤ 9 for (scores below 9 indicate

emotional disorder):

o Intervention group (N = 95) = 73%

o Control group (N = 81) = 59%

Of the 64 patients referred to C-L psychiatry

from the intervention group, the most

common diagnoses were delirium (19%),

dementia (18%) and depression (14%)

Functional/health

status

No information No information Intervention group

Gastroenterology 23%; endocrinology 9%;

cardiology 13%; infectious disease 9%;

pulmonology 10%; nephrology 12%; other

24%.

Control group

Gastroenterology 31%;endocrinology 13%;

cardiology 5%; infectious disease 55;

pulmonology 14%; nephrology 8%; other

24%.

Outcomes Rate of referral

Reasons for referral

Demographic and clinical characteristics of

referrals

Advice offered after assessment

Cost

Length of stay

Costs of medical resources

Length of stay

Quality of life

Outcome measures ICD–10 General Health Questionnaire (GHQ)

Beck Depression Inventory (BDI)

COMPRI

INTERMED

SF-36

(part 2 of 3)



Study De Leo et al. (1989)Italy Levitan and Kornfeld (1981)

USA

Molodynski et al. (2005)UK Mujic et al. (2004)UK

Service Model Old Age; Multidisciplinary

Team

Old Age; Liaison Psychiatrist Non-Age Discriminatory; Sector Model vs.

Multidisciplinary Team

Old Age; Liaison Psychiatrist

Level of Evidence II-2B II-2B II-2B II-2B

Study design Retrospective, pre- and post-

liaison service

Pre- and post-intervention

comparison; unrandomised,

controlled

Prospective comparison of 100

consecutive referrals to liaison psychiatry

service and CMHT

This before/after study (using

historic controls) evaluates the

implementation of a new liaison

service

Duration 6 years (first four years –

sector model; final two years –

liaison service)

6 months for intervention study

period

6 months (1 year prior to

intervention) for historic controls

Time taken for 100 consecutive referrals;

56 days for liaison psychiatry service

108 days for CMHT

12 months for evaluating the

new service (2000-2001)

7 months for evaluating the old

service (1998-1999)

Follow-up N/A Post-discharge N/A N/A

Setting Padua Geriatric Hospital Female orthopaedic surgical unit Liaison psychiatry service in a district

general hospital

CMHT – community

950-bed teaching hospital

Sample Size Pre-liaison service - 362

referrals

Post-liaison service - 245

referrals

50 in total (including 4

withdrawals)

N = 24 in intervention group

N = 26 in control group

100 referrals for each service New service – 336 referrals

Old service – 183 referrals

Number completed

study

N/A 46 N/A N/A

Age Pre-liaison service – Mean age

72.29 years (SD 8.65)

Post-liaison service - Mean age

72.41 years (SD 9.56)

65+ Liaison psychiatry service – mean age

49.9 years (SD 12.9), range 18-95 years

CMHT – mean age 38.8 years (SD 41),

range 18-74

New service – mean age 81.5

years (SD 7.4)

Old service – mean age 81.2

years (SD 7.1)

Gender Pre-liaison service - 66%

female

Post – liaison service - 73.1%

100% female Liaison psychiatry service – 61% female

CMHT – 62% female

New service – 67% female

Old service – 60% female



female

Psychiatric morbidity DSM-III diagnoses (N = 607)

Affective disorders (68.5%);

anxiety disorders (8.7%);

dementia (3.9%); other

organic mental disorders

(5.1%); schizophrenic

disorders (2.3%); paranoic

disorders (0.9%); somatoform

disorders (0.9%); alcohol

abuse (0.6%); personality

disorders (3.1%); no

psychiatric diagnosis (6%)

Intervention group only:

Organic brain syndrome (42%)

Adjustment disorder with

depressed mood (33%)

Adjustment disorder with anxious

mood (29%)

Major depression (4%)

Schizophrenia (1%)

o Liaison Psychiatry Service:

Organic mental disorder, 23%; mental

and behavioural disorders due to

psychoactive substance use, 19%;

schizophrenia, schizotypal and

delusional disorders, 7%; mood

disorders, 28%; neurotic, stress-

related and somatoform disorders,

6%; disorders of adult personality and

behaviour, 7%; no psychiatric

diagnosis, 10%

o CMHT:

Organic mental disorder, 0%; mental

and behavioural disorders due to

psychoactive substance use, 12%;

schizophrenia, schizotypal and

delusional disorders, 6%; mood

disorders, 49%; neurotic, stress-

related and somatoform disorders,

15%; disorders of adult personality

and behaviour, 6%; no psychiatric

diagnosis, 10%

New Service

Depression (33.6%); dementia

(33%); acute confusional state

(7.1%); psychotic or delusional

disorder (6.6%); adjustment

disorder (3.3%); other (13.9%);

no psychiatric diagnosis (1.5%)

Old Service

Depression (33.3%); dementia

(29.6%); acute confusional state

(9.3%); adjustment disorder

(3.7%); psychotic or delusional

disorder (3.7%); other (15.7%);

no psychiatric diagnosis (4.6%)

Functional/health

status

Gastrointestinal (20.7%);

cardiovascular (18.9%);

psychiatric (25.3%);

neurological (9.1%);

respiratory (5.9%);

osteodegenerative and

traumatic (4.6%);

Patients admitted for emergency

repair of fractured femur

49% of liaison service referrals with

significant physical health problems

10% of CMHT referrals with significant

physical health problems

No information



polyathological (4.5%); algesic

(4.1%); renal and urological

(3.7%); alcoholic (1.1%);

other pathologies (2.1%)

Outcomes Compliance to psychiatrist’s

recommendations

Concurrence rate between

reasons for referral and

psychiatric diagnoses

Length of stay

Discharge disposition

Source of referral

Previous or current contact with

secondary mental health services

Presence of significant physical health

problems

Whether self-harm was part of the index

episode

Urgency of referral

Follow-up

Psychiatric diagnosis

Response times

Satisfaction with service

Outcome measures DSM-III No information ICD-10 No information



(part 3 of 3) Study Scott et al. (1988)UK Strain et al. (1991)USA Swanwick et al. (1994)Ireland

Service Model Old Age; Liaison Psychiatrist Old Age; Multidisciplinary Team Old Age; Sector Model vs. Liaison

Psychiatrist

Level of Evidence II-2B II-IB II-2B

Study design Comparison study; pre- and post-liaison service Quasi-experimental, controlled study Comparison of consultation (Model A) and

liaison (Model B) models of service

delivery

Duration Three years – sector model in first two years and

liaison psychiatrist in year 3

Length of hospital stay 6 months

Follow-up N/A 6 and 12 weeks after discharge N/A

Setting District general hospital Consecutive admissions (aged ≥ 65 years) to 4

orthopaedic units for surgical repair of fractured

hips in two hospitals, Mount Sinai and

Northwestern

Two associated general hospitals

Sample Size 217 referrals over three years

N = 98 in years I and II

N = 119 in year III

452 Model A – 39 referrals

Model B – 110 referrals

Number completed

study

N/A 328 N/A

Age Median age 79.5 years

Semi-interquartile range 74-83 years

Mean age at Mount Sinai hospital (SD) = 83.7

years (8.4)

Mean age at Northwestern hospital (SD) = 80.3

years (8.3)

Mean age in model A = 72 years (SD 5.2)

Mean age in model B = 77 years (SD 6.3)

Gender 62% female 79.5% female at Mount Sinai hospital

80.5% female at Northwestern hospital

No information

Psychiatric morbidity Years I and II

Chronic organic mental disorder (28.5%); acute

organic mental disorder (24.5%); depression

(12%); anxiety/adjustment disorder (5%);

Organic mental disorder (54%), major depression

or dysthymia (5.8%), adjustment disorder, mixed

(1.4%), adjustment disorder, depressed (1.4%)

In both models, approximately 29% of

the referred patients had previous

contact with the psychiatric services



personality disorder (4%); alcohol abuse (2%);

functional psychoses (2%); other diagnoses (7%);

no psychiatric diagnosis (14%)

Year III

Depression (28%); acute organic mental disorder

(22%); chronic organic mental disorder (18.5%);

anxiety/adjustment disorders (8%); alcohol abuse

(5%); personality disorder (5%); functional

psychoses (2.5%); other diagnoses (5%); no

psychiatric diagnosis (7%)

Functional/health

status

No information Patients admitted for surgical repair of fractured

hips

No information

Outcomes Change in rate of referral

Concurrence rate between reasons for referral and

psychiatric diagnoses

Length of stay

Total direct hospital charges

Placement of patient after discharge (disposition)

- home or health-related facility

Patient demographics

Past psychiatric history

Source of referral

Reason for referral

Psychiatric diagnosis

Cognitive score

Suggested intervention

Follow-up

Outcome measures DSM-III Geriatric Depression Scale

Arthritis Impact Measurement Scale

Spielberger State-Trait Anxiety Inventory

Horn Disease-Staging Evaluation

Mini-Mental State Examination

Singh Index of Bone Density

Mini-Mental State Examination (MMSE)

DSM-III-R



Appendix 8b: Literature review – Non-randomised evaluative studies: Service make-up and interventions Study Service Make-Up and Interventions

Strain et

al. (1991)

Psychiatric liaison intervention consisted of the following components:

i. Every consenting patient was assessed by the psychiatrist, and any psychiatric symptoms were treated

ii. Liaison psychiatrist attended the weekly ombudsman ward rounds with the senior orthopaedic attending physician, social worker, nurse and physical therapist,

during which selected cases were discussed in detail. The aim of these rounds was to achieve a multidisciplinary clinical treatment and discharge plan

iii. Weekly nursing and discharge planning meetings

iv. Liaison with patients’ relatives and social workers.

Levitan

and

Kornfeld

(1981)

o A part-time (10 hours per week) liaison psychiatrist followed all patients aged 65 years or older admitted to a female orthopaedic surgical ward for

emergency surgical repair of a fractured femur

o The psychiatrist assessed all patients within 72 hours of their admission, who were then treated by the psychiatrist until their discharge.

o The psychiatrist also liaised closely with the medical and nursing staff on the orthopaedic ward, social services, attending staff, physiotherapists and friends

and relatives of the patient.

Scott et

al. (1988)

o Years I and II – Sector Model service; psychogeriatrician providing a consultation service (initiated in 1982). Referrals were made on a “doctor to doctor”

basis from any ward within the hospital and the consultant psychogeriatrician assessed the referred patients.

o Year III – a senior registrar joined the psychogeriatric team and a liaison attachment to the geriatric unit was set up, in which the senior registrar attended

the weekly multidisciplinary ward round and also case conferences and reviews. The senior registrar was actively involved in managing patients on the

geriatric unit, either as the patient’s primary therapist, or by advising and educating medical staff about psychiatric morbidity.

De Leo et

al. (1989)

o Service consists of a coordinator, three physicians specialising in psychiatry and a psychologist

o Patients referred to the unit for psychiatric consultation are assessed, and are then closely followed-up daily by the team in their own wards, or in the day

hospital clinic

o Referred patients receive psychological treatments, which may continue after the patient has been discharged from hospital

o Patients who are prescribed a specific drug schedule are also followed-up after discharge

o Unit staff also liaise with local authority social work and psychiatric services in order to make the patient’s return to the community after discharge is a

smooth transition.

Swanwick

et al.

(1994)

o Model A – Liaison psychiatrist was dedicated to meeting the goals of liaison psychiatry. The referring physician had to write a referral letter instead of just

filling out a standard consultation form, and the psychiatrist also discussed each case with the referring physician and was actively involved in meeting and

liaising with referred patients’ relatives and with the ongoing treatment and management of patients. This model employed a joint approach/responsibility to

the patient’s care and exchange of views between the teams whenever possible.

o Model B – No specialist consultant liaison psychiatrist, and the service was therefore provided on a consultation-only basis as there was insufficient time to



concentrate on liaison work. Instead of being actively involved, the psychiatrist instead simply made suggestions regarding patient management instead of

being actively engaged in managing and treating patients.

Baheerath

an (1999)

o Phase 1 of the study lasted for 12 months; during this period, all patients aged over 80 years requiring medical admission were automatically admitted under

the two geriatricians.

o Phase 2 of the study lasted 10 months, and followed on immediately from phase 1. In the first month of phase 2, the medical unit of the hospital changed its

admission policy, such that patients of all ages were initially admitted under the “on-call” physician team (normally a general medical team) and patients

aged over 80 years were only subsequently transferred to the geriatricians if necessary.

o Phase 3 followed on from phase 2, and lasted for 8 months. During this phase, a specialist registrar in old age psychiatry under the supervision of the

consultant began regular weekly attendance at one of the geriatric medicine ward rounds. Prior to the introduction of the specialist registrar to the geriatric

medicine ward round, the liaison geriatric psychiatry service constituted a consultation-only service. The specialist registrar’s task was to provide support at

the ward round, informally and formally teach the multidisciplinary geriatric medicine staff and generally develop close ties with a view to improving the

geriatric team’s ability to detect and manage psychiatric morbidity.

Mujic et

al. (2004)

o Sector Model (before) – ad hoc, off-site consultation psychiatric service. Requests for psychiatric consultation were sent by fax to a community psychiatrist

based in another hospital, who then evaluated the referred patients as soon as possible, and recorded the treatment recommendations in the patient’s

medical notes. There was little time for direct liaison.

o Liaison Psychiatrist (after) – “true” liaison model. Fully resourced, specialist service, with a dedicated part-time consultant in old age liaison psychiatry, and

a full-time staff grade psychiatrist and a senior house officer. Liaison psychiatrists attend the Health Care of the Elderly physicians’ multidisciplinary

management rounds, during which they discuss many of the inpatients, and educate the medical staff about mental health problems and their management.

They also discuss rehabilitation, discharge planning and placement. Patients receive a targeted consultation and their progress is carefully observed, and the

liaison work done by the psychiatrists is direct and constant throughout a patient’s stay in hospital.

Camus et

al. (2003)

o Intervention Patients who screened positive for emotional disorders according to the General Health Questionnaire (GHQ), in addition with other

patients who were reported by the medical team as having perceptible disturbances regardless of the GHQ score, were discussed in a multidisciplinary team

meeting. The patients were subsequently assessed by a psychiatrist if they consented to the consultation, and were subjected to a multidisciplinary

approach.

o Control In the pre-intervention group, the medical and nursing staff were not informed of the GHQ results, and requests for psychiatric consultation were

made in the normal fashion.

de et al.

(2003)

o Intervention Consultation-liaison nurse under the supervision of a consultation-liaison psychiatrist. Patients with a COMPRI score of more than 5 and

an INTERMED score of more than 20 were discussed with the appropriate medical and nursing staff, and cases were also discussed in the weekly

multidisciplinary case conference. The nurse also administered one or more of the following psychiatric or geriatric interventions accordingly: alcohol

counselling, prevention of delirium, referral to paramedical specialists for diagnosis or treatment, including consultation-liaison psychiatry, initiation of post-



discharge care within two weeks after discharge.

o Control Historic controls; usual care. COMPRI and INTERMED scores were kept hidden from the ward staff.

Molodynsk

i et al.

(2005)

o Liaison Psychiatry Service – consists of one consultant, one specialist registrar, one senior house officer, two mental health nurses. Referrals accepted from

general hospital staff, but not primary care. Service accepts referrals of patients over 17 years of age with no upper age limit, including all older patients

except those under the care of medicine for the elderly services. Patients are assessed by the service on the hospital wards, in the accident and emergency

department and in outpatient clinics. Furthermore, the service is based in a 600-bed district general hospital with approximately 67,000 accident and

emergency attendances per year.

o Community Mental Health Team (CMHT) – consists of one consultant, one specialist registrar, one senior house officer, 4.5 whole time equivalent mental

health nurses, two social workers, one occupational therapist and 0.5 whole time equivalent psychologist. Accepts referrals of patients aged 18-74 years;

majority of referrals from primary care.



Appendix 8c: Literature review – Non-randomised evaluative studies: Results Study Results

Strain et al.

(1991)

o At Mount Sinai hospital, the rate of referral was 10% in the baseline year and 79% in the intervention year. At Northwestern, the rate of

referral for units A, B and C was 2% in the baseline year, and the rate increased to 61% for liaison unit A and 6% for control units B and C

in the experimental year.

o At Mount Sinai, there was a statistically significant reduction in length of stay; the length of stay of patients who received the intervention was, on average,

2.2 days shorter than the patients seen during the baseline year. With regards to the cost of medical resources, employing an average per diem hospital

cost of $647 (1987 dollars), this reduction in length of stay corresponds to a reduction in the total cost to the hospital of $178,572.

o At Northwestern, the reduction in length of stay for the patients on liaison unit A (with outliers removed) was less pronounced than that at Mount Sinai;

nevertheless, this reduction of 1.7 days in length of stay was still a statistically significant difference compared to the length of stay of patients on the

control units. This reduction corresponded to a reduction in hospital costs of $97,361.

o At Mount Sinai, patients who received the intervention showed a significant improvement in Mini-Mental State score (t = 3.40, df = 63, p < 0.01), whereas

at Northwestern, the liaison intervention was associated with a significant reduction in the Geriatric Depression Scale score (t = 3.20, df = 92, p < 0.01).

However, fracture status, bone density, and the Horn ratings of severity of disease were did not change between the baseline and intervention years at

both hospitals.

o No significant differences were seen between the baseline and intervention years when discharge disposition was concerned in either hospital.

Levitan and

Kornfeld

(1981)

o The difference in the medians of length of hospital stay between the two groups (30 days for the intervention group and 42 days for the control group) was

statistically significant (Mann-Whitney U test = 185, P < 0.05). No significant difference was found when the length of stay for all patients receiving knee

and hip surgery was considered (excluding fractured femurs), and likewise no significant difference was found when the length of stay for all patients

receiving total prosthetic joint replacement was compared.

o Disposition - of the patients in the intervention group, 16 patients were discharged home and 7 were discharged to a nursing home or other health-related

institution. In the control group, 8 patients were discharged home and 15 were discharged to a nursing home or other health-related institution. This was

a significant difference (chi-square = 4.27, P < 0.05).

Scott et al.

(1988)

o In years I and II the agreement between the referring physician and the psychiatrist when the diagnosis was concerned was 35-40%, whereas the

agreement was 63% in year III. Moreover, the number of cases in which no psychiatric diagnosis was made fell from 14% in years I and II to 7% in year

III - this suggests that the referring physicians made fewer inappropriate referrals, which could be a consequence of the service’s educational activities.

o The number of referrals increased by over 100% in year III.

o Although most of the referrals were still referred directly to the psychogeriatricians from the staff on the medical, surgical or other wards, more referrals

were made in year III simply because of the “liaison referrals” that were made, arising directly as a result of liaison work done on the geriatric unit by

member of the liaison service.



o The number of psychogeriatric consultations made in year III increased by 78%, compared with years I and II, whereas the secondary and liaison referrals

accounted for 55% of the psychogeriatric consultation-liaison work conducted by the liaison team in year III.

o The secondary and liaison referrals accounted for 55% of the psychogeriatric consultation-liaison work carried out in year III.

De Leo et al.

(1989)

o Owing to the retrospective nature of this study, only 362 patients referred for psychiatric consultation before 1st September 1986 were identified; it should

therefore be borne in mind that there may be some missing results, which may bias the findings.

o Prior to the setting-up of the unit, the rate of referral for psychiatric consultation remained relatively constant (around 2%), and a considerable increase in

rate of referral occurred after the unit was established, which was 4.9% in September to December 1986, and 4.5% in January to June 1987. The authors

suggest that this increase in rate of referral occurred as a result of increased contacts with ward physicians.

o Mean length of stay before liaison service was 23.7 days (SD 8.1), and after liaison service was 16.7 days (SD 5.9)

o Compliance with psychiatrist’s recommendations – before liaison service, full implementation with recommendations was 59.9%, partial implementation

was 25.8%, no implementation was 14.3%. After liaison service, full implementation was 80.8%, partial implementation was 15.5%, no implementation

was 3.7%. Improved compliance after liaison service was set up.

o Number of consultations – before liaison service, 82.3% of referred patients received only one consultation, whereas after liaison service was set up,

23.2% of referred patients received three consultations and 59.6% of referred patients received over three consultations.

Baheerathan

(1999)

o There was a significant difference in the number of referrals for each month across the three phases (Kruskal Wallis one-way ANOVA, chi-square = 10.8, 2

df, p = 0.0044); it was found that this significant difference was exclusively accounted for by a drop in referrals between phases 2 and 3 (Mann-Whitney U

test, Z = -2.9, p = 0.0037), whilst there was no decline in the number of referrals between phases 1 and 2.

o Concordance between selected pairs of variables in phase 1: Referral for advice on placement and management advice given on placement κ = 0.11;

referral for advice on court of protection and management advice given on court of protection κ = 0.25; referral for advice on the management of dementia

and a diagnosis of dementia κ = 0.28; referral for advice on the management of depressive symptoms and a diagnosis of depression κ = 0.57.

o Concordance between variables in phase 2: Referral for advice on the management of depressive symptoms and a diagnosis of depression κ = 0.36.

o Concordance in phase 3: Referral for advice on placement and management advice given on placement κ = 0.46; referral for advice on the management of

dementia and a diagnosis of dementia κ = 0.57; referral for advice on the management of depressive symptoms and a diagnosis of depression κ = 0.34;

referral for advice on the management of delirium and a diagnosis of delirium κ = 0.36.

o Economic analysis - the total medical costs per month in phases 2 and 3 were £294 and £258 (£166 add £92), respectively, suggesting that the liaison

component has the potential to be cost-effective.

Mujic et al.

(2004)

o There was a higher rate of referral for the new service (1.4 compared to 0.95 new referrals per working day), and a longer period of time was spent on

referrals. The psychiatrists of the new service made a total of 674 initial and follow-up visits, which equates to an average of 2.7 patient assessment per

working day, whereas a greater proportion of referrals to the new service were seen two or more times (44%), compared to the old service (31%),

although data for the old service is incomplete. This indicates that patients referred to the new service received more follow-up. Also, the mean total



contact time with patients increased from 73 minutes (SD 43) to 83 minutes (SD 62).

o The new service saw 62% of all referrals within 24 hours, whereas all urgent referrals were aimed to be seen within 24 hours – this was achieved for 96%

of all urgent referrals, compared with 40% for the old service (P < 0.001). Moreover, the new service aimed to assess medium-urgency referrals within 5

days – this was achieved for 98% of medium-urgency referrals in the new service compared with 76% for the old service (P < 0.001), while two-thirds of

low-urgency referrals were seen within 5 days in both services.

o Levels of satisfaction improved with the new service by the referring physicians in terms of response times, with 96% reporting net satisfaction, compared

to 81% under the old service (P < 0.001). Satisfaction ratings for salience of advice from the liaison psychiatrist (98% v. 96% satisfied) and clarity of

advice (96% v. 94%) were already high, and these high levels of satisfaction were sustained after the implementation of the new service. Also increases in

the satisfaction ratings in terms of the appropriateness (86% reporting net satisfaction v. 74% under the old service, P < 0.01), clarity (85% v. 73%, P =

0.01) and completeness (76% v. 55%, P < 0.001) of the referrals.

o Disposition - just over half of referrals to the new service returned to their own homes following discharge from hospital, whereas a smaller proportion of

referrals were transferred to residential (15% of referrals) or nursing homes (17%), and a further 3% were transferred to a psychiatric hospital.

o Data for old service is incomplete, which may bias the results.

Camus et al.

(2003)

o From both study periods, 59/176 (33%) patients were identified as having emotional or mood disorder.

o The rate of referral significantly increased 4% (N = 3/81) during the baseline period to 32% (30/95) during the intervention period (P < 0.001). In terms

of patients who screened positive on the GHQ, only 10% (3/33) of screen positive patients from the baseline period were referred to and assessed by the

psychiatrist, whereas all screen positive patients during the intervention period were assessed by the psychiatrist.

o In terms of length of stay and costs of medical resources, there were no significant differences between the intervention and baseline periods. The length

of stay in both the baseline and intervention periods is similar, whereas there was a large increase in estimated costs in the experimental period – this is

probably directly attributable to the costs involved in setting up the liaison psychiatry service. This study was not performed over a sufficiently long period

of time in order to determine the true costs/savings of introducing this new service.

o In terms of staff satisfaction, staff involved in the study were asked to fill in a feedback questionnaire, and 51% returned the questionnaire. Analysing the

results from the questionnaires indicated that over half of respondents felt that the new referral procedure was “better”, whereas more respondents felt

that the patient benefited from the new approach. Many respondents also felt that they had learnt useful information from attending the meetings and

50% felt that their participation helped them with their decision making. However, this was a comparatively low response rate to the questionnaire, and

the results are anecdotal.

de et al. (2003) o In terms of survival, no significant difference was found between the intervention (82%) and control patients (85%) (chi-square = 0.47, 1 df, p = 0.49).

o The non-parametric test revealed a non-significant result when the length of stay was concerned.

o Because it was found that a significant difference existed between the two groups with regards to age, this analysis was repeated, using a pragmatic aged

cut-off of 65 years, on older and younger patients. When this analysis was repeated for the sub-group of older patients, it was found that the intervention



had had a positive effect, as older patients in the intervention group had a shorter length of stay (p = 0.05), whereas no significant differences were found

in the same analysis for the sub-group of younger patients.

o The multivariate analysis of variance of the eight SF-36 scales indicated a significant overall effect of intervention on quality of life (F = 2.1, p = 0.037).

Molodynski et

al. (2005)

o The liaison psychiatry service has a higher rate of referral than the CMHT; 100 new referrals were made to the liaison psychiatry service over a period of 56

days (mean referral rate 13 referrals per week) and to the CMHT over 108 days (mean referral rate 6.5 referrals per week).

o The CMHT received 75% of its referrals from local general practitioners, 12% from allied healthcare professionals, 9% from other psychiatric services

(including the liaison psychiatry service) and 2% were self-referrals. The liaison psychiatry service, which does not accept referrals from primary care,

received 68% of its referrals from the general inpatient wards, 22% from the A&E dept and 10% from out-patient clinics.

o There are also marked contrasts in the response times to psychiatric consultations by both services: in the liaison service, emergency referrals are

assessed immediately, urgent referrals are assessed within the same working day and non-urgent referrals are assessed within two days. In the CMHT

service, emergency referrals are assessed within one day, urgent referrals are assessed within 7 days and non-urgent referrals are seen within 28 days.



Appendix 9a: Literature review – Education/training interventions: Methods, characteristics, outcomes and outcome measures Study Shah and De (1998)UK Tabet et al. (2005)UK

Service Model Old Age; Liaison Psychiatrist (education – aggressive behaviour) Old Age; Liaison psychiatrist (education – delirium)

Level of Evidence II-2A II-2A

Study design Prospective evaluation (interrupted time-series) evaluating an

educational intervention by an old age psychiatrist to reduce

incidences of aggression

Single-blind case-control study, evaluating the effectiveness of an educational

intervention by an old age psychiatrist to improve detection of delirium

Duration 18 weeks 9 months

Follow-up N/A N/A

Setting 24-bed continuing care psychogeriatric ward within the Department

of Old Age Psychiatry at a district general hospital

Two acute admissions wards in a teaching hospital, one ward was assigned the

intervention ward (the cases), and the other ward was designated the control

ward.

Sample Size 26 patients included in study 250 acute admissions over the age of 70 years

122 patients assessed on intervention ward

128 patients assessed on control ward

Number completed

study

N/A No information

Age Older patients (age cut-off not stated) Patients aged 70 years or older included in study

Mean age on intervention ward = 81.39 years

Mean age on control ward = 79.28 years

Gender No information Male:female ratio on intervention ward = 57:65

Male:female ratio on control ward = 62:66

Psychiatric morbidity Over the study period, 24 patients were identified to be aggressive

according to the RAGE scale and 21 patients on the SOAS scale

Intervention ward

Mean DRS (all patients) = 4.22; Mean DRS (delirium patients only) = 18.83

Mean AMTS (all patients) = 6.59; Mean AMTS (delirium patients only) = 3.25

Control ward

Mean DRS (all patients) = 5.65; Mean DRS (delirium patients only) = 19.16

Mean AMTS (all patients) = 7.12; Mean AMTS (delirium patients only) = 2.30

Number of dementia cases: Intervention ward – 26; Control ward – 20



Underlying dementia in delirium: Intervention ward – 6/12; Control ward –

12/23

Functional/health

status

No information Intervention ward

Infection (27.5%), CNS disorders (15.5%), metabolic illness (5.1%)

Control ward

Infection (23.3%), CNS disorders (9.2%), metabolic illness (5%)

Outcomes Reduction in aggressive behaviour Point-prevalence of delirium established by researchers

Recognition and case-note documentation of delirium by clinical staff

Outcome measures RAGE

Staff Observation Aggression Scale (SOAS)

Abbreviated Mental Test Score (AMTS)

Delirium Rating Scale (DRS)



Appendix 9b: Literature review – Education/training interventions: Interventions Study Interventions

Shah and De

(1998)

The study duration of 18 weeks was divided into three phases of 6 weeks each:

o The first 6-week phase (phase 1) was used to measure baseline aggressive behaviour.

o The second 6-week phase (phase 2) involved implementation of an educational package directed at the nursing staff; aggressive behaviour in patients

was measured during this phase as well.

o The third 6-week phase (phase 3) was to examine the effect of this package on aggressive behaviour among inpatients; there was no educational

package during this phase.

This educational package was administered by a consultant psychiatrist, who met the nursing staff on each shift twice a week for 45 minutes for a period of

6 weeks (during phase 2 of the study). This package consisted of several components including: support, opportunity for the nursing staff to share their

views, sharing of knowledge about aggressive behaviour in older patients based on an up-to-date literature review. Each session was pre-planned and an

informal presentation was made with opportunities for discussion and questions during the course of the presentation, and the final 10 minutes of each

session were available to staff to discuss any relevant issues.

Tabet et al.

(2005)

Educational package was delivered by an old age psychiatrist to medical and nursing staff on the intervention ward. This package aimed to increase medical

and nursing staff’s awareness and knowledge of delirium and its risk factors, and comprised of the following components:

o 1-hour session including a formal presentation and small group discussion. Areas emphasised included general information on delirium and non-

pharmacological and pharmacological treatments;

o Written information and guidelines on how to prevent, recognise and manage delirium in older people;

o Regular one-to-one and small group discussions lasting up to an hour, during which staff discussed cases with delirium, and also follow-up meetings.



Appendix 9c: Literature review – Education/training interventions: Results

Study Results

Shah and De

(1998)d}

26 patients were enrolled in the study, of which 24 patients were identified to be aggressive according to the RAGE scale and 21 patients were found to be

aggressive according to the SOAS scale; 21 patients were found to be aggressive according to both scales, whereas the remaining 2 patients were deemed

not to be aggressive on either scale.

Very significant differences were found between the phases for the RAGE total (chi-square = 10.62, 2 df, p < 0.005), the SOAS total (chi-square = 19.74, 2

df, p < 0.0001) and the total number of aggressive episodes on the SOAS (chi-square = 18.26, 2 df, p < 0.0001). Furthermore, statistically significant

differences existed between the three phases, at least at the 5% (p < 0.05) level, for all SOAS subscales and all the RAGE items except RAGE items 4, 7, 9,

10, 12, 13 and 20.

Comparing phase 3 to phase 1, the aggression scores on the RAGE total had significantly decreased (Mann-Whitney U test, Z = -4.14, p < 0.00001), as had

the SOAS total (Mann-Whitney U test, Z = -3.89, p < 0.0001) and the total number of aggressive episodes on the SOAS (Mann-Whitney U test, Z = -3.93, p

< 0.0001).

Comparing phase 3 to phase 2, a significant decrease was seen in aggression scores only on the RAGE total (Mann-Whitney U test, Z = -2.95, p < 0.004),

whereas no such decrease was observed when the SOAS total or the number of aggressive episodes on the SOAS were concerned, however.

Tabet et al.

(2005)d}

12 out of a total of 122 patients on the intervention ward were diagnosed with delirium by the old age psychiatrist, compared to 25 out of a total of 128

patients on the control ward.

The point prevalence of delirium was significantly lower on the intervention ward (P < 0.05, odds ratio 0.45 (CI 0.21 – 0.94)), whereas the prevalence of

medical and nursing staff’s identification of delirium cases already recognised by the researcher was significantly higher on the intervention ward.

This was statistically significant when compared to the control ward; medical and nursing staff on the intervention ward correctly identified and reported 8

out of 12 cases of delirium, compared to 6 out of 23 on the control ward (P < 0.01).

Doctors on the intervention ward were more likely (P = 0.156) to record a diagnosis of delirium among their patients despite the lower point prevalence of

delirium established by the researchers.



Appendix 10.1: Literature review – Descriptive studies: reproduction of findings - Old age/Liaison psychiatrist Authors Grossberg et al. (1990)

USA

Camus et al. (1994)

Switzerland

Leo et al. (1997)

USA

Rao (2001)

UK

Study A prospective review of psychiatric

consultations for 147 older patients

(aged 60 years or older) over a 2-

year study period

A prospective description of 431

psychiatric consultations with 227

patients, performed over 12 months

A retrospective review of psychiatric

consultations completed for patients

aged 65 years and over that was

performed during a consecutive 24-

month period

Prospective study

examined the accuracy of

physicians' diagnosis for

depression and dementia

in consecutive referrals to

an old age liaison

psychiatry service over 18

months

Sample 147 referrals. All referrals aged 60

years or older 41% of referred

patients were aged between 60 and

69 years, 56% were aged 70 to 79

years and 16% were aged 80 years

or older.

2:1 female to male ratio

431 consultations for 227 patients

Mean age 77.5 years (SD 11.8)

56.8% female

329 referrals

Mean age for Caucasian patients 75.7

years (SD 7.4)

Mean age for African-American patients

74 years (SD 6)

59.9% female (overall)

N = 40 (aged 60+)

Mean age 80 years (SD

8.4); age range 62-96

years

57.5% female

Sources of referral Internal Medicine 71%

Surgery and orthopaedics 18%

Neurology 6%

Gynaecology 4%

Emergency room 1% Psychiatry

0.5%

Internal Medicine 36%

General and orthopaedic surgery

21%

Emergencies room 16%

Rehabilitation 13.5%

Neurology 6.3%

ORL 1.4%

Urology (1.2%)

No information No information

Reasons for referral Depression 48%; Dementia/memory

deficits/ confusion 22%; Behavioural

problems/competency evaluation 7%

each; Anxiety 6%; Medication 2%;

No information Depression 22.7%; behavioural

problems 20.9%; psychosis 14%;

confusion 10.6%; dementia 7.6%;

capacity 7%; suicide assessment 7%;

Low mood 35%

Confusion 20%

Poor memory, aggression,

behavioural problems



Suicide evaluation 2%; Psychosis or

paranoia 1%; Discharge planning

0.5%; Alcoholism 0.5%;

Personality disorder 0.5%; Pain

0.5%; Mental status change 0.5%;

Coma 0.5%; Possible psychogenic

syncope 0.5%

anxiety 3.8%; medication adjustment

3.3%; transfer to psychiatry 1.8%;

placement 1.3%.

10% each

Primary psychiatric

diagnoses

Affective disorder 27%; Adjustment

disorder 26%; Dementia 22%;

Delirium 14%; anxiety disorder 3%;

chronic schizophrenia 2%;

personality disorder 1%; organic

affective disorder 0.5%; no

psychiatric diagnosis 2%.

Dementia 17.2%; Affective disorder

16.3%; Delirium 14.1%; Delirium on

dementia 12.8%; adjustment

disorder 11.5%; anxiety disorder

5.7%; acute and chronic psychosis

4.9%; substance abuse (3.5%),

sleep disorder 1.6%; personality

disorder 0.9%; no psychiatric

diagnosis 3.1%; diagnosis deferred

8.4%

(ICD-10 criteria)

Dementia, delirium and amnestic

disorders 42.2%; mood disorders

17.2%; psychotic disorders 14.8%;

adjustment disorders 7.1%;

substance-related disorders 5.5%;

bereavement 2.8%; mental disorders

due to a general medical condition

2.5%; anxiety disorders 2.2%;

factitious disorders 0.3%; no Axis I

diagnosis 5.5%.

(Axis I criteria)

Alzheimer's disease

32.5%

Depressive disorder

27.5%

Vascular dementia 15%

Alcohol dependence 5%

No psychiatric diagnosis

15%

(DSM-IV criteria)

Physical diagnoses

No information Circulatory disease 15.4%;

Psychiatric disorder 15%; Falls

(without injury) 12.8%; symptoms

and signs NES 10.1%; injury 10.1%;

neoplasm 8.8%; neurological disease

7.6%; medicosocial problem 4.8%;

digestive system diseases 3.1%;

respiratory system diseases 2.2%.

(ICD-10 criteria)

No information Stroke 22.5%

Alcohol misuse 15%

Rate of referral No information 5.10% (for all psychiatric

consultations); 2.6% (if only

individual patients are included)

6.2% for Caucasian patients; 3.8% for

African American patients; referral rate

was significantly higher for Caucasian

No information



patients (chi-square = 10.9, 1 df, p =

0.001).

Recommendations/in

terventions

Psychotropic medications 73%

Geriatric psychiatry outpatient

follow-up 32%

Further medical work-up 21%

Psychotherapy 13%

Ward management 12%

Transfer to inpatient unit 5%

Neuropsychological testing 1%

No information Medication prescribed 27.4%;

labs/studies ordered 20.3%;

medication adjustment 13.2%;

recommend other consults 7.2%;

recommend medical treatment 6.9%;

placement recommendation 5.7%;

staff education 4.8%; psychotherapy

4.8%; transfer to psychiatry 2.5%;

legal recommendations 2.2%; one-to-

one observation 2.1%; family

interventions 1.6%; alcohol/drug

withdrawal precautions 1.3%.

No information



Appendix 10.2: Literature review – Descriptive studies: reproduction of findings - Old age/Shared care Authors Porello et al. (1995) USA Flaherty et al. (2003) USA

Study Retrospective chart review of all patients discharged from the medical-

psychiatry unit over a 12-month study period

Retrospective review of patients (aged 70 years or older) discharged from

the Delirium Room (part of the Acute Care of the Elderly unit, a shared

care ward) over a 12-month study period

Sample 323 patients discharged from unit; 290 medical records available and

examined here

Mean age 76 years (SD 10)

71% female

196 of 1,121 patients on the ACE unit were discharged from the DR


56.5% female

Sources of referral Nursing home mental health consultants 43%

Nursing home staff 13%

General hospitals 11%

Outpatient psychiatrists 9%

Emergency services 8%

Primary care physicians 6%

Elderly services agencies 5%

Visiting services 2%

Families 1%

Others 2%

No information

Reasons for

referral

Aggressive behaviour 31%

Depression 14%

Psychosis 10%

Suicide risk 9%

Food refusal 8%

Wandering 6%

Disruptive behaviour 5%

Self-injurious behaviour 3%

Refusing needed medical care 3%

Continuous yelling 2%

Sleep disorder 1%

No information



Other reasons 8%

Psychiatric

diagnoses

No information Of these 196 patients, only about a third (69/196, 35.7%) had an ICD-9

diagnosis of delirium

Dementia 47.8%

Physical Diagnoses Cardiovascular 43%

Endocrinopathies 41%

Hypertension 29%

Musculoskeletal disorders 27%

Gastrointestinal disorders 21%

Anaemia 18%

Urinary tract infection 18%

COPD 17%

Stroke 13%

Movement disorders 11%

Seizure disorders 11%

Pneumonia 5%

Mean co-morbidity score 2.1 (SD 1.2)

Mental diseases and disorders 17.4%

Diseases and disorders of the kidney and urinary tract 14.5%

Endocrine, nutritional and metabolic diseases and disorders 13%

Diseases and disorders of the circulatory system 11.6%



Appendix 10.3: Literature review – Descriptive studies: Details about the service - Old age/Shared care Study Details about the service

Porello et

al. (1995)

The medical-psychiatry unit is based in a 54-bed community general hospital in Massachusetts. The 20-bed unit was set up in 1989, and serves older patients

suffering from comorbid psychiatric and medical illnesses and functional disabilities. The aims of the unit are to “relieve emotional distress, diminish disturbed

behaviour, improve function, and maximize independence”. The clinical approach is based on the principles of comprehensive geriatric assessment, the application

of which concentrates on the following four aspects of care:

“Diagnosis and treatment of psychiatric problems seen in the frail elderly such as anxiety, depression, schizophrenia, and the psychiatric manifestations of

neurologic illness;

Recognition and management of the psychiatric complications of medical problems or their treatments;

Assessment and treatment of caregiver burden among family or nursing home caregivers; and

Functional evaluation and rehabilitation”

Looking at the staffing of the unit, the nursing staff are extensively trained and experienced in medical and surgical specialties, in addition to some psychiatric

training or experience. Each patient receives 6.3 hours of nursing care per day. The unit also employs two psychiatrists, both of which are experienced in old age

psychiatry, and whose responsibility it is to perform psychiatric evaluations and diagnoses, manage all psychopharmacotherapy (the treatment of choice for most

patients), and also individual psychotherapy. The psychiatrist also performs routine bedside cognitive and neurobehavioural evaluation, and makes daily ward

rounds to evaluate patients admitted to the unit. Each psychiatrist leads one multidisciplinary treatment team consisting of primary nurses, social workers,

occupational therapists, physical therapists and mental health counsellors. One psychiatrist also serves 15 hours per week as medical director, overseeing policy-

making, training for staff and so on.

In addition to the nursing and psychiatric staff employed in the unit, the following members of staff are also employed:

A full-time program director is responsible for the operational management of the unit

Six general internists provide concurrent medical care, seeing patients as often as possible, sometimes daily, but at a minimum of twice per week

A half-time psychologist and three mental health counsellors provide individual, group and activities therapies. Group therapy is conducted three times per week by

the psychologist.

Part-time occupational therapists evaluate functional competence and make recommendations to enhance independence or forestall institutionalisation

Part-time physical therapists to provide transfer and gait training

Two full-time social workers provide psychosocial evaluations, family therapy and case management

A third social work position is dedicated for a full-time aftercare coordinator, focusing on arranging discharge plans and nursing home placement

The multidisciplinary treatment team meets twice weekly to develop and review treatment plans for each patient.

Flaherty

et al.

The Delirium Room (DR) is a specialised 4-bed unit that provides 24-hour intensive nursing care and is completely free of physical restraints (as they are

significantly related to the severity of delirium). The DR is also part of a 22-bed Acute Care of the Elderly (ACE) unit.



(2003) Comprehensive medical care – patients in the DR are discussed 5 days a week at the multidisciplinary team meeting. In addition to typical nursing issues, nurses

are required to comment on each patient’s mental status every day. During teaching rounds (geriatric attendings with the internal medicine residents), the

importance of early identification of delirium and basic geriatric principles of care are stressed.

Behavioural therapy and appropriate non-pharmacological approaches are the standard initial approach. When pharmacological measures are necessary, the

judicial use of low-dose antipsychotics or benzodiazepines is emphasised, but these drugs are avoided whenever possible.

Multifaceted approach to early identification and early careful treatment of delirium ensure that delirium is given a high priority in the care of patients in the DR.



Appendix 10.4: Literature review – Descriptive studies: Details about the service - Old age/sector model Study Details about the service

Pauser et al.

(1987)

The integrated gerospychiatric service of the Psychiatric Department of the university hospital consists of an observation ward with 24 beds for short term care

and day care, a day unit with spaces for 60 day-patients, and an outpatient unit. The outpatient unit provides gerospychiatric consultations for inpatients aged 70

years and older at the non-psychiatric wards. After written referral from the medical staff, the referred patient is visited by the psychiatrist, who registers the

social, medical and psychiatric data and performs a psychiatric examination. He also discusses the patient with the ward staff and writes a detailed psychiatric

report. In many cases, an interview was held with the patient’s family members and with home services, which was undertaken by a social worker or a

geropsychiatrically trained nurse in the non-psychiatric departments. The response time was 2.1 days in the first year of operation, and 1.3 days in the second

year. Although there is some follow-up of patients referred to the service, psychiatrists do not have a role in educating non-psychiatric staff about psychiatric

illness, and as such, it is not a liaison service.

Wrigley

and Loane

(1991)

The old age psychiatry service began in January 1989 (the beginning of the study), consulting on general and psychiatric hospital inpatients. The service has a

catchment population of approximately 27,000 people aged 65 years or older. Although the psychiatric service described in this article is described as a

“consultation-liaison” service, the data presented suggests that this is in effect a consultation-only service, a sector model. For example, there were only 107

requests for consultation over a period of 18 months and despite the fact that no data on the number of older people admitted to hospital during this same period

is presented, which means that the referral rate cannot be calculated from the data presented alone, this does allude to the fact that the rate of referral is indeed

very low. Furthermore, no “liaison” or educational roles of the psychiatric service are mentioned, which are a key component to any consultation-liaison service.

Also, if the service did constitute a “liaison” feature to its work, it would be expected that more patients would be referred for psychiatric consultation, as the

medical staff would be better equipped and would possess the required knowledge to be able to identify psychiatric illness in medical patients, and also more

patients would be referred to the service as the liaison psychiatrist would attending ward rounds etc.

Roulaux et

al. (1993)

Sector model; no mention of liaison. The service was staffed by psychiatric residents under supervision of psychiatrists from the psychiatric hospital. Referrals

were made by telephone and recorded on the consultation form. Findings, diagnosis and recommendations were recorded on the same form. A letter was written

by the psychiatrist to the referring physician following the psychiatric consultation, and a copy was also sent to the patient’s general practitioner.

Loane and

Jefferys

(1998a)

The old age psychiatry service is led by two senior psychiatrists with a multi-disciplinary team. Assessment and management of patients in the community forms

the basic premise of the service, and a consultation-liaison service is provided to the general hospital; therefore, this is a sector model, as they refer to community

forming the basic premise of their service. Even if they do have dedicated time to spend in the general hospital, it does seem that this would not be enough time

(i.e. 2-3 sessions per week) to warrant a liaison service.

Scott Sector model – psychiatry service is based in a different hospital. Although the article mentions referrals to a liaison service, it was deemed that this was in fact a

sector model service.

Benbow

(1987)

This psychiatric service was staffed by a full-time consultant, and both GPs and hospital doctors refer to the service, and the types of intervention offered are

inpatient admission, day hospital attendance (before and/or after discharge), community follow-up by the community psychiatric nurse, social worker,



psychologist or psychiatrist, outpatient clinic attendance or follow-up consultations on the medical or surgical ward. Despite the fact that the author mentions

“Liaison” in her article, it was judged that it was a sector model service being described. The service is based at a teaching hospital, serving a catchment

population of 120,000 and approximately 18,000 older people. The service offers a comprehensive psychiatric service to people aged 65 years or older, but will

also accept referrals for patients who fall below this age threshold with pre-senile dementia.

Poynton

(1988))

From 1/6/82 to 30/11/83 (period 1), all referrals of all ages were seen by doctors of the general psychiatric liaison service. This service consists of a full-time

registrar, one or more doctors at senior registrar level and a consultant. Referrals were made by telephone, and referred patients were seen by the registrar and

discussed in the ward round. Patients were also seen by the senior registrar and the consultant, if required. If continuing psychogeriatric care was deemed

necessary, patients were then referred on to the appropriate psychogeriatric team.

From 1/12/83 to 31/1/85 (period 2), all referrals of patients aged 65 and over were seen by the psychogeriatric department. Referrals were again made by

telephone, and most referrals were initially seen by the senior registrar or consultant.

Although the authors describe this service as a liaison service, from the information provided, it was judged that this was in fact a sector model service.

Anderson

and

Philpott

(1991)

All referrals were seen by the consultant psychogeriatrician or the senior registrar undertaking a 12-month rotation in old age psychiatry.

McColl et

al. (1989)

Psychiatric Geriatric Service accepts referrals from patients aged 65 years or older, and has a catchment population of 30,000 older people.



Appendix 10.5: Literature review – Descriptive studies: reproduction of findings - Old age/sector model (part 1 of 2) Author Pauser et al. (1987) Sweden Wrigley and Loane (1991) Ireland

Study Retrospective evaluation of 294 psychiatric consultations (involving 247

patients) over two-year study period, 1982-1984

Data on geriatric inpatients referred to psychiatric service between

Jan 1989 and June 1990 (18-month study period) is described

Sample 294 consultations involving 247 patients aged 70 and over

63% female

Mean age 78 years

107 referrals to psychiatric service from the over 65s

68% female

Mean age 79 years; range 65-97 years

Source of referrals Internal medicine 52%

Geriatric (long-stay) 19%

Surgery 8%

Neurology 8%

Other departments 13%

No information

Reasons for referral Make a diagnosis/assessment 84%

Advice concerning psychotropic drugs 27%

Transfer to psychiatric care 19%

Disposition planning 17%

Placement sought 47%

Psychological problem 33%

Forgetfulness 11%

Alcohol abuse 6%

Physical problem 2%

Previous psychiatric

history

53% No information

Primary psychiatric

diagnoses

Chronic Organic Brain Syndrome with severe dementia 32%

Neurosis (depressive type) 13%

Major depression 9%

Reactive confusional state and somatogenic psychoses 8%

Toxicomania 3%

Paranoid state 2%

No psychiatric diagnosis 9%

Dementia 44%

Functional diagnosis 25%

Acute organic states 10%

Alcohol abuse 2%


Physical diagnoses Cardiovascular disease 40%

Stroke 21%

Diabetes 14%

Cardiovascular 36%

Locomotor 29%

Gastrointestinal 16%



Cancer 11%

Infectious disease 10%

Thyroid disorders 6%

No somatic illness 11%

Respiratory 15%

Cerebrovascular problems 15%

No current medical problem 16%

Recommendations /

outcomes

New consultation 22%

Transfer to geropsychiatric observation ward 19%

Transfer to geriatric long-stay ward 14%

Transfer to home for older people 8%

Follow-up at geropsychiatric outpatient unit 4%

Transfer to mental hospital 3%

Transfer to geropsychiatric day unit 3%

Advice 62%

Medication recommended 28%

CPNs involved/psychiatric admission 5% each

Psychiatric extended care 3%

Community services 2%

Day hospital 2%

Disposition Transfer to mental hospital 3%

Transfer to open geropsychiatric ward 20%

No information

(part 2 of 2) Author Roulaux et al. (1993) Netherlands Loane and Jefferys (1998b) UK Scott (1986) UK

Study Retrospective description of 417 psychiatric

consultations performed between Jan 1980

and Jan 1990 (10 years) on patients aged 65

years or older

Retrospective study of consecutive referrals from

older patients to an old age psychiatry service

Retrospective study of referrals from three

general hospitals to an old age psychiatry

service over a 12-month study period

Sample 417 psychiatric consultations with over 65s

55.4% female


71 referrals examined in study

68% female

Mean age 80.8 years; age range 60-97 years

54 patients referred to service

78% female

Mean age 85 years; age range 73-100 years

Source of referrals Internal Medicine 42.9%

Neurology 20.4%

Surgery 11.3%

Lung disease dept 10.3%

Cardiology 7.4%

Urology 3.1%


Reasons for referral No information Specific psychological symptoms 51% Depressive symptoms 41%; Dementia 37%;



Forgetfulness 23%

Behavioural problem 14%

Future placement 11%

Appropriate placement 28%’ Capacity with

regard to placement 15%; aggressive

behaviour 13%; psychotic symptoms 11%;

anxiety 6%; alcohol abuse 4%; delirium 4%;

manic symptoms 2%; refusal of medical

treatment 2%; suicide risk 2%

Previous psychiatric

history

20.10% of referrals with a past psychiatric

history

35% had contact with the old age psychiatry

service in the previous 12 months

No information

Primary psychiatric

diagnoses

Organic mental disorder 34.1%; Mood

disorder 25.4%; Adjustment disorder 1.9%;

Psychoactive substance use disorder 1.6%;

Schizophrenia, delusional disorder or

psychotic disorder 1.6%; Anxiety disorder

1.2%; Somatoform disorder 0.2%;

Dissociative disorder 0.2%; V codes 16.3%;

Diagnosis deferred 16.8%

Dementia 45%

Functional disorder 38%

Acute organic psychosis 13%

Dementia 44%; Depressive disorder 30%;

Delirium 22%; anxiety disorder 6%;

personality disorder 6%; harmful use of

alcohol (4%; although no patients were

diagnosed with alcohol dependence), other

organic disorders 4%; mania 2%

(ICD-10 criteria)

Physical diagnoses Circulatory disease 24%; Nervous system and

sense organ disease 9.6%; Endocrine,

metabolic and immune system disease 9.4%;

Respiratory disease 8.6%; Neoplasms 8.6%;

Trauma 7.2%; Urogenital disease 6%;

Digestive system disease 5.5%; Diseases of

bones and joints 2.9%; No somatic disease

12.9%

Cardiovascular problems 54%

Locomotor problems 45%

Central nervous system problems 39%

No information

Recommendations /

outcomes

No information Social services 62%

Other community follow-up (e.g. CPN, day

hospital) 59%

Prescription of psychiatric drugs 42%

Advice on psychiatric morbidity 30%

Transfer to a residential home 11%

Advice on placement 50%; Alter/commence

medication (psychotropic) 35%; Referral to

CPN/social worker 9% each; referral to day

hospital 7%; referral to psychology 7%;

referral to occupational therapy 6%; referral

to outpatient follow-up 6%; referral to



Psychiatric continuing care 7%

Psychiatric diagnostic investigations 6%

Psychiatric admissions 6%

Transfer to a nursing home 3%

inpatient transfer (6%); referral to day centre

6%; review at a later date 7%

Disposition Autonomous 47.2%

Nursing Home 6.2%

Residential Home 16.8%

Psychiatric Hospital 16.3%

Community 44%

Residential/nursing home 34%

Psychiatric continuing care 4%

Geriatric continuing care 1%

No information



Appendix 10.6: Literature review – Descriptive studies: Reproduction of findings - Old age/sector model – Benbow 1987

Referrals from:

Geriatrics Hospital doctors Community doctors

Sample 65 referrals

Median age 77 years

47 referrals

Median age 77 years

210 referrals

Median age 79 years

Reasons for referral Depression 37%

Psychotic behaviour 15%

Home support/day hospital 14%

Behaviour problem + COPS 12%

No cause for symptoms 8%

Confused/demented 6%

Placement 3%

Self-harm 2%

Depression 34%

Self-harm 17%

Placement 13%



Home support/day hospital 6%

Depression 34%


Behaviour problem + COPS 20%


No cause for symptoms 4%

Primary psychiatric

diagnoses

COPS 32%

Affective illness 23%

Neurosis 9%

AOPS 3%

Paranoid state 3%

Personality disorder 3%

Alcoholism 2%

COPS 32%


AOPS 11%

Neurosis 6%


COPS 39%


Paranoid state 11%

AOPS 10%

Neurosis 5%


Recommendations Advice on drugs 45%

Offered follow-up 34%

Advice on placement 28%

Psychotherapy 11%

Social 11%

Physical test or treatment 9%

Occupational therapy 8%

Behavioural 8%


Advice on drugs 30%

Social 17%

Placement 12%

Physical test or treatment 11%

Psychotherapy 3%

Occupational therapy 3%

Behavioural 3%


Physical state/treatment 58%

Advice on drugs 26%

Social 10%

Placement 4%

Psychotherapy 4%



Appendix 10.7: Literature review – Descriptive studies: Reproduction of findings - Old age/sector model – Poynton 1988 - Summary of findings for Poynton (1988); retrospective review of psychiatric referrals of older patients from 1st August 1982 to 31st January 1985, both before and after the setting-up of a specific psychiatric liaison service for the elderly

Period 1 Period 2

Sample 52 referrals

Median age 73 years (for all referrals); semi-

interquartile range 5.5

71.1% female

79 referrals

Median age 73 years (for all referrals); semi-interquartile

range 5.5

57% female

Rate of referral Male 0.34%

Female 0.97%

Male 0.96%

Female 1.17%


Confusion 25%

Dementia 2%

Other 42%

Depression 30%

Confusion 26%

Dementia 3%

Other 41%

Primary psychiatric

diagnoses

Depression (all) 27%

Acute confusional state 19%

Dementia (all) 17%

Other psychiatric diagnosis 27%


Depression (all) 22%

Acute confusional state 20%

Dementia (all) 18%

Other psychiatric diagnosis 25%




Appendix 10.8: Literature review – Descriptive studies: Details about the service – non-age discriminatory/multidisciplinary team

Study Details of service

Hales et al.

(1986)

The consultation-liaison service at the Walter Reed Army Medical Center, an 800-bed teaching hospital, consists of two full-time Army staff psychiatrists, a

civilian psychologist, a senior psychiatry resident (PGY-4), three or four third-year medical students, two psychiatric nurse clinicians and one or two attending

psychiatrists. Also, a neurology resident and one or two fourth-year medical students frequently rotate through the service. All patients referred for

psychiatric consultation are reviewed by one of the staff psychiatrists; referral is by completing a written consultation form. Response times to referrals are as

follows: routine – within three days, same day and emergency.

Chandarana et al.

(1988)

The full-time consultation-liaison service was introduced at an 800-bed general hospital in Ontario. The service consisted of a consultant psychiatrist, a liaison

nurse, a psychiatric resident, a third-year medical student and also psychology and social work support staff. Furthermore, a rotating intern and

psychogeriatrician have been added to the team since its inception. Patient referred for psychiatric consultation were seen by the psychiatric resident within

24 hours of the initial referral, and were then reviewed by the psychiatrist and the rest of the liaison team.

Porter (1988) The multidisciplinary service was instigated in 1984 with a psychiatrist, 6.5 social workers, a psychologist and secretary, with the plan of adding a psychiatric

clinical nurse specialist and psychiatric occupational therapist. The service offers psychosocial consultation and direct service to patients receiving hospital

care for physical problems in the non-psychiatric departments of the hospital, and any patients could be seen by only the psychiatrist or by additional

members of the team, depending on the type of assessment and management required. The service is set in a 628-bed general hospital. The aims of the

service are: psychosocial care to the medically ill; help patients adapt to their illness and hospitalization; improve staff’s capacity to detect, diagnose and

manage psychological and social problems of patients; develop continuing education programs for staff in the area of psychosocial care; provide a means of

coordinating all of the above.

In terms of implementing the service, the psychiatric coordinator initially received three sessions per week for three months to set up the program. Weekly

case management rounds were started and members of the team all carried pagers, and communicated closely with each other.

The role of the psychiatric coordinator was as follows: assessment, diagnosis and treatment requiring psychiatric expertise; coordinator of overall

management; liaison with other physicians, staff and departments; teaching; administration required in maintaining a defined service.

The role of the social workers was as follows: foster integration and acceptance of the consultation-liaison service with their presence at weekly nursing

rounds; direct work with patients, families and community resources.

The role of the psychiatric clinical nurse specialist was as follows, and is mainly involved in improving the staff nurses’ skill and knowledge in handling the

emotional care of the patient and to enhance their capabilities in managing similar problems in the future: psychiatric mental health nursing assessment;

problem identification; formulation of nursing diagnosis; treatment planning; suggestions for nursing interventions; follow-up evaluations.

The role of the psychologist was as follows: psychological assessments; liaison with neuropsychology; treatment in the form of counseling, behaviour therapy,

biofeedback and stress management.



The author notes the following benefits that have arisen as a result of the implementation of this service:

o An improved standard of psychosocial care for the physically ill patient in the non-psychiatric departments of the hospital. The part-time psychiatrist in the

service has increased the number of referred cases from 267 to 356 from the first to the second year of the service owing to the effectiveness of the

multidisciplinary team;

o If a patient is transferred to psychiatry, the assessments and treatment that have already been initiated by the liaison service may shorten the patient’s

length of stay in the psychiatric ward;

o Improved identification of psychiatric morbidity and confidence in medical staff;

o The medical staff have more positive attitudes with respect to their requests in assistance with management, patient care conferences and educational

conferences;

o Improved coordination of discharge planning – can contribute to earlier discharge and reduced readmissions;

o Other benefits such as reduced mortality rates and length of hospital stay for referred patients and also decreased utilisation of medical services by patients

referred for psychiatric consultation.

Huyse et al.

(1990a)

The consultation-liaison service was made up of one full-time consultation-liaison psychiatrist, two PGY IV psychiatric residents and a full-time liaison clinical

nurse specialist. The setting was a 614-bed university hospital, which admitted 33,218 patients during the study.

Schmaling (2002) The consultation-liaison team consisted of one attending psychiatrist (rotating between seven psychiatrists), a full-time psychiatry resident (normally in the 2nd

or 4th year), a nurse practitioner, up to three medical and/or physician assistant students. During 1999-2000, six psychology residents were added to the

consultation-liaison team for 10 to 15 hours per week, for two months each. The psychology residents contributed to ward rounds and offered some short-

term treatments. One psychologist supervised the other psychology interns, while the attending psychiatrist was responsible for supplementary training and

supervision, which was undertaken during team rounds. During 2000-2001, three psychology residents joined the consultation-liaison team full-time, for four

months each; the psychology residents contributed approximately a similar amount of time to the service as the psychiatry residents. Ward rounds were held

daily by the attending psychiatrist to assess all new cases and follow-up on other cases.

Dilts, Jr. et al.

(2003)

All patients referred for psychiatric consultation by the consultation-liaison service were examined by a board-certified or board-eligible psychiatrist who

conducts a full psychiatric assessment to establish the psychiatric diagnosis and make recommendations for treatment, assisted by a clinical nurse specialist.

The service receives an average of 2.9 new requests for psychiatric consultation per day for a wide range of problems.

Bourgeois et al.

(2005)

The adult psychiatric consultation-liaison service, at the 529-bed university hospital, consists of three faculty psychiatrists (one full-time and two part-time),

postgraduate-year-1 and postgraduate-year-4 psychiatry residents, a clinical nurse specialist, and up to five third-year and fourth-year medical students. The

referred patient is initially evaluated by a medical student or psychiatric resident, after which the faculty psychiatrist conducts a clinical evaluation with the

trainee to confirm the diagnosis and to review the treatment plan.

Kuhn et al.

(1986)

The consultation-liaison service was provided in three general hospitals, two were adjoining and privately operated and University-affiliated, with a bed

capacity of 466 and 336, and cooperate closely with each other. The two private hospitals mostly share the same medical staff and have a similar distribution



of clinical divisions. The third hospital was a public facility, operated by the University of Louisville School of Medicine, with a bed capacity of 268. The

consultation-liaison team comprised of three attending psychiatrists, three psychiatric residents, a psychiatric social worker, a psychiatric nurse and several

medical students. All team members saw patients at all sites; per month, there were approximately 40 requests for psychiatric consultation from the public

hospital, and 40 from the two private hospitals combined.

Schuster (1992) The service is staffed by two board-certified psychiatrists and three psychiatric nurses, while one or two family practice or internal medicine residents rotate

onto the service each month. The psychiatrists spend 60 per cent of their time to the clinical service, with the remainder of their time spent on a range of

academic and administrative duties. Two of the nurses devote all their time to clinical services, while the other nurse spends one-tenth of her time as an

administrator for the psychiatric service, and the rest of her time on other departmental duties.

In terms of what happens once a consultation has been requested, 20% of patients are initially seen by a psychiatric resident, with the remainder seen by the

psychiatrist. The medical record is reviewed, the patient assessed and the psychiatrist liaises with medical staff and/or relatives of the patient. The attending

psychiatrist then conducts any necessary follow-up evaluations. Patients may be re-evaluated if their clinical condition is altered substantially, when treatment

plans are not working, or when the referring services pose new questions.

Liaison involves holding clinical discussions with referring physicians and ad hoc conferences with medical and nursing staff with the view of improving care for

psychiatric patients on medical wards, and developing the knowledge of medical staff with regard to psychiatric morbidity.

Clarke et al.

(1995)

The C-L psychiatry service (based within the Division of Psychiatry), serving a 747-bed university hospital, is made up of 2.0 equivalent full-time (EFT)

psychiatrists, 4.8 EFT registrars (trainee psychiatrists), 4.0 EFT psychologists and a 0.2 EFT social worker. The service receives 1500 referrals per year. Each

registrar and psychiatrist is attached in liaison to a particular unit, as well as sharing the general referral caseload. Specifically to this study, the general

medical units are assigned a o.2 EFT psychiatrist and a 0.8 EFT trainee.

The service has a strong liaison tradition. The wards are visited daily by the psychiatric registrar, the registrar then appraises the situation and identifies any

issues that may need to be resolved. Multidisciplinary team meetings are also attended by members of the liaison team, and at wards rounds. Following on

from this, a decision is made regarding whether a patient in question requires a formal assessment by the registrar, or whether a secondary consultation will

occur. Furthermore, the wards are also visited most days by the consultant psychiatrist to review patients, supervise the registrar, teach medical students

and informally liaise with the medical staff. Clinical educational meetings at the wards are attended by both the registrar and consultant.

In terms of training and education, the psychiatrist meets with medical students working on the medical wards to discuss their patients, formally at a weekly

tutorial and informally in the wards. Moreover, interacting with members of the liaison team will enhance the medical registrar’s (working on the general

medical units) knowledge of psychiatry. Lastly, the service has a continuing research programme.

Kissane and

Smith (1996)

The service comprises a consultant psychiatrist, a 6 month rotation psychiatry trainee and a clinical psychologist. In terms of liaison activities, the psychiatry

trainee or psychiatrist visits the wards daily, and identifies particular problems; a weekly multidisciplinary team meeting is used to review all the current

patients, while the registrar also attends other ward rounds; a decision as to whether a patient will receive a formal psychiatric assessment or a secondary

consultation is then taken. The following bullet points describe the specific domains of liaison activity for this service, and have all ensured that the liaison



service has forged strong collaborative relationships with the medical and nursing staff of the oncology unit:

Nursing group debriefing – occurs fortnightly, a helpful form of staff support.

Medical group debriefing – weekly unit inpatient management meetings for the medical team, less formal than the nursing group debriefing. An event-specific

meeting with registrars and residents has also been helpful.

Psychosocial education input – unit conducts a weekly journal club; collaboration over research also educationally beneficial. Attendance at ward rounds and

unit management meetings has been the most effective means for guidance of medical staff by the liaison psychiatrist, without always requiring direct patient

consultation (these indirect methods are more cost-effective and help support an improved quality of care by the entire team).

Bereavement outreach – liaison psychiatrist has attended the monthly meetings of the bereavement outreach team, comprised of social and pastoral care

workers and nurses.

Supportive group therapy – a means of preventively reaching more patients at-risk of developing psychiatric illnesses than can be helped by the consultation-

liaison service (groups are formed according to cancer types and stage of disease). A separate educational program, “Living with Cancer”, discusses reactions

to cancer, and is attended by patients with all types of the disease.

Undergraduate medical student teaching – students complete rotations with the liaison psychiatrist in their final year.

stgraduate teaching – the psychiatry trainee learns about psycho-oncology.

search – development of quality-of-life instruments and a prospective psychotherapy project.

Rustomjee and

Smith (1996)

The consultation-liaison service at the Renal Unit comprises one consultant psychiatrist (0.2 equivalent full-time (EFT)), one six-month rotating psychiatry

trainee (0.6 EFT) and one psychologist (0.2 EFT), whereas three final-year medical students are also assigned to the service for six week placements to assist

in patient assessment and review. The renal liaison service is one of seven specific liaison attachments, all with a similar service make-up, in the large

Consultation-Liaison Psychiatry Unit at Monash Medical Centre. In terms of liaison activities, the psychiatry trainee becomes actively involved in the Renal

Unit, liaising with medical staff on the unit daily to identify and resolve issues. Patients referred for psychiatric consultation are given a comprehensive

assessment, and are then reviewed by the liaison psychiatrist, who also reviews assessments made by the psychologist. Furthermore, all members of the

liaison team partake in multidisciplinary patient assessment and review meetings, including the Unit’s bimonthly dialysis selection meetings, while weekly

meetings with the Unit’s nurses offer support and continuing training in psychiatry. As an aside, the 15-bed adult inpatient Renal Unit is part of a service with

a total dialysis load of 200 patients, performing 25 kidney transplants annually.

Andreoli and Mari

(2002)

The team comprises five psychiatrists and two post-graduate fellow physicians (one psychologist and one psychiatrist); the service operates in a 631-bed

university hospital, in which the consultation-liaison service takes care of all psychiatric/psychological consultation requests for inpatients.

Diefenbacher and

Strain (2002)

Consultation-liaison service was staffed with four full-time attending psychiatrists, two PGY 4 residents who worked three-fourths time and one full-time

clinical nurse specialist in psychiatry.



Appendix 10.9: Literature review – Descriptive studies: Reproduction of findings – non-age discriminatory/multidisciplinary team (Part 1 of 2)

Author Hales et al. (1986) USA Chandarana et al. (1988) Canada Porter (1988) Canada

Study Description of characteristics referrals for

psychiatric consultation over a 12-month study

period

Description of the activities of a C-L team over a 12-month

study period

Data from first two years of C-L

service described

Sample 1065 consecutive referrals

46.6% females

Mean age 43 years; age range 17-93 years

320 referrals

59% female

Mean age 52.5 years; range 14-88 years

623 referrals

Rate of referral 5.8% No information 1.2%

Sources of referrals Medicine 40.5%

Surgery 40.3%

Neurology 12.6%

Organ transplant service 4.1%

Obstetrics 2.5%

Internal medicine 35.6%; Neurology 8.8%; Cardiovascular

surgery/family practice 8.4% each; Gastroenterology 7.2%;

General Surgery 5.9%; oncology 4.1%; physical medicine

3.1%; geriatrics 3.1%; cardiology 2.8%; obstetrics-

gynaecology 2.8%; urology 1.6%

Medicine 35.3%; Intensive

care/orthopaedics/surgery 13.8%

each

Long-term care 12.2%; neurology

6.4%; obstetrics-gynaecology 4.8%;

coronary care 4.3%

Reasons for referral Depressive symptoms 20.1%; Unexplained

physical symptoms 13.4%; Adjustment difficulties

12.9%; mental status changes 10.3%; psychiatric

support 6.9%; psychiatric evaluation management

or disposition 5.5%; anxiety symptoms 5.4%;

pre-operative evaluation 4.9%; pain management

3.8%; patient conflict with physicians or staff

3.6%; suicide attempt or ideation 2.5%; request

for specified psychiatric treatment 2.4%;

suspected drug/alcohol abuse 2.3% prior

psychiatric history 1.9%; competency evaluation

1.9%; marital or family difficulties 1.3%


Primary psychiatric Adjustment disorders 18.7%; Organic mental Affective disorder 29.4%; Organic mental disorder 18.8%; Affective disorders 43.4%; Organic



diagnoses disorders 17.1% (with dementia accounting for

44.5% and delirium 30.8%); Affective disorders

14.4% (major depression accounting for 73.2% of

these diagnoses); psychological factors affecting

the physical condition (6.3%), substance use

disorders (4%), anxiety disorders (1.3%),

schizophrenic disorders (1.1%), somatoform

disorder (1.0%) and psychosexual disorder

(0.9%); No psychiatric diagnosis 15.3%

(Axis I criteria)

Personality disorder/adjustment disorder 11.6% each;

substance use disorder 8.1%; somatoform disorder 6.9%;

schizophrenic disorder 3.1%; psychologic factors affecting

physical condition 2.8%; anxiety disorder 2.5%; paranoid

disorder 0.9%

mental disorders 19.9%; Substance

use disorders 13.7%; adjustment

disorders 13.5%; anxiety disorders

4.5%

(Axis I, DSM-III)

Physical diagnoses Malignant neoplasms 21.1%; Ill-defined medical

conditions 13.6%; Circulatory system diseases

10.2%; Musculoskeletal and connective tissue

diseases 8.6%; Neurological, eye and ear diseases

8.6%; Orthopaedic injuries 7.7%;

Endocrinological, nutritional and metabolic

diseases 7%; Genitourinary system diseases

6.9%; Digestive system diseases 4.7%;

Respiratory system diseases 2.2%; Infectious

diseases 1%; Benign neoplasms 2.3%; No

physical diagnosis 0.1%

Injury and poisoning 26.7%; Diseases of circulatory system

16.6%; Mental disorders 12.2%; No physical diagnosis 12%;

neoplasms 7.1%; Diseases of the nervous system and sense

organs 6.1%; symptoms, signs and ill-defined conditions

6.1%; diseases of the digestive system 5.7%; diseases of

the genitourinary system 5.4%; endocrine, nutritional and

metabolic diseases and immunity disorders 5.1%; diseases

of the musculoskeletal system and connective tissue 4.4%.

Overdose 22.5%; Cardiovascular

19.9%; CNS 12%; gastrointestinal

disorders 10.6%; endocrine and

metabolic disorders 6.6%;

musculoskeletal disorders 5.9%;

respiratory disorders 3.7%; cancer

3%; gynaecological conditions

1.3%; mo physical diagnosis 5%

(Axis III, DSM-III)

Previous

psychiatric history

No information 32% previously seen by the department of psychiatry No information

Three main

recommendations

Follow-up at local psychiatry facility 19.7%

Follow-up by C-L service at readmissions

Referral to psychiatry outpatient clinic 9.9%




(Part 2 of 2) Author Huyse et al. (1990a)

Holland

Schmaling (2002)

USA

Dilts, Jr. et al. (2003)

USA

Bourgeois et al. (2005)

USA

Study Prospective review of consecutive

consultations performed by the C-

L service over a 2-year study

period

Prospective description of patients seen

by C-L service over a 10.5-month study

period

Retrospective study of all requests for

psychiatric consultation over a 4-month

study period

Retrospective review of

psychiatric consultations

over a 12-month study

period

Sample 820 consecutive psychiatric

consultations

280 patients seen by service

55% female

Mean age 49.9 years (SD 16.8); age

range 17-94 years

346 referrals to C-L service 901 referrals

48% female

Mean age 48.59 years (SD

17); age range 18-96 years

Rate of referral 3.20%; 2.6% if suicide attempts

are excluded

No information 3.7% 4.2%

Reasons for referral No information Depression, suicidal ideation 45.1%;

Mental status, cognitive symptoms

14.3%; Anxiety 10.6%; Psychosis 5.9%;

Depression and anxiety symptoms 4.4%;

behavioural issues 2.2%; substance use

issues 1.1%; somatisation 0.4%

Reasons affiliated to advice or

management, such as medication

management (6.2%), decisional capacity

(2.6%), status post-suicide attempt

(2.6%), provision of support (1.8%),

referral for mental health services (1.8%)

and referral for involuntary treatment

(1.1%) .


Primary psychiatric

diagnoses

Organic mental disorders 37%;

Adjustment disorders 13%; Substance

use disorders 11%; Affective disorders

Bipolar disorder 27.1%; Unipolar depression

19.7%; Delirium, psychosis, mood disorders

due to medical condition 18.2%; Adjustment

Depressive disorder 28.3%; Cognitive disorder

26.9%; Substance use disorder 25.4%;

Adjustment disorder 3.2%; Other mood disorders

Mood disorders 40.7%;

Cognitive disorders 32%;

(delirium 21.1%; dementia



8%; Schizophrenia 4%; Somatoform

disorders 3%; Anxiety disorders 2%;

No psychiatric diagnosis/V-codes 16%

(17% of referred patients with a

previous psychiatric history)

(DSM-III Axis I criteria)

disorders 11.5%; Anxiety disorders 6.7%;

Schizophrenia 6.3%; Substance-related

problems 5.6%; No psychiatric diagnosis 3.9%

(DSM-IV Axis I criteria)

2.3%;

Psychotic disorder 1.7%; Anxiety disorder 1.7%

7.7%); Substance use

disorders 18.6%; Psychotic

disorders (11.1%); Adjustment

disorders 10.8%; Anxiety

disorders 9%; No psychiatric

diagnosis/deferred diagnosis

1.3% Overall rate of psychiatric

diagnoses was 1.3 per patient

(DSM-IV criteria)

Physical diagnoses Oncologic disease 24%

Diseases of nervous system 13%

Injuries 13%


Cancer 22.6%; Cardiac problems 17.5%;

Cerebral problems 10.6%; Kidney or liver

damage 9.9%; Overdoses and suicide attempts

8%; Medically unexplained symptoms 7.7%;

Gynaecological or obstetric problems 6.6%;

Infectious diseases 5.1%; Respiratory problems

4.4%; Gastrointestinal problems (3.6%).

No information Infectious disease 10%;

Orthopaedic conditions 9.5%;

Cardiovascular disease 9.1%;

Gastrointestinal disease 9%;

Malignant disease 4.8%;

Neurological condition 3.9%

Recommendations

made by the

psychiatrist

Biologic

Diagnostic 41%

Management: medication 68%

Management: other 35%

Psychosocial

Diagnostic 30%

Ward 61%

Discharge 41%

Aftercare 24%

Medications only 47%,

Psychotherapy and medications 33%

Monitoring only 15%

Psychotherapy only 5%




Appendix 10.10: Literature review – Descriptive studies: studies describing C-L services to specific units Author Clarke and Smith (1995) Australia Kissane and Smith (1996) Australia Rustomjee and Smith (1996) Australia

Study Consecutive referrals to a consultation-liaison

psychiatry service referred from general

medical units over a 12-month study period

are prospectively described

This study prospectively describes the work of a

consultation-liaison psychiatry service to an

oncology unit over a three-year study period

This study prospectively reported on the

examination of a consultation-liaison service to

a renal medicine inpatient unit, conducted over

a three-year study period.

Sample 165 referrals

Mean age 58.30 (SD 20.18)

Age range 18-92 years (45% of referrals

aged 65 years or older)

271 referrals

54% female


299 referrals

44.8% female

Mean age 51.7 years (SD 15.25); age range

16-80 years

Sources of referral General medical units only Oncology unit only Renal Unit only


Suicide risk evaluation 21%

Organic brain damage 16%

Suspected psychological component 16%

Coping problems 13%

Pain 12%

Psychiatric history – psychotic 10%

Psychiatric history – neurotic 10%

Coping problems 41%

Depression 37%

Presence of terminal illness 32%

Anxiety/fear 17%

Pain 8%

Alcohol problems 1%

Judgement/ethical issues 1%

Suicidality 0.7%

Drug abuse 0.4%

Pre-dialysis assessment 45%

Coping problems 27%

Depression 20%

Non-compliance 11%

Anxiety/fear 9%

Diagnosis-suspected psychological component

9%

Organic brain syndrome 7%

Impaired relationships 2%

Suicide risk assessment 2%

Alcohol problems 2%

Drug abuse 1%

Primary psychiatric

diagnoses

Mood disorders 55%

Organic mental disorders 35%

Adjustment disorders 19%

Somatic disorders 16%

Personality disorders 15%

(DSM-III-R criteria)

Mood disorders 24%

Adjustment disorder 16%

Organic mental disorder 10%


Somatoform disorder 4%

Substance use disorder 4%

Anxiety disorder 2%

V Codes 35%


Mood disorders 24%


Somatoform and other somatic disorders 6%

Anxiety disorders 5%

Schizophrenia 1%



Schizophrenia 1%


(Axis I criteria)

(Axis I criteria)

Physical diagnoses Circulatory 45%

Respiratory 20%

Digestive 17%

Lymphoma 18.8%

Leukaemia 16.2%

Breast cancer 13.7%

Lung cancer 10.3%

Bowel cancer 5.5%

Bone cancer 4.1%

Renal cancer 3%

Other types of cancer 29.5 (as this is an Oncology

ward, all referred patients had some type of cancer)

Comorbid physical states on Axis III involved

circulatory (8.5% of cases), endocrine (6%),

respiratory (4%), neurological (4%) and

haematological (4%) disorders.

Disorders of circulatory system 33%

Endocrine disorders 20%

Non-drug

recommendations

Information from external source 58.8%

Psychological management 58.2%

Influence social support 36.4%

Psychiatric aftercare 35.2%

Influence discharge date 26.7%

Non-medical consultation 18.8%

Influence vigour of medical treatment 15.1%

Laboratory tests 14.5%

Environmental manipulation 13.9%

Behavioural management 12.1%

Additional medical or surgical consultation

8.5%

Psychometric tests 1.2%

(a total of 494 non-drug recommendations

Supportive psychotherapy 75%

Family conference 50%

Follow-up as outpatients 25%

Laboratory investigations 5%

Neuropsychiatric testing 3%

Psychological management 82%

Information gathering from external sources

64%

Social support 53%

Referral to allied health professional 34%

Implementation of medical treatment 28%

Seek further medical/surgical opinions 7%

Lab tests 5%

(98% compliance rate)



made; 99% of recommendations complied

with)

Drug

recommendations

Antidepressants 35%

Antipsychotics 21%

Sedatives/hypnotics/anticonvulsants 19%

Anxiolytics 11%

(a total of 143 drug recommendations made;

97% of recommendation complied with)

Antidepressants 24%

Hypnotics 10%

Antipsychotics 8%

Anxiolytics 7%

(98% compliance rate)

Anti-depressants 39%

Psychotropic drugs 25%

Hypnotics 22%

Anxiolytics 22%

Antipsychotics 10%

Anticonvulsants 3%

(A total of 95 psychotropic drug

recommendations made; 93% compliance rate)

Rate of referral 4.20% 10.4% 16.9%

Concordance rate

between reasons

for referral and

psychiatric

diagnoses

High concordance rate: suicide risk evaluation

(κ = 0.93), psychiatric history of psychotic

behaviour (κ = 0.90), non-compliance (κ =

0.89), behavioural management or agitation

(κ = 0.88), pain (κ = 0.88), medication

review (κ = 0.84), strange, unexplained or

bizarre behaviour (κ = 0.83) and psychiatric

history of neurotic behaviour (κ = 0.82).

Low concordance rate: impaired relationships

(κ = 0.32), anxiety or fear (κ = 0.52) and

depression (κ = 0.56)

High concordance rate: agitation (κ = 0.92), past

history of psychosis (κ = 0.91), pain (κ = 0.84) and

terminal illness issues (κ = 0.79).

Low concordance rate: non-psychotic past

psychiatric history (κ = 0.46), presence of impaired

relationships (κ = 0.50), depression (κ = 0.52) and

treatment compliance (κ = 0.49)

High concordance rate: terminal illness (κ =

0.87), suicide risk (κ = 0.85), pain (κ = 0.85)

and non-compliance (κ = 0.79)

Low concordance rate: staff problems (κ =

0.30), alcohol problems (κ = 0.38), organic

brain syndrome (κ = 0.49) and anxiety/fear (κ

= 0.54)

Hospital process

data

Mean lagtime from admission to referral 6.4

days (SD 8.4)

Mean lagtime from referral to consultation

0.5 days (SD 0.8)

Mean time spent on each referral 3.5 hours

(SD 3.3)

Mean number of visits to each referred

patient 3.2 (SD 2.9)

Mean lagtime from admission to referral 5.3 days

(SD 5.8)

Mean lagtime from referral to consultation 0.3 days

(SD 0.9)

Mean time spent on each referral 166 minutes (SD

124)

Mean number of visits to each referred patient 3.1

(SD 2.6)

Mean lagtime from admission to referral 6.85

(SD 9.13)

Mean lagtime from referral to consultation 0.52

(SD 0.94)

Mean time spent on each referral 181.2 minutes

(SD 147.6)

Mean number of visits to each referred patient

3.21 (SD 2.52)



Mean length of stay of referred patients

18.16 days (SD 19.21)

Mean length of stay of referred patients 13.7 days

(SD 11.7)

Mean length of stay for other oncology admissions

6.4 days (SD 8.1)

Mean length of stay of referred patients 20.50

days (SD 20.56)

Mean length of stay for other renal unit

admissions 8.67 days (SD 12.49)

Urgency of referrals Same day 40%

Routine 51%

Immediate 9%

No information Immediate 5%

Within the day 19%

Routine 76%

Disposition No information Followed-up as psychiatric outpatients 23%

Discharged home 57%

Transfer to hospice 9%

Voluntary transfer to a psychiatric inpatients

unit 2%; Discharge to a place other than home

8%; Died during admission 5%; Follow-up as

outpatients in Psychiatry 20%



Appendix 10.11: Literature review – Descriptive studies: Summary of findings for Diefenbacher and Strain (2002) Sample 4,429 consecutive referrals

Mean age of referrals 52.2 years (SD 18.8); 13.5% of referrals aged 66-75 years and 14% of referrals aged 76 years and older

54.1% female

Sociodemographic variables remained constant over the 10-year study period

Rate of referral Fluctuated between 0.9% and 1.7% over the study period

Sources of referral Internal medicine, infectious diseases and nephrology 50.3%

Surgery, orthopaedics, ENT, neurosurgery and cardiac surgery 19.2%

Neurology 5.4%

Obstetrics-gynaecology 4.4%

Transplantation services 2.9%

Reasons for referral

(range)

Depression 12.6%-18.3%

Behaviour management/agitation 8.3%-13.3%

Judgement/informed consent/Against Medical Advice 6.9%-11.1%

Suicidal risk/attempt assessment 5.8%-10.1%

Psychiatric diagnoses

(Axis I)

Organic mental disorders (deliria, followed by dementias and substance-induced organic mental disorders) 40.1%

Depressive disorders (including adjustment disorders with depressed mood(AD)) - AD diagnoses decreased by half (19.8% to 13.5% in 1988 and

1997, respectively); other depressive disorders doubled (6.4% to 14.7%) (chi-square = 8.539, 1 df, P = 0.004)

Substance use disorders 8.5%

Schizophrenia 4.7%

Bipolar disorder 1.7%

No Axis I diagnosis 6.4%

Psychosocial

recommendations and

interventions

Psychological interventions (e.g. counselling, psychotherapy, patient education) 73.7%

Behaviour management 22.1%

Non-medical consultations (e.g. referrals to social work) almost doubles (19.9% to 37.1%; chi-square = 188.164, 9 df, P = 0.000)

Biological

recommendations and

interventions

Laboratory tests – steady increase from 20.7% to 57.4% (chi-square = 284.253, 9 df, P = 0.000)

Psychotropic drugs – increase from first to second half of observation period, 39.1% to 49.2% (chi-square = 7.616, 1 df, P = 0.006)

Increase in recommendations for antidepressants – 11.9% to 32.8% (chi-square = 28.105, 9 df, P = 0.001)

Hospital process variables Total time per consultation remained stable at 2-3 hours

Number of follow-ups performed increased from 2.9 (SD 3.9) to 4.9 (SD 7.2) (F = 9.14, 9 df, P = 0.000)



Obtaining information from primary care increased – 38.1% to 83.3% (chi-square = 431.048, 9 df, P = 0.000)

After care referrals increased – 31% to 62% (chi-square = 126.070, 9 df, P = 0.000)

Transfers to private or other psychiatrist increased – 1.5% to 10.5%

Transfers to psychiatric inpatient unit increased – 2.2% to 14.5%

Lagtime and Length of Stay Mean lagtime of referred patients decreased from 10.0 days to 7.8 days

Mean length of stay of referred patients reduced from 25.7 days to 13.4 days



Appendix 10.12: Literature review – Descriptive studies: Details of service; non-age-discriminatory/liaison psychiatrist Study Details of Service

Folks and Ford

(1985)

Liaison psychiatrist. Senior residents see all patients referred for psychiatric consultation, supervised by a department of psychiatry faculty member.

Ruskin (1985) Liaison psychiatrists.

Mainprize and

Rodin (1987)

The consultation-liaison service had been running for ten years when this study was published; it is staffed by seven psychiatrists on a full- or part-time basis.

The service provides training for residents in Psychiatry, Family Medicine and Emergency Medicine.

O'Neill et al.

(2003)

Liaison service is provided to older patients on general wards by a psychogeriatric team. As the make-up of the team is not described in this article, this

study has been categorised as “Liaison Psychiatrist”.

Karasu (1977) The psychiatric service is staffed by six second-year psychiatric residents, supervised by attending psychiatrists. Requests for psychiatric consultation are

made by the medical or nursing staff on the ward, and the case is referred to the psychiatric liaison resident. The psychiatric liaison residents also make ward

rounds and conduct conferences with medical staff on psychiatric morbidity, and other psychiatric issues on medical wards. Arrangements for patients

requiring special services are made by the resident by liaising with a mental health worker, liaison psychiatric nurses, drug abuse consultation service and the

alcoholism service, for example.

Ries et al.

(1980)

Consultation-liaison service in a university hospital in Seattle; no further information.

Craig (1982) Liaison psychiatrist; active liaison component serving two of the four services (medicine and neurology) studied here. Each resident was assigned to a specific

ward for liaison activities, attending ward rounds with the medical staff at least weekly, and liaising with medical staff regularly, including performing all

psychiatric consultations to the assigned ward.

McKegney et al.

(1983)

During the study, the service was composed of three attending psychiatrists, two consultation-liaison fellows, two PGII or PGIII psychiatry residents on six-

month rotations, and medical students (four to six per eight-week rotation). The service has active liaisons with medicine, oncology, renal dialysis,

neurosurgery and orthopaedics, and the consultation-liaison team are also part of the Burn Team and the Spinal Cord Injury Service and all patients admitted

to these services are seen by members of the consultation-liaison service. In terms of interventions offered by the service, ward rounds are held daily, during

which patients are seen by the attending psychiatrist, and potential DSM-III diagnoses are discussed, whereas the fellows, residents and medical students

perform any follow-up required. At the time of the patient’s discharge, a data card is filled out by the resident or the fellow following discussion with the

attending psychiatrist, specifying diagnoses on Axes I, II and III, the classification of the patient according to Axes IV and V and any interventions and follow-

up are also noted. Specific interventions and follow-ups are not discussed in this study.

Hengeveld et

al. (1984)

Consultation-liaison service. Referrals for psychiatric consultation are accepted from all departments in the university hospital, with the exception of

Paediatrics, and are performed by two psychiatric residents and two faculty psychiatrists. Consultations are requested by telephone by the attending

physician, and the psychiatric consultation is then normally conducted on the same day by the consultant psychiatrist assigned to that particular ward. After



each consultation, the consultant psychiatrist writes a letter to the referring physician and to the patient’s general practitioner.

Trzepacz et al.

(1985)

All cases were seen by a psychiatric resident and an attending consultation-liaison psychiatrist.

Schofield et al.

(1986)

The psychiatric unit of 50 beds provides a liaison service to the rest of the 65-bed general hospital (serving a catchment population of half a million people).

Ormont et al.

(1997)

Study reports on consultations performed by the psychiatric resident only; however, all consultations were performed under direct supervision of an attending

physician within 24 hours of the request.

Kishi et al.

(2004)

The consultation-liaison service consisted of an attending psychiatrist, psychiatric residents and medical and pharmacy students.

Levitte and

Thornby (1989)

Liaison psychiatrist. This service comprised a second year resident, fourth-year resident and a full-time staff psychiatrist.

Rothenhausler

et al. (2001)

Liaison psychiatrist. Referrals for psychiatric consultation are accepted from the attending physicians from the medical and surgical wards, and the resulting

psychiatric consultation were carried out by a member of the consultation-liaison service at the patient’s bedside or in an interview room within 3 days,

depending on the urgency of the referral. When patients are referred from the emergency room, or with great urgency from another ward, these

consultations are requested by beeper, and are conducted within an hour by the C-L psychiatrist on duty. Furthermore, since 1993, the senior staff

psychiatrists have attended the monthly case conferences of the liver, heart and lung transplant programs, during which they discussed their psychiatric

evaluations of the organ transplant patients.

Ramchandani et

al. (1997)

All five hospitals had active consultation-liaison services, consisting of full-time consultation-liaison psychiatrists. Referrals for psychiatric consultation are

made by the medical-surgical house staff, supervised by the attending physicians. Psychiatric residents (PGY-2, and sometimes PGY-4) are involved in the

evaluation and management of at least half the patients referred for psychiatric consultation, and they are supervised by the attending psychiatrists. This

entails a review of history and mental status examination with the attending physician, bedside examination of the patient confirm the resident’s findings,

review of recommendations, daily rounds and independent follow-up of patients several times a week.

Diefenbacher

(2001)

The consultation-liaison service comprised of a 0.75 full-time equivalent psychiatric attending, operating within regular work hours. The psychiatrist also had

an 8-hour liaison with the multidisciplinary pain clinic of the hospital every week. In terms of requests for psychiatric consultations for inpatients, referrals

were made by the medical or nursing staff on the wards by telephone to the outpatient clinic of the psychiatric department, where the psychiatrist was based,

as the consultation-liaison service had no designated office.

Rosse et al.

(1986)

C-L service is made up of a senior staff psychiatrist, a fourth-year psychiatric chief resident (who is on service for 12 months) and four senior medical

students who rotate monthly.



Appendix 10.13: Literature review – Descriptive studies: Studies describing referrals from older patients only, non-age discriminatory/liaison psychiatrist

Author Folks and Ford (1985)

USA

Ruskin (1985)

USA

Mainprize and Rodin (1987)

Canada

O'Neill et al. (2003)

Ireland

Study Psychiatric consultations for the over-

60s reviewed from a consecutive series

of 1000 referrals

Description of referrals to a C-L

service from older patients over a

12-month study period

Description of referrals to a C-L

service from older patients

(prospective and retrospective

collection of data)

Data was gathered prospectively

over 18 weeks on 100 consecutive

referrals from patients aged 65

years or older

Sample 195 psychiatric consultations for the

over-60s

102 out of 617 psychiatric referrals

were for the over 60s

67 referrals described here

64% female

49% aged between 60 and 69

years

238 referrals in total; 70 for

older patients (comprising 28%

of all referrals for psychiatric

consultation)

59% female

215 referrals in total, 106 (49%)

for over-65s

Mean age 78 years (range 66-96)

66% female

Rate of referral No information 2.8% (for all referrals)

2.7% (for older patients only)

Prospective study period:

8 referrals per week (all

referrals)

2.75 referrals per week (older

patients only)

Retrospective study period:

9 referrals per week (all

referrals)

2.3 referrals per week (older

patients only)

The rate of referral for older

patients (3.9%) was higher than

the rate of referral for patients

aged under 65 (1.97%) (relative

risk 1.99; 95% CI 1.53-2.59),

whereas the hospital-wide rate of

referral was 2.6%

Sources of referral Medicine/Neurology 74.5%; Surgical

sub-specialties 14.9%; General surgery

4.1%; Surgical sub-specialties 14.9%;

Gynaecology 2.5%

Internal medicine 34%; Neurology

16%; General surgery 15%;

Orthopaedics 10%

Medicine 77%

Surgery 17%

Obstetrics and Gynaecology 4%

ICU (1%)

All referrals 2.6%

Old age referrals 3.9%



Reasons for referral No information Competency evaluation 19%;

Diagnosing/treating psychosis

12%; Diagnosing/treating

depression/agitation 10% each;

Hysterical cause of physical

symptoms 7%; Confusion 6%;

Assistance with differentiating

between organic and functional

cognitive deficits 9%; Help with

the use of psychotropic

medications 7%

Specific psychiatric symptoms:

Depression 37%; Behaviour

17%; Confusion 14%; Psychosis

or paranoia 4%; Functional

cause 3%; Alcoholism 3%

Advice or assessment:

competency 9%; Discharge

planning 3%; Certification 3%;

Suicidal evaluation 3%;

Psychotropic medication

assessment 3%; Diagnosis 3%;

Preoperative evaluation 1%

Assessment of depressive

symptoms 47%; Assessment of

psychotic symptoms 16%;

Confusion 16%; Assessment of

psychotic symptoms 16%;

Confusion 16%; Behavioural

disturbance 14%; Advice

regarding competency 7%

Primary psychiatric

diagnoses

Organic mental disorders 41.5%

(dementia 45%; delirium 28%);

Depressive spectrum disorders 35.9%

(unipolar depression 47%);

Somatoform disorders 6.2%;

Substance use disorders 3.1%;

Personality disorders 3.1%;

Schizophrenia 3.1%; Paranoid

disorders 1.5%; No psychiatric

diagnosis 5.6%

Depression 24%; Delirium 19%;

Dementia 18%; Chronic

schizophrenia 16%; Personality

disorder 12%

(DSM-III criteria)


Affective disorders 17%


Personality disorders 14%;

Substance use disorders 6%;

Somatoform disorders 4%;

Psychotic disorders 1%; No

psychiatric diagnosis 11%

(DSM-III criteria)

Cognitive impairment 62%

Depressive disorders 48%

Psychotic disorders 11%; Anxiety

disorders 7%; Disorders

associated with psychoactive

substance misuse 6%;

Adjustment disorders 6%; No


Recommendations

made by psychiatrist

No information Use of psychotropic medication

61%

Further medical treatment/referral

to another team 36%

Psychotherapy 28%

Competency assessment 25%;

Assistance in planning disposition

or follow-up 24%; ward

Psychotropic medication 43%

Follow-up plans 30%

Further medical work-up 29%

Ward management 13%;

Psychotherapy 13%; Transfer to

inpatient psychiatry 9%;

Neuropsychological testing 7%;

Certification 7%

Psychotherapy 74%

(antidepressant medication 44%;

antipsychotic therapy 25%,

anxiolytic or hypnotic medication

5%)

Rationalisation of medications

14%

Further medical evaluation 9%



management 13%; Transfer to the

inpatient geropsychiatry unit 12%;

Neuropsychological testing 4%

Disposition No information No information No information Transfer to long-term residential

care 9%

Transfer to the psychiatric unit for

further evaluation and treatment

8.5%

Follow-up by psychiatric services

32%

Follow-up by the treating team

and general practitioners 68%

Hospital Process

Data

No information No information No information Mean lagtime between referral

and consultation 1.3 working days

Mean number of visits to referred

patients 2.1 visits, range 1-8.

Total of 210 visits to the 100

patients included in the study



Appendix 10.14: Literature review – Descriptive studies: Results - non-age-discriminatory/liaison psychiatrist (Part 1 of 4)

Author Karasu (1977)

USA

Ries et al. (1980)

USA

Craig (1982)

USA

McKegney et al. (1983)

USA

Study Rate of utilisation of psychiatric

consultation by various services at

two general hospitals studied over 3

month study period (1st quarter of

1973)

Prospective data from psychiatric

consultations described

An epidemiologic study of

psychiatric consultations

performed by the psychiatric

liaison service over a

consecutive 12-month period

Description of C-L service

over an 18-month study

period (July 1980 to Dec

1981)

Sample 151 referrals to service

43% female

Mean age 43 years; age range 15-83

years

388 psychiatric consultations

66% female

Mean age 41 ± 17 SD years; range

12-87

362 consultations performed;

308 from non-private services

and studied here

See main text for data on

gender and age of referrals

756 referrals to service

51% female

Mean age 45 years; range

16-90 years

Rate of referral 2.7% No information No information on hospital-wide

rate of referral

3.40%

Sources of referral General medicine 40.4%; Surgery

15.9%;

Neurology and neurosurgery 9.3%;

Genitourinary 8%; Obstetrics and

gynaecology 5.3%; Plastic surgery

4.6%; Rehabilitation 4.6%;

Orthopaedics 3.3%; Ear, nose and

throat 2%

Internal medicine 30%; Neurology

12%; Obstetrics-gynaecology 11%;

General surgery 11%; Orthopaedic

surgery 11%; Rehabilitation

medicine 3%; Oncology 3%

Medicine 64.2%

Surgery 12.4%

Neurology 12.1%

Medicine 38%

Neurosurgery 16%

Orthopaedics 16%

General surgery 11%

Neurology 9%

Intensive care 4%

Obstetrics-gynaecology 3%

Rehabilitation 2%

Reasons for referral Depression 35.1%

Uncooperative, management

problem 28.5%

Bizarre behaviour or affect 22.5%

organic brain syndrome, as stated in

just over one-fifth of referrals

Psychiatric evaluation 43%; Illness-

related problems 30%; Medication

management 25%; Pain evaluation

23%; behaviour management 20%;

Disposition and outpatient referral

16%; Conflicts between the patient

See main text No information



(21.9% of referrals); psychological

maladjustment to illness (15.9%);

suicidal behaviour (13.9%);

alcoholism and drug abuse (9.9%

each); refusal of treatment (9.3%)

and acute anxiety (6.6%).

Consultations were also requested

for evaluation of symptoms; 19.2%

of referrals were for the evaluation of

previous psychiatric history and

15.9% for evaluation of

psychogenesis of somatic problems.

and either staff or the doctor

collectively account for 36% of

referrals

Primary psychiatric

diagnoses

Depression 21.2%; Organic brain

syndrome 20.5%; Schizophrenia

12.6%; Personality disorders 9.3%;

drug abuse 6.6%; alcohol

dependence 4.6%; anxiety 4%;

adjustment reaction 3.3%;

conversion reaction 2%; no


Depression 39%; Personality

disorder 17%; Adjustment reaction

16%; Organic brain syndrome 12%;

Psychoses 8%; Drug abuse 6%;

Alcoholism 4%; Conversion reaction

4%; Family-marital discord 6%;

Borderline syndrome (Gunderson)

5%

See main text Adjustment disorder 33%


Substance use disorder 12%

Affective disorder 10%

Somatoform disorders 6%

Schizophrenia, paranoia and

other psychotic disorders 4%

Psychological factors

affecting physical condition

3%


(DSM-III Axis I criteria)

Physical diagnoses Infectious disease 18%

Physical trauma 14%

Cardiovascular disorders 14%

Neurological disorders 24%

Psycho-physiological disorders 16%

Cancer 11%

No information Musculo-skeletal/connective

21%; CNS 16%; Neoplastic

13%; Circulatory disorders

12%; Endocrinologic,

metabolic or nutritional

disorders 10%; Injury,



trauma or poisoning (includes

self-inflicted) 10%;

Gastrointestinal disorders

7%; No Axis III diagnosis 1%

(DSM-III Axis III criteria)

Recommendations Mental status evaluations 77.6%;

Suggestions to staff about patient

management 57.9%; Supportive

consultation with staff 40.8%;

Follow-up visits with patients 37.5%;

Recommendations for disposition

arrangements 20.4%; Referral to

psychiatric outpatient clinic 17.9%;

Follow-up visits by social worker

15.1%; Interview with family

12.5%; Referral for neurological

consultation 8.6%; Other (e.g.

presentations of cases at ward

conferences, referral to drug abuse

counselling or alcoholism service)

12.5%

Psychiatric follow-up 64%;

Medications 54%; Staff interaction

changes 13%; Specific behavioural

modification 10%; Transfer to

psychiatry 10%; Social work follow-

up 10%; Doctor interaction changes

4%

See main text No information

Hospital Process Data Response times

two-thirds of referrals were seen

on the same day

Next day 21%

Two or more days 10%

No information

(Part 2 of 4) Author Hengeveld et al. (1984)

Netherlands

Trzepacz et al. (1985)

USA

Schofield et al. (1986)

Ireland

Gobar et al. (1987)

USA

Study Prospective study of psychiatric Data on patients referred for Survey of referrals to a liaison Retrospective review of C-L



consultations over a 4-year study

period

psychiatric consultation described

over a two-year study period (1980-

1982)

psychiatry service over a 12-

month study period

service over 3-year study

period

Sample 1814 referrals for psychiatric

consultation

54.7% female

16.2% of referrals aged ≥ 66 years

771 patients referred for psychiatric

consultation

55.6% female

Mean age 60 years

49% of referrals for patients aged 65

years or older

370 referrals

60% female

815 referrals

Referral rate 2.1% No information Hospital-wide rate of referral

1.60%

(Accident and Emergency –

11%; General Wards – 1%)

2%

Neurology and neurosurgery

department 3.5%)

Medicine 2.7%

Surgery 1.9%

ICU 2.9%

Sources of referral Medicine (including neurology)

80.3%

Surgery 13.7%


Internal medicine 53%

Neurology 23%

Surgery 15%

Accident and Emergency Unit

41%; Neurology 20%;

General medicine 9%; General

surgery 6%; Gastroenterology

5%; Nephrology 4%;

Endocrinology 4%; Geriatrics

2%; Orthopaedics and

rheumatology 2%;

Neurosurgery 2%

Medicine 42.9%

Surgery 25.2% Intensive care

unit 13.4%

Reasons for referral Suicide attempt 33.6%;

Psychological problems related to

physical disorder 24.5%; Probable

psychogenesis of unexplained

physical symptoms 17.8%; Problems

related to substance abuse or

Isolated psychiatric symptoms 57%

Affective symptoms/diagnosis 37%

Need for management 23%

Change in personality or mental

status 11%

“Nuisance” behaviour 7%

Parasuicide or suicidal risk

38%; Suspected psychiatric

illness 31%; Suspected

psychosomatic basis for

symptoms 11%; Past

psychiatric history 6%;

No information



dependence 9.3%; psychological

problems not related to physical

disorder 8.9%

Alcohol-related problems 5% Management problem 3%;

Acute reaction to stress 1%;

Self-referrals 1%

Primary psychiatric

diagnoses

Affective psychoses and neurotic

depressions 18.8%

Organic psychotic and non-psychotic

disorders 15.7%

Personality disorders 11.9%

Alcohol and drug dependence or

abuse 10.6%; Other neurotic

disorders 8.4%; Acute reactions to

stress or adjustment reactions 8.3%;

Physiological malfunction arising

from mental factors and special

symptoms 8.2%; Other psychoses

(5.8%); no psychiatric diagnosis

5.6%

(ICD-9 criteria)

Delirium (all) 58% (48% of these

cases were for older patients; mean

age 59 years)

Dementia (all) 34.2% (two-thirds of

these cases were for older patients;

mean age 69 years)

Personality - organic syndrome 4.5%

Delusional disorders 1.6%

Hallucinosis 3.1% Amnestic disorders

1.6%

(DSM-III)

In only three cases did the stated

reasons for the referral include the

correct diagnosis.

Neurotic disorders 44%;

Alcohol dependence syndrome

10%; Personality disorders

10%; Functional psychotic

disorders 7%; Organic

psychotic disorders 4%; Drug

dependence 0.4%; No


(ICD-9 criteria)

(40% of referrals had a past

psychiatric history)

Dysthymic disorder 20% of

referrals; organic mental

disorders 19.3%; adjustment

disorders 14.1%; substance

abuse and dependence 10%;

schizophrenia 9.5%;

personality disorders 5.8%;

major depression 4%; suicidal

attempts 3.1%; psychological

factors affecting physical

condition 2.3%; anxiety

disorders 1.9%;

schizophreniform disorders

1.4%

(DSM-III criteria)

Physical diagnoses No information No information No information No information

Recommendations/interv

entions

Discharge to psychiatric outpatient

clinic 31.8%; Management of

psychiatric medication 28.8%;

Diagnosis and/or advice only 19.2%;

Discharge to the psychiatric inpatient

unit 12.6%; Psychiatric treatment on

the ward 11%; Follow-up by social

work 7%; Advice on further somatic

examinations or tests 5.2%

Recommendations by the consultants

for various tests, procedures or

interventions were complied with by

the consultees in 91% of the cases,

and were partially followed in 3.8%.

Recommendations normally included

performing lab tests, EEGs, ECGs,

radiologic studies, adjusting

medications, or adding medications

such as neuroleptics or

benzodiazepines. Transfer to a

Initiation of drug treatment in

hospital 29% (antidepressants

14%); Outpatient

appointment for further

treatment or psychotherapy

24%; Admission to psychiatric

unit 13%; Discharge to family

doctor 9%; Day hospital for

group therapy 4%; Referral to

psychologist for management

and follow-up 3%; Crisis

No information



psychiatric inpatient unit was

necessary in only ten cases

intervention and

psychotherapy in hospital 3%;

Referral to social worker for

management and follow-up

2%

(Part 3 of 4) Author Freyne et al. (1992) Ireland Clarke et al. (1995) Australia Ormont et al. (1997) USA

Study Description of referrals to a liaison

psychiatry unit over a six-month period

Prospective study on 987 consecutive inpatient

referrals to a consultation-liaison service over a

2-year study period (1989-1991)

Description of referrals to a PGY-3 resident over

a 12-month study period (July 1991 - June

1992)

Sample 205 referrals over 6 months

55.6% female

987 consecutive referrals

53% female

Mean age 52.4 years (SD 17.8); range 15-91

145 referrals over 12 months (these 145

consultations performed by one resident

comprised approximately 20% of the total

number of consultations performed by the

entire consultation-liaison service over the same

12-month study period)

52% females

Mean age 49 years; range 17-95 years

Rate of referral 2% No information Mean of 12.1 consultations per month (range 5-

19 consultations per month)

Sources of referral Medical 76.7% of referrals

Surgical 16.1%

Geriatric 7.2%

General Medicine 45.4% of referrals; Renal Unit

26.5%; Neurology 9.6%; Oncology 6.1% ;

General surgery 6%

No information

Reasons for referral Management and behavioural problems

44.3% of referrals

Differential diagnosis 17.4%

Assessment of psychiatric symptoms

16.1%

Past psychiatric history 9.4%

Depression 34% of referrals

Suspected psychological component 22%

Coping problems 17%

Pre-operative evaluation 13%

Suicide risk evaluation 13%

Anxiety or fear 10%

Evaluation of competency 29% of referrals

Evaluation for suicidal attempts and ideation

19%

Psychiatric diagnosis and management (17%)

Behavioural problems 12%

Depression 9%



Deliberate self-harm (12.7%) Organic brain syndrome 8%

Medication review 8%

Mental status assessment 8%

Anxiety 3%

Discharge planning 2%

Dementia (1%)

Primary psychiatric

diagnoses

Reactive depression 20.1% of referrals

Alcohol/drug abuse 12.8%

Personality/behavioural 12.1%

Schizophrenia or psychosis 9.4%

Anxiety neurosis 9.4%

Dementia 8.1%

Psychosomatic disorders 5.4%

Organic psychosis 4%

Grief reaction 3.3%

Hysteria 2%

Mood disorders 43% of referrals



Psychoactive substance use disorders 14%

Somatic spectrum disorders 13%

V codes 12%


(DSM-III-R)

Alcohol and substance abuse/dependence 29%

of referrals

Dementia 16%



Organic affective and delusional syndromes 9%

Delirium 8%


Schizophrenia 4%


(DSM-III-R)

Physical diagnoses No information No information No information

Recommendations by

psychiatrist

Advice 44.3% of referrals; Referral to

other psychiatric services 20.1%;

Referral to outpatient dept 19.5%;

Referral to inpatient psychiatric care

7.4% Discharge 2%; Referrals for

biofeedback 1.3%; Referral to day centre

(0.7%)


Hospital Process Data No information No information Lagtime from admission to referral

Within 48 hours 25% of referrals

Between 2 and 5 days 32%

Over 5 days 28%

(Part 4 of 4) Author Ramchandani et al. (1997) USA Diefenbacher (2001) Germany Kishi et al. (2004) USA



Study Study of C-L services across five

hospitals; data on 10 referrals from each

hospital studied, giving a total of 50

patients

This single-site observational study aimed to

describe the first year of work after the

introduction of a liaison psychiatrist

Medical records of 541 consecutive psychiatric

consultations over a 12-month study period

evaluated (2001)

Sample 50 referrals 280 referrals


57.9% female

541 consecutive psychiatric consultations

52.7% female

Mean age 49.23 years (SD 16.32); median age

48 years

Rate of referral No information No information 3.10%

Sources of referral Medicine and the medical subspecialties

76%

Surgical services 24%

Attending physician 76%

Nurses, social workers and relatives 20%

Routine protocol 4%

No self-referrals

General Medicine 33.5%

Surgery 20.7%

Infectious diseases 15.7%

Cardiology/gastroenterology/oncology 13.5%

Dermatology 10.7%

Medicine 43.3% of referrals

Surgery 17.9%

Family practice 22.7%

Intensive care 10.7%

Reasons for referral Evaluation of behaviour problems, such

as refusal of treatment or other physician

recommendations (this accounts for

almost half of this category), agitation,

confusion, angry, exaggeration of

symptoms or manipulation 50%

Evaluation of suicidality 18%

Evaluation of depression 12%

Evaluation of psychosis 8%

Evaluation of pre-existing psychiatric

illness 8%

Other 4%

Current psychiatric symptoms 51.8%

Unexplained physical symptoms 16.1%

Suicide attempt 16.1%

Psychotropic/substance abuse 3.6%

Depression 35.4% of referrals

Chemical dependency 27.5%

Suicidal ideation/behaviour 11.5%

Confusion or delirium 8.1%

Evaluation 7.6%

Psychosis 6.1%

Anxiety 5.9%

Somatic complaints 3.9%

Behavioural problems 3.7%

Competence or refusal of treatment 2.4%

Agitation 1.8%

Primary psychiatric Cognitive disorders 24% No information Depression 54.8% of referrals



diagnoses Personality disorders 18%

Psychotic disorders 16%


Substance-related disorders 10%

Major mood disorders 10%


(DSM-IV criteria)

Alcohol-related disorders 25%

Delirium 19.1%

Drug-related disorder 13.7%

Anxiety disorder 13.5%

Psychosis 9.1%

Adjustment disorder 8.5%

Bipolar affective disorder 6.6%

Personality disorder 5% Dementia 4.7%

Somatoform disorder 3.1%

No psychiatric diagnosis 1.5%

(74.1% of referred patients with a past


(DSM-IV criteria)

Physical diagnoses No information No information No information

Recommendations by

psychiatrist

Psychotherapy 29%

Medication 21%

Triage 15%

Evaluation only 10%

Family intervention 6%

Conference with staff 5%

Administrative action 4%

Testing 2%

No information

Hospital Process Data Mean total time spent on consultation

2.66 hours (range: 30 minutes to 12

hours)

Mean length of stay of referred patients

10.9 days

Mean length of stay of patients not

referred for psychiatric consultation 5-7

days

ICU 22.8%

Within an hour/same day 70.3%

Routine 29.7%

Inpatients (general wards) 76.1%

Within an hour/same day 21.6%

Routine 78.4%

Mean length of stay for all patients admitted to

hospital during the study period was 5.7 days

Mean length of stay for patients referred for

psychiatric consultation was 17.91 days, (SD

34.09), and the median length of stay was 7

days (SD 14.00)



Mean number of follow-ups 2.62 visits

Compliance rate (fully or partially) with

recommendations 74% of referred

patients

Mean length of stay 35.2 days (SD 36.1)

Mean lagtime between admission and referral

14.5 days (SD 13.8)



Appendix 10.15: Literature review – Descriptive studies: Summary of findings for Wallen et al. (1987) All medical-surgical patients (n = 262,796) All medical-surgical patients with psychiatric

consultation (n = 2374)

Gender 59.2% female 62.6% female

Age > 60 years 27.7% > 60 years 24.3%

Number of procedures 1.3 1.6

Mean length of stay 7.3 days 16.3 days

% discharged to another facility 3.5% 9.1%

Mean number of other (non-

psychiatric) consultations

0.3 0.6

Physical diagnoses Circulatory system diseases 12.2%

Digestive system diseases 9.7%

Accidents, poisoning and violence 9.6%

Genitourinary system diseases 9.1%

Respiratory system diseases 7.7%

Neoplasms 7.2%

Symptoms and ill-defined conditions 5.2%

Musculoskeletal and connective tissue diseases 4.7%

Diseases of the nervous system and nerve organs 4.3%

Infective and parasitic 2.3%

Endocrine, nutritional and metabolic diseases 2%

Diseases of skin and subcutaneous tissue 1.4%

Diseases of blood and blood-forming organs 0.5%

Other 24.4%

Accidents, poisoning and violence 30.5%

Circulatory system diseases 13.1%

Symptoms and ill-defined conditions 11.4%

Digestive system diseases 9.5%

Musculoskeletal and connective tissue diseases 6.9%

Genitourinary system diseases 4.6%

Diseases of the nervous system and nerve organs 4.5%

Endocrine, nutritional and metabolic diseases 4.5%

Respiratory system diseases 4.5%

Neoplasms 3.9%

Infective and parasitic 1.5%

Diseases of skin and subcutaneous tissue 1%

Diseases of blood and blood-forming organs 0.5%

Other 3.8%

Psychiatric diagnosis Yes (any) – 4% Yes (any) – 51.5%

Psychiatric diagnosis Neurosis 1.7%

Organic brain syndrome 0.7%

Alcoholism, alcohol abuse 0.7%

Psychosis 0.3%

Drug addiction, drug abuse 0.1%

Neurosis 51.3%

Psychosis 12.8%


Alcoholism, alcohol abuse 8.8%

Drug addiction, drug abuse 3%



Other 0.6% Other 15.3%

Depression of any type Yes – 0.1% Yes – 23.6%



Appendix 10.16: Literature review – Descriptive studies: Summary of findings for non-age discriminatory/liaison nurse studies

Author Newton and Wilson (1990) (Canada) Kurlowicz (2001) (USA)

Study Description of referrals to liaison nurse over a 3-month study

period

Records of older patients consecutively examined by

psychiatric consultation liaison nurse (PCLN) over a 12-month

study period were retrospectively studied

Sample 75 referrals

Age – ranged from infancy to 90 years; mean age 50.23 years

43.4% female

103 referrals to nurse for older patients

Mean age 73.5 years (SD 8.6); age range 60-87 years

41% female

Sources of referrals General medical units 37.7%

Surgical wards 24.6%

Specialty units or clinics 24.6%

Surgical services 65%

General medicine 35%

Referrals from staff nurses 80%

Referrals from medical and surgical house-staff physicians

20%

Reasons for referral Non-specific requests for evaluation 29%

Requests for intervention with the patient’s family 24.6%

Requests for advice regarding nursing management 18%

No information

Psychiatric diagnoses Phase of life problem 44.9%

Family circumstances 20.3%

Organic mental disorder 10.1%

Affective disorder 7.3%


Uncomplicated bereavement 4.4%


Sexual dysfunction 1.4%


(DSM-III-R)

No information

Physical diagnoses Cancer 27.5%

Kidney disease 18.8%

No information



Cardiovascular disorders 14.5%

Trauma 11.6%

Recommendations made

by the nurse consultant

Have consultant follow-up 52.2%

Recommendations regarding staff interactions 31.9%

Bring in other consultants 26.1%

Arrange outpatient follow-up 10.1%

Review/revise medications 4.3%

Other specific recommendations 4.3%

No further contact beyond initial meeting with consultee nurse

7.2%

No information

Response times 65.2% of referrals seen within 24 hours

Response time of 4 days or more 17.4%

No information

Outcome of consultation Patient only seen by nurse 53.6%

Patients’ relatives also seen 17.4%

Patient’s relatives only seen 20.3%

Nursing staff only seen 11.6%

No information



Appendix 10.17: Literature review – Descriptive studies: Details of service; non-age-discriminatory/shared care

(part 1 of 2) Study Details about the service

Hoffman

(1984)

This 14-bed teaching service is located on an unlocked 24-bed ward. Staff employed in the unit are trained in both medical/surgical and psychiatric management.

Collaborative management of the patients in the unit is achieved by a psychiatric and medical/surgical attending, the psychiatric house staff and specialty

consultants. The unit has three psychiatric house staff; a PGY-1 and PGY-3 resident and a PGY-5 fellow in psychosomatic medicine and consultation psychiatry.

The psychiatric resident is the primary physician for all patients admitted to unit, supervised by the unit chief, fellow and medical and psychiatric attendings. An

occupational therapist is also employed by the unit, who specialises in the functional assessment and care of older patients and patients with neurologic or cognitive

impairments. The unit staff also perform some outreach activities, such as operating the hospital’s consultation-liaison service and the community liaison activities.

All staff attend ward rounds every day. In terms of nursing, staff on day or night shifts consist of two or three RNs and the remainder LVNs or hospital attendants.

In the terms of the unit’s educational activities, the unit educates training psychiatrists, teaching them the necessary skills and aptitudes to be able to treat patients

with co-morbid physical and psychiatric illnesses. Psychiatric residents spend seven months of their four-year training on the medical-psychiatric unit. The unit

also runs a neurology and neuropathology course, a workshop on problems in applied biological psychiatry, a psychosomatic medicine seminar, a diagnostic case

conference, neuropsychiatry rounds with an attending neurologist, a neuroradiology conference and consultation rounds.

Kathol et al.

(1989)

The unit is a self-contained 12-bed inpatients locked ward. Nursing and medical staff on the unit are trained to handle all levels of medical and psychiatric acuity.

The unit is staffed by a senior medical resident, a senior psychiatry resident or fellow, a psychiatry intern and a medical intern. The following bullet points briefly

describe the role played by members of the team employed in the medical-psychiatry unit:

The psychiatry and medical interns are responsible for the medical and psychiatric evaluations of patients admitted to their care; each intern is responsible for half

the patients admitted to the unit. The interns present new patients admitted to the unit to the psychiatrist during unit rounds, describing their medical and

psychiatric symptoms.

Senior psychiatry residents also evaluate the medical and psychiatric problems of patients admitted to the unit, assisting the interns and medical students and

supervising the administration of recommended treatments and interventions. The senior psychiatry resident also provides some formal and informal education on

psychiatric disorders to medical students and other residents working in the unit.

The senior medical resident has a similar role in the unit to the senior psychiatry resident, except that s/he educates medical students other and residents on

medical illnesses.

Nurses assist in all medical procedures.

Social worker is trained in commitment procedures, manages the placement of difficult patients, and administers cognitive psychotherapy and group and family

counselling.

Pharmacist assigned to the unit advises on drug interactions and pharmacologic options.

In addition to this, other ancillary medical services such as neuropsychologic testing, activities therapy, physical therapy and occupational therapy have ongoing



interactions with the medical-psychiatry unit.

The aims of the medical-psychiatry unit were to improve patient care, improve resident education and to facilitate research in patients with organic mental

disorders; all of which have been realised since the introduction of the unit.

In terms of the first aim of the unit, improving patient care, both patients’ medical and psychiatric problems can be treated simultaneously in the unit, where staff

are trained and experienced in administering treatment for both medical and psychiatric symptoms.

In terms of the second aim of the unit, improve resident education, this can be separated into three areas: the patient evaluation, units rounds and the medical-

psychiatry lecture mini-series.

(part 2 of 2) Author Hoffman (1984)

(USA)

Kathol et al. (1989)

(USA)

Study Description of patients referred to medical-psychiatry unit over a 15-month

study period

Description of patients referred to medical-psychiatry unit over

a 6-month study period

Sample 215 admissions to medical-psychiatry unit

60% of admissions aged 60 years or older

140 admissions to the unit

Psychiatric diagnoses Depression 25.6%

Delirium 18.1%

Dementia 16.3%

Neurologic illness with behavioural symptoms 5.6%

Schizophrenia 5.1%

Psychosomatic disorders 4.2%

Acute medical illness with behavioural management 3.7%

Alcohol or substance abuse 3.3%

Other organic mental disorder 1.8%

Other 16.3%

Primary and organic affective disorder 17%

Depression 10%

Mania 7%

Delirium/organic psychosis 16%


Acute drug or alcohol withdrawal 13%

Rule out psychiatric condition 12%

Rule out depression 10%

Schizophrenia 8%

Somatisation disorder 5%

Other 15%

Physical diagnoses No information Neurologic 15%

Gastrointestinal 13%

Renal 13%

Endocrine/metabolic 12%

Clinical pharmacology 11%



Cardiac 11%

Pulmonary 7%


Other 12%

Length of stay of patients

admitted to the unit

Median 4 days

Range 1 – 127 days

Mean 11 days

Discharge Discharge within 7 days 37% - of patients

Discharge within 14 days – 47%

Discharge within 21 days – 76%

Discharge within one month – 87%

No information



Appendix 10.18: Literature review – Descriptive studies: Details of service; non-age-discriminatory/liaison clinic

(part 1 of 2) Study Details of service

Rowan et al.

(1984)

The liaison clinic assesses and treats all patients with psychologic problems related to their physical complaints. The clinic’s population includes patients with

somatoform disorders, as well as disorders characterised by difficulty coping with illness and/or treatment.

The clinic is staffed by the Associate Director of the Liaison Division and the liaison fellow. In addition, during their consultation-liaison rotation, residents and

medical students saw outpatients under the supervision of an attending liaison psychiatrist.

Whilst the availability of space and other liaison activities usually necessitate afternoon appointments, the liaison clinic has no formal hours of operation.

The liaison clinic psychiatrist, through his daily work in the medical setting, publicised the new outpatient service. Such interpersonal contact with medical

colleagues and social workers is the primary means of referral, and the clinic was also publicised in liaison, inpatient and general outpatient psychiatry staff

meetings.

Also, during the first year of the clinic’s operation, the liaison fellow attended the weekly intake conference of the general psychiatry clinic to discuss potential

referrals.

The liaison clinic contact ranged from an initial evaluation to ongoing individual or group psychotherapy; evaluations generally lasted for a single 45-60 minute

visit.

In terms of treatments offered by the clinic, scheduled individual psychotherapy sessions ranged from twice a week to biweekly and were of 45 minutes duration.

A group psychotherapy for the medically ill met weekly for 90 minutes. Medication visits, which included supportive counselling, were monthly to quarterly and of

20-30 minutes duration. Formal behavioural treatment such as hypnosis was not available.

If the psychiatrist is the primary therapist; the psychiatrist in the liaison clinic would frequently see the patient initially in the referring clinic, where the proposed

psychiatric management was discussed with the doctor, nurse, and/or social worker. If his physical presence in the medical setting was not immediately possible,

the Liaison Clinic psychiatrist began the patient’s evaluation by a telephone contact with the referring health care professional. During treatment, the frequency of

contact with the consultee(s) depended mostly on the reason for referral and the patient’s psychiatric disorder. Contact ranged from weekly to quarterly.

For example, the liaison clinic psychiatrist met weekly with the Haemophilia Clinic physicians and staff to develop a treatment strategy for a non-compliant

haemophiliac with a severe personality disorder. Thus, his treatment of the patient with individual psychotherapy had an impact on health care delivery as well as

the patient’s psychopathology.

On the other hand, only occasional discussion with the referring neurologist took place for a patient with multiple sclerosis with secondary organicity and anxiety.

Here, the issue was the choice of the appropriate psychotropic medication, which required much less liaison effort.

If the primary therapist was the referring clinic’s social worker or psychiatric nurse-clinician, the psychiatrist’s contact with the social worker or nurse-clinician was

an integral part of the patient’s Liaison Clinic visit; usually, the contact was in person as the primary therapist accompanied the patient in the clinic visit. For this

patient group, contact with the referring clinic’s physician was less frequent and usually confined to the need for medication change or additional consultations.



The primary therapist was encouraged to provide not only counselling and social services, but also liaison to the referring clinic. Thus, the psychiatrist facilitated

the coordination of the medical and psychologic care and encouraged a team approach.

Wilkinson et

al. (2001)

The consultation-liaison psychiatry clinic is staffed by a consultant liaison psychiatrist and trainee psychiatrists. The service is non-age discriminatory, and sees

patients from the age of 17 upwards, and referrals are received from both hospital specialists and GPs. It was stated in the article that a range of interventions

are offered, but they were not discussed by the authors.

Bass et al.

(2002)

The outpatient clinic comprises of one component of the consultation-liaison service to the general hospital and primary care doctors. The clinics were held twice

weekly in the afternoons, and were supervised by the consultant, who interviewed all patients and assigned all ICD-10 diagnoses. Initial assessments usually

lasted between 1 and 2 hours.

(part 2 of 2) Author Rowan et al. (1984) USA Wilkinson et al. (2001) UK Bass et al. (2002) UK

Study This study describes the first year of

operation for the Mount Sinai Medical Center

liaison clinic

Study is concerned with patients aged 65 and over

referred to a (non-age discriminatory) adult

consultation-liaison psychiatry outpatient clinic in a

general hospital. All referrals to clinic discussed in study

by Bass et al. (2002)

Consecutive referrals to an outpatient

liaison psychiatry clinic over a study

period of 7 years are described

Sample 96 patients were seen in 390 visits

71% female

Age range was 17-86 years

45 (5%) of 900 referrals were for older patients

Mean age 71 years (SD 5), range of 65-88 years

900 referrals

Mean age 41 years (SD 14)

63% female

Rate of referral No information No information No information

Sources of referral Medical and surgical clinics 72%

Medical group practices 9%

Psychiatry 17%

Community Agencies 2%

Hospital specialists 60%

General Practitioners 40%

General hospital physicians 39%

Primary care doctors 34%

General hospital surgeons 9%

Pain clinic 8%

Other psychiatric services 6%

Reasons for referral Anxiety 24%

Behaviour management 2.1%

Coping 2.1%

Depression 25%

Diagnosis 14.6%

Non-compliance 1%

Somatic symptoms or pain (71%), followed by confusion

and disordered mood

Somatic symptoms or pain 86%

Mood disorders 5%

Poor coping 2%

Alcohol-related problems 2%




Pain 3.1%

Pre-operative evaluation 2.1%

Psychiatric history of psychosis 2.1%

Psychotropic medication assessment 6.3%

Sexual problem 4.2%

Sleeping disorder 2.1%

Social performance impaired 1%

Suicidal risk evaluation 3.1%

Other 2.1%

Primary psychiatric

diagnoses

Major depressive illness 17.7%

Dysthymic disorder 11.5%


Post-traumatic stress disorder 1%

Generalised anxiety disorder 8.3%

Panic disorder 1%

Conversion reaction 1%


Heroin abuse 1%


Schizophrenia 3.1%

Schizophreniform disorder 1%

Atypical psychosis 2.1%

No axis I diagnosis 12.5%

(49% of referrals with a past psychiatric history)

(ICD-10 criteria)

Somatoform disorders 66.7%

Depressive disorders 13.3%

Conversion disorder 2.2%

Neurasthenia 2.2%

Agoraphobia 2.2%


Benzodiazepine withdrawal 2.2%

Delusional disorder 2.2%



Depressive disorders 6.5%

Panic disorder 6%

Mixed anxiety and depression 4.6%

Adjustment disorders 3.4%

Conversion disorders 2.6%

Somatoform disorders 55%

Neurasthenia 10.2%

Eating disorders 1.8%

Factitious diseases 0.4%

Other 3.9%

(ICD-10 criteria)

Physical diagnoses Diseases of the circulatory system 20.8%

Endocrine disorders 11.5%

Diseases of the nervous system 11.5%

No physical diagnosis 16.7%

53% of referred cohort with a concurrent physical illness

at the time of the assessment

Cardiovascular disease 20%

Gastrointestinal 9%

Neurological 4%

Respiratory 2%

No information



Others 18%

Recommended

interventions

Psychiatric treatment 91.7% (all referrals who

received an Axis I/II diagnosis)

Treatment in the liaison clinic (includes

individual or group psychotherapy or

counselling)

70.8%

Medication 50%

Follow-up in conjunction with referring clinic

66.7%


Outcomes/Follow-Up (For 68 patients who were treated in liaison

clinic)

Psychiatrist only 4.2%

Psychiatrist and medical/surgical clinic

physician 33.3%

Psychiatrist with psychiatric nurse-clinician

11.5%

Psychiatrist with social worker 21.9%




Appendix 10.19: Literature review – Descriptive studies: Details of service; non-age-discriminatory/sector model Study Details of service

Stoppe and Staedt

(2004)

The department of psychiatry provides a consultation service, staffed by psychiatric residents and supervising specialists in the department.

Shevitz et al. (1976) The Psychiatric Consultation Service is staffed by three full-time psychiatric residents, changing about every three months, who are supervised by two senior

staff psychiatrists, who see every referred patient and make final decisions regarding diagnosis and subsequent recommendations. Referrals are formally

requested, and are received from the medical and surgical resident staff.

Perez and Silverman

(1983)

Consultations to non-psychiatric inpatients were performed by psychiatric residents, supervised by a staff psychiatrist.

Sobel et al. (1988) Sector Model; psychiatric residents and consultants.

Loewenstein and

Sharfstein (1983)

Consultation-liaison service, consisted of psychiatrists who perform consultations on both the wards and in the outpatient departments; consultations were

requested by medical staff, and were performed on a short term or emergency evaluation basis. However, the authors state that this study was

performed “prior to the establishment of the consultation-liaison program”, which means that this is a sector model service.

Popkin et al. (1984) The consultation service provides psychiatric interventions, support and diagnostic skills to the medical, neurologic and surgical inpatient services of the

hospital. The referred patient is normally seen within 24 hours. After the initial interview, a handwritten or typed evaluation is placed in the progress notes of

the medical chart. The consultations were written by the service’s attending staff, fellows, third- or fourth-year residents, or other personnel in an emergency.

All cases were evaluated by one of the service’s two attending physicians.

Perez et al. (1985) Sector model; consultations to non-psychiatric inpatients were performed by psychiatric residents, supervised by a staff psychiatrist.

Small and Fawzy

(1988)

Sector Model. The service provides diagnostic and treatment recommendations for primary physicians and response times are within 24 hours, at a general

hospital with 600 acute medical and surgical beds.

Grant et al. (2001) Despite the fact that this service was officially called a consultation-liaison service, it was decided that the service had no active liaison component and thus was

effectively a consultation-only, sector model service. Furthermore, the authors do state in the article that this is “primarily a consultation, not a liaison,

service”. The team in 1990 consisted of a single attending trained in C-L psychiatry, a second-year resident assigned to the service for the two-month period

and a staff psychologist, whereas the service in 2000 consisted of the same attending, a second-year resident, but no staff psychologist. Response time was

within 8 hours, and in terms of interventions offered by the service, in both 1990 and 2000, all patients seen for consultation were followed by the C-L service

daily until discharge. The activities of the C-L service were largely unchanged between 1990 and 2000, providing psychiatric interventions and diagnostic skills

to the medical, neurological and surgical inpatient services of the hospital.



Appendix 10.20: Literature review – Descriptive studies: Studies describing referrals from older patients only, non-age discriminatory/sector model Author Krakowski (1979) (USA) Stoppe et al. (2004) (Germany)

Study Two-year study of old age referrals to a general psychiatric

service

A structured retrospective chart review of all psychiatric consultations requested for older

patients over a period of 2.5 years

Sample Total of 371 referrals to service

113 (30.4%) referrals were for the over-65s

Mean age 76.6 years, range 65-94

278 psychiatric consultations (30.3% of total referrals) for older people

Old age referrals aged 60+

Two thirds of the older patients (66.2%) belonged to the younger age group of up to 74

years of age, 9% were aged 85 years or older

Rate of referral All referrals 2.1%; Old age referrals 1.8% All adult inpatients referred for psychiatric consultation 0.72%; Older patients referred for

psychiatric consultation 0.66%

Sources of

referral

Internal medicine 39% of referrals; Family practice 29%;

Surgery 27.5%; Neurology 1.8%; Psychiatry 1.8%; Obstetrics-

gynaecology 0.9%

Internal medicine 47% of referrals

Surgery 18%

Neurology 13%

Reasons for

referral

No information Delirium 20.7% of referrals; Depression 14.7%; Assessment of suicidality 11.7%;

Assessment of competence 3.3%; Request for psychiatric hospitalization 2.7%

Psychiatric

diagnoses

Organic brain syndromes 66.4% of referrals

Depression 24.8%

Neuroses and personality disorders 6.2%

Schizophrenia 0.9%

No mental disorders 1.7%

Organic brain disorders 18%; Affective disorders 17.6%; Disorders in context with

alcohol and/or psychotropic drugs 12.6%; Adjustment disorders 6.5%; Schizophrenia

and/or delusional disorders 4.3%

No psychiatric disorder 13.3%; (Retrospective study – the psychiatric history was not

known in a large proportion of referrals (38.1%))

Physical

diagnoses

No information Cardiovascular disorders 66.6% of referrals; Endocrine dysfunctions 30.9%; Surgical

interventions 27.7%

Gastrointestinal and liver disease 22.7%; Renal dysfunctions 15.1%; Malignancies 15.1%

; CNS disorders 14.4%; No physical disorder 2.2% (Retrospective study - medical history

was not known for 7.2% of referrals)

Recommended

Interventions

No information Antipsychotics 36.7% of referrals; Antidepressants 25.9%; Psychosocial therapy after

discharge 24.1%; Follow-up consultations 15.8%; Inpatient treatment in psychiatry

10.8%; Continuous surveillance 2.2%



Disposition No information Returned home 46.4%; Returned home, professional help was organized 5.4%; Returned

to nursing home 4%; Moved to nursing home, or nursing home was recommended 7.2%;

Was transferred to another hospital / rehabilitation clinic 18.7%; Psychiatric treatment

was recommended/initiated 18.7%; Died 6.5%; Not known 6.5%

Outcomes No information Condition improved 46%; No change in condition 15%; Condition worsened 2%

Hospital process

data

No information 85.6% of referred cohort received one visit from the psychiatrist

10.4% of referred cohort received two visits; may suggest a lack of follow-up of referred

patients

Lagtime between admission and referral

Consultation carried out on day of admission 21.6%

Within 3 days 23.5%

Four days or more 47.5%



Appendix 10.21: Literature review – Descriptive studies: Results - non-age-discriminatory/sector model Author Shevitz et al. (1976)

(USA)

Loewenstein and Sharfstein

(1983)(USA)

Perez and Silverman (1983)

(Canada)

Sobel et al. (1988)

(Israel)

Study Review of 1,000 psychiatric

consultations performed over a 3-

year study period

100 requests for psychiatric

consultation from a 3-year study

period were randomly selected from

all requests are and retrospectively

described here

The authors reviewed 255

psychiatric consultations over a

one-year period

Retrospective review of psychiatric

consultations at two hospitals over

12 months

Sample 1,000 referrals for psychiatric

consultation

63.7% female

25.5% of referrals aged ≥ 60 years

Patients aged 70 years or older

comprised 17% of the total hospital

population, on the other hand only

9.7% of this age group were

referred for psychiatric consultation;

patients in the 30-59 years age

group comprise 42% of the hospital

population, they account for 52% of

the referrals for psychiatric

consultation

100 psychiatric consultations 250 referrals to general psychiatric

service

61% females

32% of referrals aged ≥ 60 years

610 consultations performed over 12

months; 479 referrals included in

study as 56 patients excluded

because of incomplete consultation

forms

479 patients referred for psychiatric

consultation

M:F ratio 1.5:1

Mean age 44.0 years (SD 18)

Rate of referral 3.39% 150 referrals/year 2% No information

Sources of referral Medical 59% of referrals

Surgical 19.4%

Neurology 14%

National Cancer Institute 30.1%

National Institute of Arthritis,

Metabolism and Digestive Diseases

16.5%

NI of Neurological and

Communicative Disorders and Stroke

14.6%

Medical 65%

Surgical 17%

Neurological 8%

Emergency ward 47.6%

Internal medicine 32.6%

Surgical sub-specialty 6.5%


General surgery 5.2%

Neurology and neurosurgery 1.7%

Medical subspecialties 1%



National, Heart, Lung and Blood

Institute 11.7%

National Institute of Allergy and

Infectious Diseases 9.7%

National Institute of Child Health and

Human Development 4.9%

National Institute of Dental Research

1%

Reasons for referral Diagnosis 57.4% of referrals

Management 55.6%

Disposition 27.7%

Psychosocial intervention 75.8%

Assistance with diagnosis 59.2%

Post hospital psychiatric referral

38.8%

Psychopharmacologic medication

(initiation or change) 31%

Advice on management 27.2%

Non-psychopharmacologic

medication (initiation or change)

11.7%

Diagnostic tests 15.6%

Parasuicidal behaviour 23.6% of

referrals

Depression 19.2%

Psychological factors affecting

physical illness 15.2%

Other psychiatric disorders besides

depression or psychosis 11.2%

Psychotic state 8.8%

Assessment to rule out a

psychiatric problem 7.6%

Previous history of psychiatric

illness 6.8%

Alcoholism 5.6%

Marital and family problems 2%


Intense emotional reaction (e.g.

anger, fear, anxiety, depression)

22.3%

Severely disturbed behaviour (e.g.

delirium, psychosis) 20%

Past psychiatric hospitalisation or

treatment 8.5%

Suicide threat 4.9%

Uncooperative behaviour 3.9%)

Psychiatric side-effects owing to

medication 2.5%

Patient-staff conflict 1.4%

Primary psychiatric

diagnoses

Depression 50.2% of referrals

Organic brain syndromes 15.5%

Anxiety neurosis 6.8%

Hysterical neurosis (conversion

type) 5.2%

Schizophrenia and paranoid

psychoses 3.1%

Alcoholism 3%

Affective disorder 27.2%

Personality disorder 16.5%




Substance use disorder 4.9%



Neurotic depression 27.2%

Organic brain syndromes 18.8%

Transient situational disturbances

15.6%

Psychotic depressive reaction or

manic depressive illness 9.2%


Alcohol and drug dependency 7.2%


Depression 14.9%

Organic mental syndrome 10.3%


Schizophrenia 7.9%

Anxiety 6.6%

Psychotic states 5.6%

Neurotic states 4.4%



Psychophysiologic reactions 1.9%


Schizophrenia 3.2%

Psychophysiological disorders 2.8%

Other neurotic disorders 2.8%

Marital maladjustment 0.8%

Sexual deviation 0.4%


(DSM-II)

(52% of referrals had a past


Adjustment reaction 3.9%

Drug addiction or alcoholism 1.5%

Family problems 1.2%

Paranoid state 1%

Bipolar affective disorder 1%

Confusional state 0.8%


Physical diagnoses Neurological disease 19.5% of

referrals

Cardiovascular disease 16.6%

Gastrointestinal disease 15.5%

No information Overdose 22%

Neurological disorders 16.1%

Gastrointestinal disorders 11.2%

Cardiovascular disorders 8.5%

Endocrine and metabolic disorders

8.5%

Musculoskeletal disorders (6.7%)

Respiratory diseases 3.3%

Dermatological disorders 3.3%

Renal disorders 3.3%

Cancer 0.9%

Gynaecological disorder 3.6%

No physical disorder 0.9%

No information

Recommendations Psychotherapy 38% of referrals

Psychotropic drugs only 36%

Medication between patients and

staff 12%

Family interviews 7%

Psychosocial intervention 75.8%

Medication (initiation or change)

42.7%

Diagnostic tests 15.6%

Referral for ambulatory psychiatric

treatment 42.8% (only 54% of the

patients referred for ambulatory

care complied)

No further psychiatric intervention

38.4%

Transfer to psychiatric inpatient

unit 14.4%

Treatment in psychiatric clinic 48.1%

Second visit by consultant 23.3%

Discharge from hospital 5.3%

Other 23.3%



Referral to family physician 2.8%

Referral to community social

agency 1.6%

Hospital process data No information No information Lagtime between admission and

referral

Four days or fewer 47% of

referrals

Between five and eight days

27%

Nine days or more 26%

No information

Concurrence rate

between psychiatrist

and referring

physician

No information Assistance with diagnosis (as

assessed by the consultant, 48.5% of

patients were referred for this

reason)

Advice on management (41.7% of

referrals, as assessed by the

consultant)


Psychophysiological disorders 57%

Organic brain syndrome 35%

Schizophrenia 12%

(low rates)

No information



Appendix 10.22: Literature review – Descriptive studies: Summary of findings; liaison services in A&E

Author Ryrie et al. (1997) (UK) Callaghan et al. (2001) (UK) Callaghan P (2006) (UK)

Study Article describes a study into a liaison

psychiatric nursing service at an

accident and emergency department in

central London, study period 3 months

The work of a liaison mental health service at the

A&E department is studied; an audit of clinical and

non-clinical referrals to the service from its inception

over a 14-month period was conducted

Reports on all patients referred to the liaison

mental health service for psychiatric

consultation over a 12-month study period

Sample 249 face-to-face patients assessments

were undertaken, equating to

approximately 2.6 assessments per

day

820 referrals

Median and mode ages (in years) are 33 and 36,

respectively

49.3% female

48.3% were new referrals

423 referrals made during study period

43% female

Median age 33 years

Sources of

referrals

No information General A&E department 66% Other wards in the

patients’ home or neighbouring NHS trusts 27%

Community services, such as drug teams, teams

working with mentally ill homeless people, GPs and

the police 3.3%

No information

Reasons for

referral

Deliberate self-harm 38.6%

Depression 16.9%

Exhibiting psychotic-type behaviour

14.1%

Disturbed/aggressive behaviour 6.8%

Somatic/complaints 5.6%

Poor coping/adjustment 4.4%

Medication requirement 4%

Other 2.4%

Follow-up by EPN 7.2%


Psychiatric

diagnoses

Depression 20.5%

Alcohol dependence 20.1%

Psychosis 20.1%

Depression 12.2%

Dual diagnosis 7.7%

Alcohol dependency 7.3%

Depression 31%

Drug-related 13%

Schizophrenia 10%




Neurosis/anxiety/panic attacks 8%

Drug dependence 4.4%

Poor coping/adjustment 3.6%

Learning difficulties 0.4%

No diagnosis made 13.3%

Drug dependency 6.3%

Schizophrenia 6.2%


Overdose 4.9%

Anxiety 4.2%

Deliberate self-harm 4.1%


Not mentally ill 7%


(ICD-10 criteria)

Urgency of

referrals

No information “Urgent” (should be seen within 1 hour) 67%

“Non-urgent” (should be seen within 24 hours) 23%

“Emergency” (patient should be seen immediately)

10%

Emergency (seen immediately) – 30% of

referrals

Urgent (within the hour) – 53% of referrals

Non-urgent (within 24 hours) – 17% of referrals

Mean lagtime

between referral

and consultation

No information 33% of referred patients were seen immediately

upon arrival to the service, with an average waiting

time of 10 minutes

Emergency referrals – 17 minutes

Urgent referrals – 35 minutes

Non-urgent referrals – 75 minutes

Outcomes Brief counselling intervention by liaison

nurse 19.6%

Referral to alcohol/drug misuse service

12.7%

Referral to community mental health

team 12.7%

Referral to GP 9.3%

Temporary hostel accommodation

sought 6.3%

Referral to Social Services 6.3%

Transfer to other catchment area

Mental Health Unit 5.7%

Referral to specialist counselling

agency 5.7%

Referral for outpatient psychiatric

appointment 5.3%

Admission to mental health unit 5.7%

Referred to duty psychiatrist 24.9%

Discharged home 12.4%

Crisis intervention service 8.5%

General practitioner 6%

Admitted 4.2%

Outpatient appointment 4.1%

Community psychiatric nurse 3.5%

Community drug team 3.3%

Others (social worker, homeless help team) 33.1%

No information



Admission to medical ward 3.7%

Follow-up appointment arranged with

liaison nurse 3%

No specific outcome intervention 1%

Left dept before being seen 3%

Other data Staff involved in consultation:

Liaison nurse with A&E doctor 44.2%

Liaison nurse only 18.5%

Liaison nurse/A&E doctor/duty

psychiatrist 10.8%

Liaison nurse and duty psychiatrist

11.2%

Liaison nurse and senior A&E nurse 2%

Follow-up/inaccurate records 13.3%

No information Strengths of the service:

Short waiting time; Understanding, listening

staff; Time to talk; Privacy (in A&E);

Involvement in decisions; Clear outcomes

Weakness of the service:

Environment (no privacy (at the bedside); being

seen in a busy A&E); Lack of access to doctors;

Too brief; Outcome not helpful; Outcome didn’t

happen

(from survey)



Appendix 10.23: Literature review – Descriptive studies: Summary of findings for Alison Howe study, comparing referrals made in 2001 and 2002

2001 2002

Patients referred to service Number of referrals 163

52% female

13% of referrals aged 65 years or older

Number of referrals 119

59% female

5% of referrals aged 65 years or older

Sources of referral Wards 62%

A&E 26%

OP 12%

Wards 63%

OP 28%

A&E 9%

Referring specialties A&E 49%

Gastroenterology 11%

Surgical 8%


Other medical 31%

Gastroenterology 38%

Surgical 13%

A&E 11%


Other medical 36%

Urgency of referrals Not recorded in 2001 Within 24 hours 29%

Within two days 31%

Within 1 week 22%

Reasons for referral Depressed 31%

Psychotic 18%

Confused 13%

Anxiety 9%

Alcohol abuse 5%

Anorexia 4%

Somatising 3%

Drug abuse 1%

Other 16%

Depressed 33%

Confused 12%

Alcohol abuse 12%

Anxiety 11%

Somatising 11%

Drug abuse 7%

Psychotic 6%

Anorexia 4%

Other 4%

Psychiatric diagnoses Depression 28%

Alcohol abuse 19%

Psychosis 12%

Anxiety/panic 12%

Depression 32%

Alcohol abuse 23%

Drug abuse 7%

Other organic 6%



Acute confusion 7%

Other organic 7%

Drug abuse 4%

Mania 4%

PD 4%

Adjustment reaction 3%

Other neurotic disorder 3%

BPAD in remission 1%

Eating disorder 1%


Psychosis 6%

Anxiety/panic 6%

Eating disorder 6%

Acute confusion 5%

Other neurotic disorder 5%

PD 5%

Mania 1%

BPAD in remission 1%

Adjustment reaction 0%


Physical diagnoses Gastro-intestinal 21%

Neurological 16%

Tumour 12%

Obstetric 9%

Infection 7%

Respiratory 5%

Cardiac 4%

Endocrine 4%

Trauma 2%

Renal 2%

Dementia 2%

Other 5%

No physical diagnosis 11%

Gastro-intestinal 31%

Neurological 13%

Tumour 8%

Cardiac 6%

Endocrine 6%

Infection 5%

Obstetric 4%

Trauma 4%

Respiratory 2%

Renal 2%

Dementia 0%

Other 15%

No physical diagnosis 4%

Follow-up arrangements GP/referrer care 34%

Liaison psychiatrist 30%

CMHT 26%

Psychiatric admission 4%

Drug/alcohol services 2%

Crisis team 2%

Death 2%

GP/referrer care 35%

Liaison psychiatrist 32%

CMHT 19%

Drug/alcohol services 12%

Death 2%



Appendix 10.24: Literature review – Descriptive studies: Summary of results for Paul Whelan study, comparing referrals made in 2003 and 2004 Phase 1 (2003) Phase 2 (2004)

Patients referred to service 48 referrals

65% female


48 referrals

62.5% female


Urgency of referrals Within 24 hours (urgent) 29.2%

Within 1-2 days 0%

Within 5 days 54.2%

Within 24 hours (urgent) 8.3%

Within 1-2 days 77.1%

Within 5 days 14.6%

Patient seen by Consultant 22.2%

SpR 55.5%

Associate specialist/staff grade 14.8%

Community Psychiatric Nurse (after discharge)

7.4%

Consultant 37%

SpR 2.2%

Associate specialist/staff grade 6.1%

Community Psychiatric Nurse (after discharge) 0%

Psychiatric diagnoses Dementia 44.4%

Delirium 25.9%

Depression 11.1%

Psychosis 3.7%

Anxiety 3.7%

Substance misuse 0%


Dementia 37%

Delirium 26.1%

Depression 23.9%

Substance misuse 4.3%

Psychosis 0%

Anxiety 0%


Physical diagnoses at discharge Cardiovascular 44.4%

Infection 44.4%

Cognitive problems (including dementia) 44.4%

Fall(s) 27.8%

Cancer 11.1%

Anaemia 5.6%

COPD 0%

Infection 35.4%

Cognitive problems (including dementia) 31.3%

Cardiovascular 29.2%

Fall(s) 20.8%

COPD 10.4%

Cancer 2.1%

Anaemia 0%

Length of stay Mean 43.8 days (SD 27.6) Mean 48.2 days (SD 40.9)



Lagtime (delay in seeing patient from time of

referral)

Mean 7.8 days (SD 14.5) Mean 2.0 days (SD 2.6)

Time from admission to referral Mean 21.5 days (SD 21.4) Mean 14.4 days (SD 21.9)

Time after referral to discharge/death Mean 23.0 days (SD 23.5) Mean 35.4 days (SD 32.6)

Referral to CMHT 21.7% 33.3%

Died 15.4% 27.1%



Appendix 10.25: Literature review – Descriptive studies: Summary of findings for Gary Denton study

Patients referred to service 87 referrals

57% female

2.3% aged under 65 years

3.4% aged 65-69 years



13.8% aged 90 years or older

Psychiatric diagnoses Dementia 65.8%

Delirium 8.8%

Depression 7.7%

Anxiety 1.3%

Bipolar affective disorder 1.3%

Schizophrenia 0%

Other 8.8%


Lagtime from receipt of referral to psychiatric consultation 3.41 days (63.6% of referrals seen within 3 days)



Appendix 10.26: Literature review – Descriptive studies: Summary of findings for Catherine Mack study

Patients referred to the service 164 referrals (in 27 working weeks)

73 referred patients already known to the psychiatric service

Each referral required an average of 5-6 visits until discharge

820 follow-up visits in total

Reasons for referral Cognitive impairment – 70 patients

Depression – 54 patients

Discharge planning – 60 patients

Delirium – 46 patients

Average weekly rate of referral 5 referrals per week

Hours of operation 9am-5pm, weekdays

Response times Same day to 48 hours

Target population Central Manchester hospital acute medical areas

Interventions provided Mental health nursing assessments

Use of appropriate assessment tools, such as the MSE, MMSE and GDS

Advice regarding nursing care interventions and recommendations for inclusion into care planning

Advice regarding psychotropic and anti-depressant medication (in consultation with psychiatrists)

Advice on appropriateness, availability and accessing mental health services for older people after liaising

with the consultant psychiatrist

Attendance at case reviews

Recommended referrals to other disciplines to assist with specialist opinion and interventions as required

Recommended usage of community based services to assist a smooth transition and return to community

living



Appendix 10.27: Literature review – Summary of results for grey literature

Accreditation Council for Graduate Medical Education

www.acgme.org

This website provides some general guidelines on residency education in psychosomatic medicine in a report entitled “Program Requirements for Residency Education in Psychosomatic Medicine”. Although there is no specific mention of liaison psychiatry, this report does outline the curriculum, the role of the faculty, the program director and the supervision of residents, all of which could potentially be applied to the training and education of residents in a consultation-liaison service.

Academy of Psychosomatic Medicine

www.apm.org

The Academy of Psychosomatic Medicine website had some guidelines on consultation-liaison psychiatry. The first set of recommendations (http://www.apm.org/papers/managed-care.shtml), entitled “Managed Care: psychiatric consultation services for medical/surgical patients. Recommendations”, is summarised below:

Recommendation I. “All managed care contracts should include specific plans to cover psychiatric consultation services to medical/surgical inpatients”.

Recommendation II. “Psychiatric consultation services for medical/surgical inpatients should be specifically covered under general medical capitation, comparable to other specialty consultations to medical inpatients”.

Recommendation III. “Whether psychiatric consultation services to medical/surgical inpatients are covered through a behavioural healthcare “carve-out” or included in the general medical plan, the following guidelines are recommended;

“Psychiatric consultations in the inpatient medical setting should be reimbursed”.

“Psychiatric consultations should be performed only by psychiatrists who are credentialed and privileged for these services at the institution where the patient is hospitalized. Treatment may then be delegated to other behavioural healthcare specialists under the clinical supervision of the consulting psychiatrist”.

“The initial consultation, and at least one follow-up visit, should be automatically covered without pre-certification”.

Furthermore, the author of these guidelines makes the following additional recommendation: “Psychiatrists expert in the provision of psychiatric care to the medically ill should be included in the development of mental health/primary care linkages. Specifically, such individuals should participate in “co-ordination of care” agreements between the medical care providers and behavioural health providers”.

A second set of guidelines, relevant to this review, was obtained from the Academy of Psychosomatic Medicine website: “Recommended guidelines for consultation-liaison psychiatry training in psychiatry residency programs”. This report documents the following: goals of consultation-liaison training; objectives for psychiatry residents in consultation-liaison psychiatry; recommended curriculum content for consultation-liaison psychiatry rotations; structure and integration; faculty staffing; teaching and supervision.

In terms of the goals of consultation-liaison training, the report makes the following recommendations:



“To educate residents about the role of psychiatric, psychological, and behavioural factors in the pathogenesis of medical disorders”;

“To increase residents fund of knowledge in C-L psychiatry through didactics, including case conferences, teaching rounds, literature review, and formal lectures”;

“To promote liaison relationships with medical and surgical services, with a particular focus on Primary Care, that emphasise awareness, assessment, and management of mental disorders in medical patients”;

“To demonstrate appropriate approaches to the execution of a psychiatric consultation”; and

“To demonstrate a variety of interventions and therapies relevant to medically ill patients”.

With regards to the objectives for psychiatry residents in consultation-liaison psychiatry, the guidelines state that, after completing their rotation in consultation-liaison psychiatry, residents should be adept in the consultation-liaison process, examination skills and therapeutic interventions. The report also details the recommended curriculum content for consultation-liaison psychiatry rotations, stating that “[t]raining rotations should provide teaching on a variety of topics pertinent to consultation-liaison psychiatry. This may be accomplished by a variety of didactic methods, including case conferences, teaching rounds, literature reviews, reading lists, and formal lectures”. The report also lists the topics residents should know about, and include psychiatric disorders, psychopharmacology and psychotherapy, treatment of different subsets of patients, and more advanced topics such as research and ethics of consultation-liaison psychiatry, and the administration and setting-up of a consultation-liaison service.

In terms of the structure and integration of the consultation-liaison service, the report recommends that “[t]he C-L experience should be of sufficient intensity for the resident to master the goals and objectives” summarised here; “C-L training is maximised when it is the primary focus of the resident, and other responsibilities should be kept to a minimum”. The report then describes the ideal training scenario: “This “block” model will best meet the goals of comprehensive teaching, continuity of care, and a broad-based consultation experience. Based on these considerations, the minimum rotation should be no less than a 3-month full-tom equivalent, and no less frequent than half-time (20 hours/week). The ideal rotation would be a full-time “block” of four to six months in duration”. The report also discusses the minimum number of consultations a resident should perform in order to develop the appropriate skills and aptitudes, the authors conclude that approximately 50 consultations would be adequate, although “[a]n ideal of 100 consults [would] allow ample training and sufficient variety of cases, [whereas] [s]ervices that have residents see over 150 consults during a rotation may sacrifice training for service”. Furthermore, “[c]onsultations should provide the resident with exposure to the widest variety of general hospital medical-surgical patients”, and residents should gain experience in some specialty areas, including geriatrics, whereas “[l]iaison activities will enhance the overall C-L experience and improve understanding of the C-L process”.

The following recommendations were made with regards to the teaching and supervision of consultation-liaison residents:

“In the early part of each resident rotation the resident should observe the attending and perform all the elements of a clinical consultation. This may occur over several supervisory sessions and include a preliminary discussion with the consultee and other clinical staff regarding the reason for consultation, a full chart review, the



clinical interview, history from outside sources, a follow-up discussion with the consultee, and the written consultation and follow-up chart note”:

“Attending psychiatrists should have the opportunity to observe the resident complete an entire initial consultation, providing the resident with appropriate feedback as part of the process”; and

“An attending should have the opportunity to observe the resident complete parts of the consultation process. Emphasis should be placed on supervising the ongoing management of patients in the hospital, not just the initial consult”.

The final report from this website is entitled “The Academy of Psychosomatic Medicine Practice Guidelines for Psychiatric Consultation in the General Medical Setting” (RM6667), supplementing the “Psychiatric training in C-L psychiatry” guidelines described above. This report contains the following guidelines:

Population at risk and case identification – “Each institution is responsible for the continuing medical education of medical/surgical staff about the psychological consequences of illness and the indications for psychiatric consultation”.

Training and skills assessment – “All students and trainees must be closely supervised”.

The consultation process – “In all medical settings, there must be adequate staffing to provide psychiatric consultation 24 hours/day, throughout the day. . . Psychiatric consultation involves an initial consultation and follow-up examinations (two on average)”.

Assessment; reasons for referral – “When the consultee asks for a psychiatric consultation, the consultant should establish the urgency of the consultation (i.e., emergency or routine – within 24 hours)”.

Emergency consultations – “Coverage for emergencies should be available on a 24-hour basis by on-call psychiatric consultants”.

Psychiatric history and consultation note – “The development of the medical-psychiatric history, as well as pertinent aspects of the physical and mental status examination, must be integrated by the psychiatric consultant to yield a carefully structured consultation note, i.e., one that synthesises the data, provides a diagnosis, and recommends appropriate testing and treatment”.

Diagnostic testing and consultation – “The C-L consultant must be familiar with [a range of] diagnostic testing”.

Follow-up – “Interventions; psychotherapy – “The psychotherapeutic approach to the medically ill should be considered carefully, and the modality introduced should be primarily selected in response to the patient’s need. No single psychotherapeutic modality will be effective with all patients, at all times, in the medical setting”.

Interventions; pharmacotherapy and other somatic therapies – “The C-L psychiatrist must be a licensed physician with extensive clinical experience and knowledge about the use of pharmacological agents. The psychiatric consultant should recommend and prescribe medications whenever a major psychiatric syndrome is diagnosed and when the benefits of treatment outweigh its risks”.

Referral and requests for services of other consultants - “Psychiatric consultants should recommend consultation with other physicians and non-physician specialists, when appropriate. . . When appropriate, the psychiatric consultant may end his/her involvement with the patient when another specialist is prepared to deliver the necessary care to the patient. When the consultant recommends psychotropic medications, he/she should continue to follow the patient for the duration of the



hospitalisation, until psychotropics have been discontinued, or until the consultee no longer requires the consultant’s services”

Outpatient follow-up and disposition – “It is the responsibility of the consultant to suggest outpatient psychiatric treatment and to discuss these recommendations with both the patient and the consultee”.

Signing out and signing off – “When the decision to stop seeing a patient has been made, the consultant should discuss the planned termination with the consultee and with the patient. A sign-off note should be placed in the patient’s medical record with information as to how the C-L consultant can be reached, should the need arise”.

Constant observation – “Although the initial need for constant observation is generally instituted by the physician of record, psychiatric consultation is recommended for these patients to facilitate diagnostic evaluation and to reduce harmful behaviours and litigious outcomes”.

Restraints – “Psychiatric consultants must be knowledgeable of all applicable state, local, and institutional guidelines with regard to restraints”.

Competency evaluations – “The C-L psychiatrist’s role is to evaluate a patient’s capacity for medical decision making with regard to a specific medical determination”.

Psychiatric commitment and transfer to psychiatry – “The psychiatric consultant should be familiar with the clinical indications for, and potential benefits of, inpatient psychiatric admission for particular psychiatric conditions”.

Data collection and quality control – “C-L consultants should create a system for regular internal quality review of the service’s clinical, research, and supervisory activities”.

Supervision of trainees – “A sufficient number of faculty should be made available so that all new patients consulted by a resident can be seen by an attending psychiatrist, preferably within 24 hours”.

Ethical guidelines – “C-L consultants should follow the principles of medical ethics in all patient interactions”.

Other short reports and articles from the Academy of Psychosomatic Medicine website included the following:

RM6488 Stoudemire et al. (1998)

A report on “Sub-Specialty Information”

http://www.apm.org/subspecialty.index.shtml)

Position statement on the “Psychiatric aspects of excellent end-of-life care”

http://www.apm.org/papers/eol-care.shtml)

The following articles of interest, not directly concerned with liaison psychiatry: Harpole et al. (2005); Barsky et al. (2005) and Gaudreau et al. (2005).

Royal Australian and New Zealand College of Psychiatrists

www.ranzcp.org

The RANZCP regulations on “Basic training and advanced training for fellowship”, which included a short section on consultation-liaison psychiatry, detailing the following bullets points, in which trainees were expected to be competent:



“Demonstrate an understanding of the impact of medical illness and the system in which it is treated and how this affects the presentation, experience, and impact of psychiatric and psychosocial morbidity”;

“Demonstrate the skills needed to conduct a biopsychosociocultural assessment, create a formulation, and implement appropriate treatment in the context of the general hospital including effective communication with the rest of the treatment team”;

“Demonstrate the ability to assess reactions to illness, and to differentiate the presentation of depression and anxiety in the medical setting”;

“Demonstrate an understanding of the combined trajectories of illness and the developmental issues of the person with mental health problems and mental illness”;

“Demonstrate an understanding of and ability to assess and treat somatisation and somatoform disorders”;

“Demonstrate an understanding of and ability to assess and manage common neuropsychiatric disorders, with a particular emphasis on delirium”;

“Demonstrate an understanding of the particular needs of special populations with psychiatric and psychosocial morbidity in the medical settings, including the young, the old, the indigenous and those with intellectual disability”;

“Demonstrate an ability to assess and manage acute and emergency presentations of psychiatric morbidity in the general medical setting”; and

“Demonstrate an ability to formulate the key ethical dimensions that arise in providing psychiatric care in a medical setting” (Guideline 8.7).

Furthermore, the same report also makes the following points on old age psychiatry (Guideline 8.8), which may also be applicable to this review:

“Demonstrate a knowledge and understanding of the importance of developmental issues in the assessment and management of older people”;

“Perform an assessment of the mental state of older persons, in hospital, community and long term residential care settings. This should include an appreciation of the differences between young and old”;

“Demonstrate a knowledge and understanding of the significance of underlying medical conditions and pharmacological treatment in the presentation of older people”;

“Assess the competence of an older person to care for themselves and manage their own affairs and evaluate their testamentary capacity”;

“Participate in the assessment and management of older persons by a multidisciplinary team”;

“Demonstrate knowledge of community resources including government programs, voluntary agencies, self-help groups and private facilities that are available to meet the needs of older people”;

“Demonstrate an understanding of the key role of family members and other carers in the care of older people”; and

“Demonstrate knowledge and skills in assessment and management of issues facing some older people, including elder abuse, suicide, euthanasia and ageist attitudes”.

The RANZCP also published a position statement (#22) on “Psychiatry services for the elderly”, in which the need for specialised psychiatric services for older patients is



highlighted. Although this statement does not specifically refer to consultation-liaison services, the ideal psychiatric service for older patients discussed in this statement appears to point towards a liaison service (for example, “[i]deal psychiatric services for the elderly work in close cooperation with geriatric medical services”); however, the statement appears to be discussing psychiatric services in both the general hospital and the community.

The European Association for Consultation Liaison Psychiatry and Psychosomatics

www.eaclpp.org

The EACLPP website contained a summary of the European Guidelines in Consultation-Liaison Psychiatry and Psychosomatics, drawn up in 2004. The following general points were made:

Rotation to a C-L service is mandatory in Spain (4 months full-time) and Portugal (3 months full-time)

Rotation to a C-L service is recommended in the Netherlands (6 months full-time), Norway (6 months full-time), the UK (6 months full-time) and Germany (3-6 months part-time)

A specified number of supervised consultations in C-L psychiatry or Psychosomatics are required for recognised training. For example, in Germany this is 20 sessions, and in Italy it is 25 sessions

The number of seminars or case-conferences required for approved training varies between 10-128 hours in different countries

Official recognition of training in C-L psychiatry exists in Finland, Germany and the UK.

The report states that the following recommendations should be adhered to in order for training in C-L to be satisfactory:

Full-time training

A minimum of 6 months’ full-time rotation to a C-L department

Supervision of trainees should be clearly defined and organised

The ratio between regular C-L team members and trainees should be fixed so that a single trainer is not responsible for an excessive number of trainees

Residents should either have basic expertise in general medicine prior to commencing their training in C-L psychiatry or obtain this as part of the training in C-L psychiatry

The C-L trainee should have the following knowledge: an awareness of the different theoretical models that form the basis of C-L psychiatry, an awareness of the “consultant’s role in advising general medical doctors and nurses and the different roles and responsibilities in such working” and an understanding of the ethical and medico-legal issues. In addition to this, trainees should know how to assess and manage a wide range of psychiatric symptoms. Other aptitudes required include basic communication skills (communication with medical staff and with referred patients and relatives), diagnostic and formulation skills and clinical intervention skills (drawing up and implementing treatment plans etc).

In terms of the form of the training the following should be utilised: seminars and case conferences, journal clubs, tutorials and supervision, courses and conferences and assessment of competency and efficacy.



Royal College of Psychiatrists

www.rcpsych.ac.uk

Many documents on liaison psychiatry were found on this website. There was some valuable information on the development of a liaison psychiatry service, which made the following points:

The need for clarification of the exact job description of the consultant in liaison psychiatry, and the identification of liaison sessions, and that they should be protected, if the liaison post is part-time and is associated with sessions in general psychiatry;

Most of the work will involve assessing patients referred from medical and surgical wards, and the work should be shared between the consultant and psychiatric trainee;

Psychiatric trainees require regular supervision from the consultant;

Referrals should be seen quickly (report suggests within 24 hours), which will result in more referrals as the service will be appreciated;

Psychiatrist should summarise the findings of the psychiatric consultation immediately in the patient’s medical notes, so that the medical and nursing staff will be aware of this;

An outpatient service should also be developed, so that patients can also be referred from other clinics from within the hospital;

Liaison psychiatry service should be offered to all patients attending the hospital in question, regardless of where they live;

At the setting-up of the service, the consultant should write to the medical staff, informing them of the liaison service (perhaps followed up by meetings);

Regular multi-disciplinary meetings should be held, in order to facilitate good communication between all the staff involved in the care of patients;

The liaison psychiatry service should be funded from the medical and surgical budget, but should be managed within a mental health service;

The service should have appropriate support from the junior medical staff;

If there is no SHO post, the consultant should arrange for such a post to be implemented, preferably whole-time, lasting six months, and forming part of a rotational training programme;

The consultant should devise an educational programme to train the SHO and SpR;

This report states that a “liaison psychiatry service functions best if it is delivered by a multidisciplinary team”. The report advocates the addition of the following staff members to the liaison team, if appropriate: liaison nurses, nurse therapists, clinical psychologists and social workers;

In terms of a teaching role, undergraduates can benefit from liaison psychiatry. Furthermore, members of the liaison team should present cases at medical grand rounds or departmental meetings, as well as giving lectures to groups of medical specialists at postgraduate meetings;

Research opportunities should also be developed.

Furthermore, the report “The Psychological Care of Medical Patients: A Practical Guide”, published by the Royal College of Psychiatrists, also has some information



regarding developing a liaison psychiatry service. This report documents the psychological problems suffered by patients with medical conditions, and how “[p]sychological problems are common in general hospital patients” and “[p]sychiatric disorders adversely affect outcomes of medical illness”. In this light, this report suggests that liaison psychiatry services may be the best way of managing these problems. This report makes the following points:

“The psychological care for an entire general hospital is best delivered by a multidisciplinary liaison psychiatry team based at the general hospital site. This enables close links to be developed with various medical specialties”.

“The model operates on a consultation and liaison basis: referrals are received in response to a specific request from the referring physician but also sought proactively through the introduction of staff training and multidisciplinary meetings to improve the detection of psychiatric problems”.

“Service planning should ideally be based upon epidemiological data from which the likely need can be estimated”.

“The objectives of improving psychological care in the general hospital setting are to ensure that:

Earlier and better assessments are made

The most appropriate advice and treatment are provided

The skill mix matches the needs of patients

Appropriate locations for care are determined

Patients receive optimal care”.

“It is therefore essential for the development and ongoing management of liaison psychiatry services that effective links between acute trusts and mental health trusts are established so that the development of services can be planned jointly”.

“Current funding of liaison psychiatry services, like so much else in the NHS, reflects historical patterns of provision at local level”.

“Specifically in terms of this review, the report also states that “[m]ental health services for older people are beginning to appoint specialist liaison staff, similar to those developed for working age adults some 20 years ago. This is a particularly important issue, since older people occupy 60% of general hospital beds and have high levels of psychiatric comorbidity”.

“Doctors are also often required to demonstrate that their service is cost-effective. This is much more difficult to establish for liaison psychiatry services, since trials to demonstrate service effectiveness are expensive and difficult (though not impossible) to carry out. An effective liaison psychiatry service might reduce the cost of medical care by reducing length of hospital stay or by avoiding the use of unnecessary and expensive investigations. On the other hand, costs might be increased by virtue of increasing the numbers of patients identified and treated. We do not believe that the available evidence allows conclusions to be drawn on this topic. Until such evidence for cost-effectiveness is available, the justification for developing liaison psychiatry services should rest on their clinical effectiveness rather than on their potential to save money”.

Liaison Psychiatry for Older People Website (Principal Investigator’s website)

www.leeds.ac.uk/lpop



This website repository had several reports and audits pertaining to the development of liaison psychiatry services for older people in the UK (the unpublished service audits have already been summarised in a previous section).

One such report (“A Greater Manchester Targeted Consultation-Liaison Strategy. Meeting the needs of older people who present with mental health problems, whist in general hospital wards across Greater Manchester”, written by Helen Pratt, with Drs. Baldwin and Ratcliffe), described the need for such services for older people in general hospitals, examining the extent of the problem of older people occupying general hospital beds and the prevalence rates for mental health disorders in these patients, and the impact of patients, families and staff. They also examine how the current service provision is mostly sector model, and how liaison services have been set up in certain areas, and also the advantages and disadvantages of some service models. The authors examine in-depth a collaborative integrated targeted consultation-liaison strategy, which would consist of a pro-active specialist team working within the general hospital, to include clinical sessions from psychiatrists, social workers, occupational therapists and psychologists. The strategy would comprise targeted consultation (pro-active specialist advice on assessment, diagnosis, functioning, treatment, psychological issues and nursing management) and targeted liaison (education and training of general hospital staff in detecting, treating and managing a range of psychiatric morbidities). In terms of advantages, this strategy would result in a reduction in bed occupancy day, reduction in readmissions, and overall reduction in morbidity and mortality, as well as increased detection and improved management of psychiatric symptoms by the general hospital staff, as a result of training and education. However, this strategy would be expensive to implement.

Also on this website was the operational policy (2003) of the Liaison Psychiatry of Old Age Service in Leeds. The service is provided for older people with a range of mental health problems in physical care settings in the two general hospitals noted below, and is staffed by a 0.5 whole-time equivalent Senior Lecturer/Honorary Consultant Old Age Psychiatrist and a 0.5 whole-time equivalent Senior House Officer (with part-time secretarial support), whereas a Specialist Registrar may also be present for training purposes. Referrals for psychiatric consultation are accepted from general hospital consultants and other general hospital professionals, consultant old age psychiatrists and other mental health professionals, as well as general practitioners (this final referral source only applies in situations where a specialist old age liaison psychiatry outpatient assessment is required).

In terms of response times, urgent referrals from the general hospital are seen within one hour, whereas non-urgent referrals from the general hospital are seen within one working day. Non-urgent outpatient referrals are seen within 6 weeks. In terms of interventions provided by the service, referrals from the general hospital (including the Accident and Emergency department) are accepted and assessed; depression, delirium, dementia, self-harm, alcohol misuse and physically unexplained symptoms are all managed by the service, as well as providing assessment on competence, capacity, suitable placement or other follow-up. Given that this is a liaison service, the service also provides training and education for general hospital staff to “improve their core skills of diagnosis and basic management of common mental health problems in older people under their care”.

This report provides the following statements regarding the purpose of the service:

“Provide responsive and comprehensive mental health assessment of older people in the general hospital settings at Leeds General Infirmary and Chapel Allerton hospital”;



“Work collaboratively with health care professionals in the general hospital setting to meet the mental health needs of the older people and promote patient centred care”;

“Provide advice, education and support to health care professionals, older people and their carers in the general hospital setting on mental health issues”;

“Provide the highest quality of service possible for the population within available resources”;

“Maintain and develop close links with the Leeds Mental Health Trust Community Mental Health Teams for Older People”;

“Utilise the care programme approach to ensure continuation of care for service users and their families”;

“Communicate effectively with all agencies involved in the older persons’ care, including the primary care team”;

“Provide a unique specialist liaison psychiatry outpatient service for older people”;

“Utilise evidence-based practice to provide high quality care”;

“Implement and comply with the Mental Health Act 1983”;

“Maintain links with universities and training establishments to develop the skills of staff and contribute to research initiatives”.

The website also contains a similar report, written by Colin Hughes of the Chesterfield Primary Care Trust, “Protocol for the role of the consultant nurse-older people (mental health) in developing mental health liaison for older people in Chesterfield”. This report explores the different service models on offer, and discusses the differences between consultation and liaison models. In addition to this, the role of the consultant nurse for older people is also examined. The author also provides the following data, obtained from a 12-month audit of the service.



Appendix 11: Service mapping – Brief survey



Appendix 12: Service mapping – Geriatrician survey



Appendix 13: Service mapping – Extended survey



Appendix 14: Evaluation - Mental health services focus group topic guide

Liaison Mental Health Services for Older People Project

Discussion/interview guidelines

Topic guidelines for interviews and/or discussion groups with staff providing mental health services

Introduction to interview (purpose/length/confidentiality/agreement to audio-taping/signed participation agreement)

Service model currently in use and preferred model Recent/projected changes to service model Factors influencing development of services Sources of funding for services Staff activity/skill mix Staff training undertaken – past/present/future Number of referrals to service Source of referrals (by wards and approx % received from hospital and other

sources) Changes in referral rates/patterns seen Referral procedure Referral criteria Response time/prioritisation procedure Process after initial assessment Procedure for patients already under mental health services care Protocols in use for diagnosis and management of common mental health

problems Formal/informal training education provided to general hospital staff Relationships between different services Interface issues Routine clinical outcome measures Thoughts/ideas on how services can develop Closure/thanks/contact details



Appendix 15: Evaluation - Service characteristics variables Management responsibility

Funding responsibility

Number of referrals received 12 months prior to evaluation period

Number of referrals received during evaluation period

Referral response rates

Number of reviews undertaken

Age of service

Office location

Access to electronic notes/PAS

Service database

Level of staffing

Staffing activity

Staff changes within 6 months prior to evaluation period



Appendix 16: Evaluation – Referred patient data collection form

Mental health services for older people in general hospital settings

Prospective patient data collection To be completed for 100 patients admitted throughout the evaluation

period Section A Identification details

Section B Admission details

D7 Reasons for admission

Chest pain Cancer Collapse COPD Stroke Heart failure Pneumonia Abdominal pain UTI Broken

Bone Other

D10 Are any of the medications listed above used for psychotropic use?

Yes (If yes, please go to question D11) No (If no, please go to question D13) D11 If answered yes to D10, which conditions are these medications prescribed for:

I1

Site code

I2

Hospital code

I3

Patient ID

NHS number

I4

DOB I5

Age I6

Gender I7

Ethnicity

D1

Date of admission

D2

Admitting ward

D3

Speciality code

D4

PCT area/ postcode

D5

Type of admission

D9 Medication on admission:

D8 Please describe reasons for admission if not shown above:



Schizo/delusional disorder Dementia Delirium

Delirium with dementia Alcohol related Depression/low mood

Anxiety Drug related Other

D14 Charlson rating

D15 Previous hospital admissions within the last 12 months

Date Length of stay

Reason Reason code

1(a)

2(b)

3(c)

4(d)

4 or more(e)

Average Most common reason

D16 Previous psychiatric history noted within acute hospital notes Yes (If yes, please go to question D17) No (If no, please go to section F) D17 Please tick if any of the following conditions are mentioned in previous admissions

notes:

Schizo/delusional disorder Dementia Delirium

Delirium with dementia Alcohol related Depression/low mood

Anxiety Drug related Capacity assessment

Other

D13 Please list concurrent medical conditions:

D12 If prescribed medication are used to treat a mental health condition that is not listed above, please state what this is:

D18 If a mental health problem is indicated that is not listed above, please state what this is:



Section F Social details S1 Marital status

Married/ Co-habiting Single Widowed Divorced Separated

S2 Housing

Owner/Occupier Council/HA Tenant Private Landlord Other

S4 Residential Classification:

Living alone Living independently with spouse/partner

Living with relative/friend Sheltered accommodation Residential home

Nursing home Hospice/Hospital

S5 Does the patient have an existing care package? Yes (If yes, please go to question S7) No (If no, please go to section G) S6 If patient has an existing care package, please state what this consists of

Care package Hours per month Social care Family care Home care Nursing care S7 Other (please state)

Section G Consent to participation – Part 1 - patients C1 Patient still in hospital at time of first research assessment visit?

Yes (If yes, please go to question C3) No (If no, please go to section I)

C3 Patient has capacity to give consent? Yes (If yes, please go to question C5) No (If no, please go to question C4) C4 If incapicitious, is this due to a mental health problem?

Yes (If yes, please go to question C10) No (If no, please go to question C5)

C5 If patient is incapacitious which is not due to a mental health problem, please state what incapacity is related to:

S3 If other housing arrangements to those listed above, please state what these are:

C2 If patient is no longer in hospital, please state reasons for this including dates:



C6 Patient agreement to participate? Yes (If yes, please go to question C8) No (If no, please go to question C7)

C8 Patient consent form signed?

Yes (If yes, please go to part 2, question C14) No (If no, please go to question C9)

C10 If patient is incapacitious, has assent been sought?


C12 Patient assent form signed?

Yes (If yes, please go to section G) No (If no, please go to question C13)

Section G Consent to participation – Part 2 – relatives/carers

C14 Has a relative/carer been asked to consent to participation?


C16 If approached, has a relative/carer consented to participation?


C18 Relative/carer consent form signed?

Yes (If yes, please go to section I) No (If no, please go to question C19)

Section H Symptom assessment – Time 1 T1 Patient still in hospital at time of first research assessment visit?

Yes (If yes, please go to question T3) No (If no, please go to question T2)

T3

Date of T3a

Number of days T4

MMSE score T5

DRS score T6

Barthel T7

Self rated

C9 If patient has not signed a consent form please state reasons for this:

C11 If assent is required but has not been sought, please state reasons for this:

C17 If consent by relative/carer has not been agreed, please state reasons for this:

C19 If a relative/carer has not signed a consent form, please state reasons for this:

C7 If patient has not agreed to participate, please state reasons given for this:

C13 If assent has been agreed and no form has been signed, please state reasons for this:

C15 If a relative/carer has not been approached to participate, please state reasons for this:

T2 If patient is no longer in hospital, please state reasons for this including dates:



GDS (Yesavage J et al 1983) No Question Yes No 1 Are you basically satisfied with your life? 0 1

2 Have you dropped many of your activities and interests?

1 0

3 Do you feel that your life is empty? 1 0

4 Do you often get bored? 1 0

5 Are you in good spirits most of the time? 0 1

6 Are you afraid that something bad is going to happen to you?

1 0

7 Do you feel happy most of the time? 0 1

8 Do you often feel helpless? 1 0

9 Do you prefer to stay at home, rather than going out and doing new things?

1 0

10 Do you feel you have more problems with memory than most?

1 0

11 Do you think it is wonderful to be alive now? 0 1

12 Do you feel pretty worthless the way you are now? 1 0

13 Do you feel full of energy? 0 1

14 Do you feel that your situation is hopeless? 1 0

15 Do you think that most people are better off than you are?

1 0

Total x x

BDS (Blessed G et al 1968) No Event Score 1 Changes in performance of everyday activities

2 Changes in habits

3 Changes in personality, interests, drive

4 Information test

5 Memory

6 Concentration

Total T9

T10 All assessment tools completed?


assessment between assessment and admission date

score health



T12 Do the results of these assessments need reporting to care staff?

Yes (If yes, please go to question T13) No (If no, please go to question T14) Section I Case note and medication chart review N1 Evidence of assessment of mental health needs during this admission by general hospital staff Nothing Mentioned Unstructured history taking Structured assessment

N3 Evidence of actions taken by general hospital staff as a result of above assessments Please tick all that apply Referral to services Changes to medication (If yes, please go to question N5) Other

N5 Please state what if any changes have been made to medication as a result of any mental health assessments undertaken by general hospital staff New prescription Existing dosage increased Existing dosage decreased Other

N7 Is there any evidence in the case notes indicative of mental health needs not already mentioned above? Yes (If yes, please go to question N8) No (If no, please go to question N10)

N8 Please state what evidence indicates mental health needs not already mentioned Please tick all that apply Wandering Poor appetite Poor sleep Confusion Memory loss

Other

T11 If all of the above assessment tools have not been completed, please state reasons for this below:

T13 If yes, please state reasons for this below. Please also state what action you have taken:

T14 Please document the main comments, if any, made by patients (and/or their relatives/carers) on the quality of care they receive whilst in hospital:

N2 If structured assessment undertaken, please state what was used:

N4 If other actions taken as a result of the above assessments, please state what these are:

N6 If other changes to medication noted as a result of mental health assessments, please state what these are:



N10 Are there any mental health needs protocols in place on this ward? (please ask staff on ward if not sure)

Yes (If yes, please go to question N11) No (If no, please go to question N13) N11 If there are protocols in place, is there any evidence for these protocols being used for

this patient?

Yes (If yes, please go to question N12) No (If no, please go to question N13)

Section J Symptom assessment – Time 2 (To be completed for patients assessed at Time 1)

P1 Patient still in hospital at time of second research assessment visit?

Yes (If yes, please go to question P3) No (If no, please go to question P2)

GDS (Yesavage J et al 1983) No Question Yes No 1 Are you basically satisfied with your life? 0 1

2 Have you dropped many of your activities and interests? 1 0




6 Are you afraid that something bad is going to happen to you? 1 0




1 0

10 Do you feel you have more problems with memory than most? 1 0



P3

Date of assessment

P3a

Number of days between first and

second assessment

P4

MMSE score P5

DRS score P6

Barthel score

P7

Self rated health

N12 If protocols have been used for this patient, please state what has been used and why:

N9 If other evidence of mental health needs, please state what this is:

P2 If patient is no longer in hospital, please state reasons for this including dates:

N13 Any other comments on case notes/nursing notes contents:





15 Do you think that most people are better off than you are? 1 0

Total x x


2 Changes in habits


4 Information test

5 Memory

6 Concentration

Total P9

P10 All assessment tools completed?


P12 Do the results of these assessments need reporting to care staff?

Yes (If yes, please go to question P13) No (If no, please go to question P14) Section K Discharge E1 Has the patient been discharged within the evaluation period?

Yes (If yes, please go to question E2) No (If no, please go to question E6)

E7 Is there any evidence of delays in discharge experienced due to non-medical need?

E2

Date discharged E3

Length of stay E4

Where discharged to E5

Discharge code

E6 If the patient has not been discharged within the evaluation period, please give reasons for this:

P11 If all of the above assessment tools have not been completed, please state reasons for this below:

P13 If yes, please state reasons for this below. Please also state what action you have taken:

P14 Please document the main comments, if any, made by patients (and/or their relatives/carers) on the quality of care they receive whilst in hospital:




E9 Have these delays been related to a mental health need?


E12 Are any of the medications listed above used for psychotropic use?

Yes (If yes, please go to question E13) No (If no, please go to question E15) E13 If answered yes to E12, which conditions are these medications prescribed for:

Schizo/delusional disorder Dementia Delirium Delirium with

dementia Alcohol related Depression/low mood Anxiety

Drug related Other

E15 Does the patient have a discharge care package? Yes (If yes, please go to question E16) No (If no, please go to question E18) E16 If patient has a different care package on discharge, please state what this consists of:

Care package Hours per month Social care Family care Home care Nursing care E17 Other (please state)

Section L Patient/relative feedback This section should be completed only for those patients and/or relatives/carers

for whom consent or assent has been obtained

E11 Medication on discharge:

E18 Any other comments on discharge:

E10 If no, what was the reason for this delay?

E8 If yes, please give reasons for this including dates:

E14 If prescribed medication are used to treat a mental health condition that is not listed above, please state what this is:



F8 Patient interview: Has the patient agreed to telephone interview?

Yes (If yes, please go to question F11) No (If no, please go to question F9)

F10 If yes, please state date/time arranged F11 Has the interview been carried out?


F13 Taped interview code

F14 Relative/carer interview: Has the relative/carer agreed to telephone interview?





Further comments on this admission: This data should not be returned with any documentation sent to the main site at The University of Leeds. Please ensure contact details are removed and shredded at the point of form completion. Patient name

Date due to be contacted

Date questionnaires

sent

Date questionnaires

returned Patient F1

F3 F5

Relative/ Carer

F2

F4 F6

F7 Reasons for any delays in follow-up:

F9 If no, please state reasons if given below:






Patient address

Patient tel no

Relative/carers name

Relationship to patient

Relative/carers address

Relative/carers tel no



Appendix 17: Evaluation – Mental health staff diaries


Mental Health Service – staffing activity

Site code:

To be completed by all members of staff (not including general hospital staff) providing mental health care for older people in the general hospital(s) at your site: please

complete for a typical four week period Please state your profession, grade and amount of dedicated time you spend providing mental health input for older people in

general hospital settings. Please also state your length of time with this service:

Profession Grade Dedicated hours per week Length of time in service

Please complete this diary for the next month. Please indicate what day/date the work was carried out, the type of work as listed

below, the amount of time spent carrying out this work and any other information you think is relevant.

Type of work codes: 1. Clinical work – including assessments, therapeutic work and reviews 2. Supervision – of general hospital and mental health staff (please include details of the disciplines involved in the other information section) 3. Teaching/training – opportunistic and structured (please include details of the disciplines involved in the other information section. Please also include details of any service user and carer training) 4. Administration 5. Audit 6. Research 7. Professional development (please provide details of this in the other information section) 8. Other

Day/date Type of work Total time Other information

Received Entered



Day/date

Type of work

Total time



Please use the space below to tell us about any other regular activity you carry out as part of providing the above service that

you haven’t told us about already:

Please use the space below to describe any specific training in Liaison Psychiatry for Older People that you have undertaken. Please include details of any formal training modules, as well as details on attendance at training events and conferences and memberships of liaison networks:

Please use the space below to provide any comments you have on the training needs of specialist staff providing mental

health input for older people in general hospital settings:



Thank you for completing the questionnaire



Appendix 18: Evaluation – Team Climate Inventory

Team Climate Inventory

For the following items, please indicate the extent to which each statement is true of your team on a 7-point scale ranging from 1 = not at all to 7 = completely 1. How clear are you about what your team’s objectives are? 2. To what extent do you think they are useful and appropriate objectives? 3. How far are you in agreement with these objectives? 4. To what extent do you think other team members agree with these objectives? 5. To what extent do you think your team’s objectives are clearly understood by other members of the team? 6. To what extent do you think your team’s objectives can actually be achieved? 7. How worthwhile do you think these objectives are to you? 8. How worthwhile do you think these objectives are to the organisation? 9. How worthwhile do you think these objectives are to the wider society? 10. To what extent do you think these objectives are realistic and can be attained? 11. To what extent do you think members of your team are committed to these objectives? For the following items, please indicate the extent to which each question relates to your team on a 5-point scale ranging from 1 = a very little extent to 5 = a very great extent 12. We share information in the team rather than keeping it to ourselves 13. We have a ‘we are in it together’ attitude 14. We all influence each other 15. People keep other informed about work related issues in the team 16. People feel understood and accepted by each other 17. Everyone’s view is listened to even if it is in a minority 18. There are real attempts to share information throughout the team 19. There is a lot of give and take 20. Do your team colleagues provide useful ideas and practical help to enable you to do your job to the

best of your ability? 21. Do you and your colleagues monitor each other so as to maintain a higher standard of work ? 22. Are team members prepared to question the basis of what the team is doing? 23. Does the team critically appraise potential weaknesses in what it is doing in order to achieve the

best possible outcome? 24. Do members of the team build on each other’s ideas in order to achieve the best possible outcome? 25. Are there any real concerns among team members that the team should achieve the highest

standards of performance? 26. Does the team have clear criteria which members try to meet in order to achieve excellence as a team? For the following items, please indicate the extent to which each statement is true of your team on a 5-point scale ranging from 1 = strongly disagree to 5 = strongly agree 27. This team is always moving toward the development of new answers 28. Assistance in developing new ideas is readily available 29. This team is open and responsive to change 30. People in this team are always searching for fresh, new ways of looking at problems 31. In this team we take the time needed to develop new ideas 32. People in the team co-operate in order to help develop and apply new ideas 33. Members of the team provide and share resources to help in the application of new ideas 34. Team members provide practical support for new ideas and their application 35. We keep in touch with each other as a team? 36. We keep in regular contact with each other? 37. Members of the team interact frequently to talk both formally and informally? 38. We interact frequently?



Appendix 19a: Evaluation – Patient satisfaction questionnaire

Site ID Pt ID

Date sent Date rec’d

Services for patients aged 65 years and over in General Hospital Settings

Patient satisfaction with care received whilst in general hospital

To assist in the improvement of care that people aged 65 years and over receive whilst in a general hospital setting, we are asking patients who have recently been discharged how satisfied they are with the care they have received during their most recent stay in hospital. Your opinion about these services is very important and will assist in planning the future directions of the service. Participation in this survey is voluntary. Only complete the survey if you want to. Your responses are entirely confidential and will not adversely affect the care you receive in the future. If you are unable or unwilling to complete the questionnaire, please ask a relative or carer to complete the relative/carer questionnaire. If you need any further help or assistance to complete this survey please contact: Carolyn Montaňa Project Manager Academic Unit of Psychiatry and Behavioural Sciences 15 Hyde Terrace Leeds LS2 9LT Tel: 0113 3431964 Mob: 07931 442242 The questions in Section A ask about your experience during your most recent stay in a general hospital. Please answer as many questions as you feel able. If you do not wish to answer a question, please leave it blank and move on to the next. If you also received help from the mental health services during your most recent stay in the general hospital, please also answer the questions in Section B.



Once you have completed the survey, please indicate in Section C whether or not you are willing to be contacted to participate in a telephone interview during which we would like to ask you about your experiences of staying in hospital. Please return the survey in the pre-paid envelope provided. May we take this opportunity to thank you for your valuable contribution towards

improving care.

Section A

The following questions ask about your views of the care received whilst staying in the general hospital

Hospital and Ward 1. During your stay in hospital, did you ever share a room or bay with patients of the opposite Yes No Don’t know 2. Were you ever bothered by noise at night from other patients? Yes No 3. Were you ever bothered by noise at night from hospital staff?

Yes No 4. In your opinion, how clean was the hospital room or ward that you were in?

Very clean Fairly clean Not very clean Not at all clean 5. How clean were the toilets and bathrooms that you used in hospital? Very clean Fairly clean Not very clean Not at all clean Didn’t use 6. How would you rate the hospital food provided for you? Very good Good Fair Poor Didn’t have any Doctors

7. When you had important questions to ask a doctor, did you get an answer that you could understand?

Yes, always Yes, sometimes No I had no need to ask 8. Did you have confidence and trust in the doctors treating you? Yes, always Yes, sometimes No 9. Did doctors talk in front of you as if you weren’t there? Yes, always Yes, sometimes No



Nurses 10. When you had important questions to ask a nurse, did you get an answer that you could understand?

Yes, always Yes, sometimes No I had no need to ask 11. Did you have confidence and trust in the nurses treating you? Yes, always Yes, sometimes No 12. Did nurses talk in front of you as if you weren’t there? Yes, always Yes, sometimes No 13. In your opinion, were there enough nurses on duty to care for you in hospital? There were always or nearly always enough nurses There were sometimes enough nurses There were rarely or never enough nurses



Your care and treatment 14. Sometimes in a hospital, a member of staff will say one thing and another will say something quite different. Did this happen to you? Yes, often Yes, sometimes No Don’t know 15. Were you involved as much as you wanted to be in deciding about your care and treatment? Yes, definitely Yes, to some extent No 16. How much information about your condition or treatment was given to you? Not enough The right amount Too much 17. If your family or someone else close to you wanted to talk to a doctor, did they have enough opportunity to do so? Yes, definitely Yes, to some extent

No No family or friends were involved My family did not want or need information I did not want my family or friends to talk to a doctor 18. Did you find someone on the hospital staff to talk to about your worries and fears? Yes, always Yes, sometimes No I had no worries or fears 19. Were you given enough privacy when discussing your condition or treatment? Yes, always Yes, sometimes No 20. Were you given enough privacy when being examined or treated? Yes, always Yes, sometimes No 21. Did you get enough help from staff to eat your meals? Yes, always Yes, sometimes No 22. How many minutes after you used the call button did it usually take before you got the help you needed? 0 minutes-right away 1-2 minutes 3-5 minutes More than 5 minutes I never got help when I used the call button I never used the call button Pain

23. Were you ever in any pain? Yes No Don’t know

Please go to Q24 Please go to Q25

24. Do you think the hospital staff did everything they could to help control your pain?



Yes, definitely Yes, to some extent No Operations and procedures

25. During your stay in hospital, did you have an operation or procedure?

Yes No Don’t know


26. Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way you could understand? Yes, completely Yes, to some extent No I did not want an explanation 27. Beforehand, did a member of staff explain to you what would be done during the operation or procedure? Yes, completely Yes, to some extent No I did not want an explanation 28. Beforehand, did a member of staff answer your questions about the operation or procedure in a way that you could understand? Yes, completely Yes, to some extent No I did not want an explanation 29. Beforehand, were you told how you could expect to feel after you had the operation or procedure? Yes, completely Yes, to some extent No 30. Before the operation or procedure, were you given an anaesthetic to put you to sleep or control your pain? Yes No Don’t know


31. Before the operation or procedure, did the anaesthetist explain how he or she would put you to sleep or control your pain in a way that you could understand?

Yes, completely Yes, to some extent No

32. After the operation or procedure, did a member of staff explain how the operation or procedure had gone in a way that you could understand? Yes, completely Yes, to some extent No Leaving Hospital 33. Did a member of staff explain the purpose of the medicines you were to take home in a way that you could understand? Yes, completely Yes, to some extent No I did not want an explanation

Please go to Q34

I had no medicines Please go to Q40



34. Did a member of staff tell you about medication side effects to watch for when you went home? Yes, completely Yes, to some extent No I did not want an explanation

35. Were you given clear written information about your medicines? Yes, completely Yes, to some extent No Don’t know Can’t remember 36. Did a member of staff tell you about any danger signals you should watch for after you went home?

Yes, completely Yes, to some extent No It was not necessary 37. Did the doctors or nurses give you all the information needed to help you recover? Yes, completely Yes, to some extent No Don’t know 38. Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?

Yes No Don’t know Cant remember 39. Did you receive copies of letters sent between hospital doctors and your family doctor (GP)?

Yes, I received copies No, I did not receive copies Don’t know Overall

40. Overall, did you feel you were treated with respect and dignity while you were in the hospital?

Yes, always Yes, sometimes No

41. Overall, how would you rate the care you received? Excellent Very good Good Fair Poor

42. During your hospital stay, were you asked to give your views on the quality of your care?

Yes No Don’t know Cant remember

Section B

Please answer the following questions only if you were referred to mental health services during your most recent stay in the general hospital

1. Were you referred to the mental health services during your most recent stay in hospital?

Yes No Don’t know

Please go to Q2 Please go to Section C

2. Were you able to get help from this service when you needed it?

Yes, definitely Yes, to some extent No Don’t know



3. When you had important questions to ask about your mental health needs, did you get an

answer that you could understand?

Yes, always Yes, sometimes No I had no need to ask

4. Did you have confidence and trust in the mental health services treating you?

Yes, always Yes, sometimes No 5. Were you involved as much as you wanted to be in deciding about your mental health care and treatment?

Yes, definitely Yes, to some extent No I did not want to be involved Don’t know 6. How much information about your mental health condition or treatment was given to you?

Not enough The right amount Too much I did not want any information Don’t know

7. Did you find that you could talk through your worries and fears with the mental health staff?

Yes, definitely Yes, to some extent No I had no worries or fears Don’t know

8. Were you given enough privacy when discussing your mental health condition or treatment?

Yes, always Yes, sometimes No I did not want to discuss it Don’t know

If there is anything else you would like to tell us about your experiences of the mental health services available to you during your most recent stay in the general hospital, please tell us about it here.

9. Was there anything particularly good about this service?

10. Was there anything that could be improved?



11. Any other comments?

12. Please tell us about any mental health care you are receiving at the moment:

Section C We would like to invite you to participate in a telephone interview in order to discuss your views on the care you received. This will last approximately 20 minutes. The interview will be recorded to help us to understand key factors that need to be addressed. The content of this discussion will remain strictly confidential and your anonymity will be guaranteed at all times. If you would like to participate please indicate this by completing the information below:

Would you be willing to participate in a telephone interview?

Yes No

When would be a convenient time to call?

Date Time

What is your telephone number?



Name ………………………………………………………



Appendix 19b: Evaluation – Relative satisfaction questionnaire

Site ID Pt ID

Date sent Date rec’d

Services for patients aged 65 years and over in General Hospital Settings

Relative/Carer satisfaction with care received by relative/patient whilst

in general hospital

To assist in the improvement of care that people aged 65 years and over receive whilst in a general hospital setting, we are asking relatives and carers of patients who have recently been discharged how satisfied they are with the care received by their relative/patient during their most recent stay in hospital. Your opinion about these services is very important and will assist in planning the future directions of the service. Participation in this survey is voluntary. Only complete the survey if you want to. Your responses are entirely confidential and will not adversely affect the care you or your relative/patient receive in the future. If you need any further help or assistance to complete this survey please contact: Carolyn Montaňa Project Manager Academic Unit of Psychiatry and Behavioural Sciences 15 Hyde Terrace Leeds LS2 9LT Tel: 0113 3431964 Mob: 07931 442242 The questions in Section A ask about your relative’s experiences during their most recent stay in a general hospital. Please answer as many questions as you feel able. If you do not wish to answer a question, please leave it blank and move on to the next. If your relative also received help from the mental health services during their most recent stay in the general hospital, please also answer the questions in Section B. Once you have completed the survey, please indicate in Section C whether or not you are willing to be contacted to participate in a telephone interview during which we would like to ask you about your experiences of your relative staying in hospital.



Please return the survey in the pre-paid envelope provided. May we take this opportunity to thank you for your valuable contribution towards

improving care.

Section A The following questions ask about your views of care whilst staying in the general hospital

Hospital and Ward 2. During your relatives stay in hospital, did they ever share a room or bay with patients of

the opposite sex? Yes No Don’t know 2. Were they ever bothered by noise at night from other patients? Yes No 3. Were they ever bothered by noise at night from hospital staff?

Yes No 4. In your opinion, how clean was the hospital room or ward that they were in?

Very clean Fairly clean Not very clean Not at all clean 5. How clean were the toilets and bathrooms that they used in hospital? Very clean Fairly clean Not very clean Not at all clean Didn’t use 6. How would you rate the hospital food provided for them? Very good Good Fair Poor Didn’t have any Doctors

7. When your relative had important questions to ask a doctor, did they get an answer that they could understand?

Yes, always Yes, sometimes No I had no need to ask Don’t know 8. Did you have confidence and trust in the doctors treating them? Yes, always Yes, sometimes No Don’t know 9. Did doctors talk in front of them as if weren’t there? Yes, always Yes, sometimes No Don’t know Nurses



10. When your relative had important questions to ask a nurse, did they get an answer that they could understand?

Yes, always Yes, sometimes No I had no need to ask Don’t know 11. Did you have confidence and trust in the nurses treating them? Yes, always Yes, sometimes No Don’t know 12. Did nurses talk in front of them as if they weren’t there? Yes, always Yes, sometimes No Don’t know 13. In your opinion, were there enough nurses on duty to care for your relative in hospital? There were always or nearly always enough nurses There were sometimes enough nurses There were rarely or never enough nurses



Your relatives care and treatment 14. Sometimes in a hospital, a member of staff will say one thing and another will say

something quite different. Did this happen to your relative? Yes, often Yes, sometimes No Don’t know 15. Were they involved as much as they wanted to be in deciding about their care and treatment? Yes, definitely Yes, to some extent No Don’t know 16. How much information about their condition or treatment was given to them? Not enough The right amount Too much Don’t know 17. If you wanted to talk to a doctor about your relative, did you have enough opportunity to do so? Yes, definitely Yes, to some extent

No I was not involved I did not want or need information My relative did not want me to talk to a doctor 18. Did your relative find someone on the hospital staff to talk to about their worries and fears? Yes, always Yes, sometimes No They had no worries or fears Don’t know 19. Were they given enough privacy when discussing their condition or treatment? Yes, always Yes, sometimes No Don’t know 20. Were they given enough privacy when being examined or treated? Yes, always Yes, sometimes No Don’t know 21. Did they get enough help from staff to eat their meals? Yes, always Yes, sometimes No Don’t know 22. How many minutes after they used the call button did it usually take before they got the

help they needed? 0 minutes-right away 1-2 minutes 3-5 minutes More than 5 minutes They never got help when they used the call button They never used the call button Don’t know Pain

23. Were they ever in any pain? Yes No Don’t know




24. Do you think the hospital staff did everything they could to help control their pain? Yes, definitely Yes, to some extent No Operations and procedures

25. During their stay in hospital, did they have an operation or procedure?

Yes No Don’t know


26. Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way that they could understand?

Yes, completely Yes, to some extent No Don’t know 27. Beforehand, did a member of staff explain to your relative what would be done during

the operation or procedure? Yes, completely Yes, to some extent No Don’t know 28. Beforehand, did a member of staff answer any questions about the operation or

procedure in a way that your relative could understand? Yes, completely Yes, to some extent No Don’t know 29. Beforehand, were they told how they could expect to feel after you had the operation or

procedure? Yes, completely Yes, to some extent No Don’t know 30. Before the operation or procedure, were they given an anaesthetic to put them to sleep

or control their pain? Yes No Don’t know


31. Before the operation or procedure, did the anaesthetist explain how they would put your relative to sleep or control their pain in a way that they could understand?

Yes, completely Yes, to some extent No Don’t know

32. After the operation or procedure, did a member of staff explain how the operation or procedure had gone in a way that they could understand?

Yes, completely Yes, to some extent No Don’t know Leaving Hospital 33. Did a member of staff explain the purpose of the medicines that your relative was to

take home in a way that they and or you could understand? Yes, completely Yes, to some extent No Don’t know



Please go to Q34

They had no medicines Please go to Q40 34. Did a member of staff tell them or you about medication side effects to watch for when

they went home? Yes, completely Yes, to some extent No Don’t know

35. Were they or you given clear written information about their medicines? Yes, completely Yes, to some extent No Don’t know Can’t remember 36. Did a member of staff tell them or you about any danger signals you should watch for

after they went home? Yes, completely Yes, to some extent No It was not necessary Don’t

know

37. Did the doctors or nurses give them or you all the information needed to help them recover? Yes, completely Yes, to some extent No My relative/I did not want any information Don’t know 38. Did hospital staff tell them or you who to contact if you were worried about their

condition or treatment after they left hospital? Yes No Don’t know Cant remember

39. Did they receive copies of letters sent between hospital doctors and their family doctor (GP)?

Yes, I received copies No, I did not receive copies Don’t know Overall

40. Overall, did you feel they were treated with respect and dignity while they were in the hospital?

Yes, always Yes, sometimes No

41. Overall, how would you rate the care they received? Excellent Very good Good Fair Poor

42. During their hospital stay, were they or you asked to give views on the quality of thier care?

Yes No Don’t know Cant remember

Section B

Please answer the following questions only if your relative/patient was referred to mental health services during their most recent stay in the general hospital

1. Were they referred to the mental health services during thier most recent stay in hospital?

Yes No Don’t know



Please go to Q2 Please go to Section C

2. Were they able to get help from this service when they needed it?

Yes, definitely Yes, to some extent No Don’t know 4. When they had important questions to ask about their mental health needs, did they get

an answer that they could understand?

Yes, always Yes, sometimes No I had not need to ask

4. Did they have confidence and trust in the mental health services treating them?

Yes, always Yes, sometimes No 5. Were they involved as much as they wanted to be in deciding about their mental health car

treatment?

Yes, definitely Yes, to some extent No I did not want to be involved Don’t know

6. How much information about their mental health condition or treatment was given to them

Not enough The right amount Too much I did not want any information Don’t know

7. Did they find that they could talk through their worries and fears with the mental health sta

Yes, definitely Yes, to some extent No I had no worries or fears Don’t know

8. Were they given enough privacy when discussing their mental health condition or treatmen

Yes, always Yes, sometimes No I did not want to discuss it Don’t know

If there is anything else you would like to tell us about yours or your relatives experiences of the mental health services available to them during their most recent stay in the general hospital, please tell us about it here.

9. Was there anything particularly good about this service?

10. Was there anything that could be improved?



11. Any other comments?

12. Please tell us about any mental health care your relative is receiving at the moment:

Section C We would like to invite you to participate in a telephone interview in order to discuss your views on the care your relative received. This will last approximately 20 minutes. The interview will be recorded to help us to understand key factors that need to be addressed. The content of this discussion will remain strictly confidential and your anonymity will be guaranteed at all times. If you would like to participate please indicate this by completing the information below:

Would you be willing to participate in a telephone interview?

Yes No

When would be a convenient time to call?

Date Time



What is your telephone number?

Name ………………………………………………………



Appendix 20: Evaluation – Patient and relative telephone interview schedule


Formal evaluation process

Patient and relative telephone interview schedule - guidelines Suggested introduction: Ensure speaking to consented participant Hello, my name is …. I’m calling from … hospital. You may remember that during your (your relatives) recent stay in hospital, we asked you if you would like to take part in a research project aimed at looking at how we can improve the services available to you. Thank you for returning the questionnaire we sent to you recently, and for agreeing to take part in a telephone interview. Is this a convenient time to conduct the interview? If agree to proceed: Thank you. The interview should last for approximately 20 minutes. The interview is designed to understand your experiences of care in the general hospital. (If received services from mental health: It is also designed to ask about your experiences of the care received from your local mental health services). To help us to understand what your experiences have been, we would like to record this conversation. This will allow me to look back over what we have discussed in more detail. Once I have reviewed the recording, the tape will be destroyed. Anything that you say will be kept completely confidential and your anonymity will be maintained at all times. Is this ok with you? Do you have any questions before we proceed? If do not agree to proceed: Please record reasons for this, if known. Question guidelines Could you describe your (or your relatives) recent stay in the general hospital? What were you (or your relatives) admitted for? How long did you (or your relatives) stay in hospital this time? What was good and bad about the service offered/given? What help was offered? Was this ok? What else could have been done to help you? Did you require help from the mental health services? Was this at your (or your relatives) request? If not, who requested help? When was this help requested offered? Should you have been offered this help sooner? If so, why? What help was offered? If offered, did you understand the advice given and any information you received? What was good and bad about the service offered/given? Do you continue to have contact with the mental health services?



What follow arrangements were made when you were discharged? Was this ok with you? If not, why? If yes, why? Conclusion Suggested ending: We have been talking for over --- minutes now and I don’t want to keep you any longer. Thank you very much for taking the time to help with this research. Your views on the care you (or your relative) received are very important to us. We must finish the interview now. Do you have any questions before we close?



Appendix 21: Evaluation – Staff skills questionnaire

Mental Health Needs of Older People

in General Hospital Settings Dear colleague,

We are interested in how we can improve the care of patients over the age of 65 years in

general hospital, some of whom may have mental health needs. Given all the competing demands upon your time, we would like to know your views about caring for these patients and what

changes might work,

Numbers of these patients admitted to general hospital wards are increasing, affecting staff health and morale, but the problem is a low priority for commissioning managers. Your views will

be an important influence upon future changes in the care provided.

Please help us by completing this short survey (about 5 minutes): you will contributing towards a national study taking place in 12 hospitals across England. The findings will be used to lobby

commissioners to make positive changes that will help you and patients identify appropriate and feasible care.

We will value all of your responses but of course leave any questions you do not wish to answer.

Your responses will remain completely anonymous (there is no identification on this form) and treated as confidential. Findings will only be reported for the whole survey, not individual

hospitals.

As a ‘thank you’ for participating, we will make a gift of £50 of M&S vouchers to the ward with the highest number of returned questionnaires.

When returning this questionnaire, please seal it in the envelope provided and leave it in the box

placed on your ward. Questionnaires will be collecting over the next week.

If you have any questions about this, please contact your local researcher or a member of the research team at The University of Leeds: details below.

A big thank you to you from us for taking time to read this and for considering our questionnaire. (Local researcher) Dr John Holmes (Chief Investigator)

tel: 0113 343 2469 e-mail: [email protected] Carolyn Montaňa (Project Manager) tel: 0113 343 1964 e-mail: [email protected] Academic Unit of Psychiatry and Behavioural Sciences The University of Leeds, 15 Hyde Terrace, Leeds, LS2 9LT



Is it fair?

1. Do you think that older people with mental health needs get a bad deal when compared to younger adults with mental health needs when admitted to a general hospital?

Strongly agree Agree Neutral Disagree Strongly disagree Don’t know


2. Please tick any of the reasons listed below if you feel these contribute to the bad deal.

Amount of information given to patients Level of involvement in decisions about care Lack of recognition about longer rehabilitation/recuperation period Amount of training available to staff to help care for these patients Level of staffing needed to help care for these patients Support from other professionals/agencies Other (please state below)

3. Do you think that patients with mental health needs should be admitted to a

general hospital ward?

Yes No Don’t know

4. Do you think that older patients with mental health needs should be admitted to the ward that you work on?

Yes No Don’t know

Guidelines?

5. Does your ward have a protocol or guideline in place to help you care for older patients with mental health needs?

Yes No Don’t know


6. What is covered in your protocol/guidelines (Please tick all that apply)



Referral Diagnosis Treatment Don’t know

Delirium

Dementia

Depression 7. Which of the following NHS documents are available to you at work?

NSF for Older people NICE guidelines on Dementia NICE guidelines on Depression

Size of the problem?

8. Approximately what percentage of older people admitted to your ward do you perceive as having mental health needs?

Less than 10% 10-20% 20-30% 30-40% 40-50%

50-60% 60-70% 70-80% 80-90% more than 90%

9. What do you think should take place when an older person is admitted to your ward? Read each statement carefully and score the extent that you agree it.

Score: 1 Strongly disagree 2 Disagree 3 Neutral 4 Agree 5 Strongly Agree

For patients aged 65 years or over in the general hospital: Score

Patients should routinely have a mental health assessment on admission

General nursing staff should be adequately trained to conduct mental health assessments

General nursing staff should be adequately trained to care for older people with common mental health needs

10. Do you assess patients for mental health needs?

Yes No Don’t know

11. How do you assess patients for mental health needs? (please tick all that apply)

History taking Assessment tools Don’t know

12. How comfortable do you feel when assessing older patients for mental health needs? Read each statement carefully and score the extent that you agree with it.

Score: 1 Strongly disagree 2 Disagree 3 Neutral



4 Agree 5 Strongly Agree


I feel comfortable assessing older patients for low mood

I feel comfortable assessing older patients for confusion

I feel comfortable assessing older patients who may have self harmed

I feel comfortable assessing older patients following a suicide attempt

I feel comfortable assessing capacity in older patients

13. What level of support would allow you to care for this group of patients?

Read each statement carefully and score the extent that you agree it.

Score: 1 Strongly disagree 2 Disagree 3 Neutral 4 Agree 5 Strongly Agree


I have received adequate training to help me to assess older people’s mental health needs

I have received adequate training to help me care for older people with mental health needs

I know what psychiatric service is available in this hospital for older patients

I am in a position to contact the psychiatric service to request their input

I know how to go about referring older patients with mental health needs for psychiatric input

Mental ill health is a common reason for delayed discharge of medically fit patients

Mental ill health in patients aged 65 or over in my care is adequately managed

Help available to you?

14. Have you ever requested help from the psychiatric services in this hospital to help you care for your patients?

Yes No Don’t know

15. If you have requested help, please indicate if you have found the service helpful:

Strongly agree Agree Neutral Disagree Strongly disagree Don’t know

16. Do you think patients presenting with symptoms of mental health needs should be referred for specialist assessment? How often would you or your colleagues request for the following issues: Always Often Sometimes OccasionallyNever



Acute confusion such as delirium Longstanding confusion such as dementia Low mood Self harm Attempted suicide Wandering Refusal to take medications Aggression Agitation Discharge planning/capacity advice On psychotropic meds (for review/advice)

Can we make things work better?

17. Would you like further training in assessing and/or caring for older patients with mental health needs?

Yes No Don’t know

18. In these patients what specifically would you like further training in?

Assessing Caring

Acute confusion such as delirium Longstanding confusion such as dementia Depression Self harm Attempted suicide Wandering Refusal to take medications Aggression Agitation Discharge planning/capacity advice Psychotropic medication use Other (please state below)

19. What training style best suits your needs? Please tick all that apply Small group teaching Advice/fact sheets Role-modelling Half-day

courses

Lectures Case studies Day courses Short

presentations

20. Tell us about you: Hospital: Profession:

Department: Grade:

Ward: Today’s date:



21. Hang on a moment!

If you have further comments or think we are missing something please tell us:

21. If our ward wins the £50 M&S vouchers, I think the best way to spend this money would be on:

Thank you for completing this questionnaire! Please feel free to add any further comments or suggestions on the back page



Appendix 22: Evaluation – General hospital staff focus group guidelines


Topic guidelines for interviews and/or discussion groups with general hospital staff

Introductions Thank you Self Purpose – interested in own experiences Confidentiality

Of the project - remove identifiers, transcribe external to Trust, delete tapes Within the group - what's said in the group stays in the group

Information sheets and Consent forms (read out and signed and returned) Any questions? Groundrules - refreshments; talking one at a time. Have you at some time nursed an older person on a hospital ward you thought had mental health problems? Those experiences and thoughts about them that are the subject for the group. Questions Care experience What are your experiences? (What happens at the moment when there is an older person on the ward who you think may be experiencing mental health difficulties?)

Think back to the last time this happened, relate the events and your experiences of them. What happened? To who? (who was involved) What was the outcome?

o For you o For the patient o others

How satisfied were you with this? o What was good? o What was not good?

Is this familiar to others – in what ways the same, in what ways different? What types of mental health problems do you come across? (how do staff recognise someone has a mental health difficulty and at what stage is it recognised?)

How do you recognise it/them? What are the procedures to manage it? Is this familiar to others – in what ways the same, in what ways different? Are there any other types of mental illness encountered not already mentioned?

How able are you and how able do you think most general nurses are to recognise if an older patient has a mental health problem? How able are you and how able do you think most general nurses are to manage older patients with mental health difficulties?



How well do you think the ward is able to meet the needs of older people with mental health difficulties? Mental health service What types of problems do you think should be referred to the mental health services (state what these are i.e. liaison nurse)? Thinking about the strong points of the service the ward offers to this patient group and the weaknesses?

ward environment procedures organisation staff skills

Are there other people or services they can call on? Who? What are the strong points of these services and what are the weaknesses? What steps could be taken to improve the service given to older people with mental health difficulties on the ward where they work (not already discussed)?

staff – knowledge and skills, skill mix environment procedures

Knowledge/guidelines Are you aware of any national guidelines or policies published to help you to care for older people with mental health needs? If so, have you read them or do you know how they are designed to help? If haven’t read them, why is this? Training Would any type of training help you to manage older people with mental illness better than at present?

What would this training look like? (How can training needs be best met?) Are there any particular training priorities? What would help you put this training into practice once you are back on the ward? Do

you think there are any barriers to acting on what you will have learned through training and development?

Winding up Is there anything else it would be helpful for me to know? Are there any questions before we finish? Check participants have contact details Thank you



Appendix 23: Evaluation – Referrer feedback questionnaire

General hospital-based referral to psychiatric services for patients aged 65 years and over

Referrer feedback survey Please use the following rating scale to rate your level of satisfaction with the current service provision to the following questions: 1-Very dissatisfied / 2-Dissatisfied / 3-Neither satisfied or unsatisfied / 4-Satisfied / 5-Very satisfied /6-not applicable (please tick this box if you do not know) please tick one box for each question All questions relate to patients aged 65 years or over in the general hospital 1 2 3 4 5 6 How satisfied are you with the speed of response of the service?

How satisfied are you with the feedback you receive from the service following their assessment? (please tick box 6 if you do not receive feedback)

How satisfied are you with the speed of the feedback you receive regarding your referral?

How satisfied are you with the way in which feedback information is provided?

How satisfied are you with the follow-up arrangements after assessment?

How satisfied are you with the current service for older people overall?

Please state your most common reasons for referral: Have the reasons for your referrals changed at all recently (within the last 6 months)? Yes No If yes, please state reasons for change:

MEDICAL (training grade)

NURSE Status of feedback giver

(please tick ) MEDICAL (senior grade)

OTHER



If your expectations of the psychiatric service have changed recently, please state reasons for this:

Does the current service meet your expectations? (please tick one box) Yes Partially No

If not (or only partially), why not?



Please return this questionnaire sealed in the return envelope to the name and address given below:

Insert address label here

Many thanks for your help

Appendix 24: Evaluation – Admitted patient data collection form


Prospective patient data collection To be completed for all patients referred to the Mental Health

Services Section A Identification details

Section B Referral details

What have the psychiatric services done well? What could the psychiatric services do better?

Any other comments or feedback about the service?

I1

Site code

I2

Hospital code

I3

Patient ID

NHS number

I4

DOB I5

Age I6

Gender I7

Ethnicity



R6 Reasons for referral Please put number 1 next to main presenting reason and tick all other reasons that are

mentioned

Reason Mentioned Reason Mentioned

Depression/low mood Dementia

Delirium Memory loss

Dementia with delirium Alcohol related

Drug related Self harm related

Anxiety related Confusion

R7 Other (please state)

Section C Referral outcome

Initial action taken Please tick all that apply

Telephone adviceO2 Assessment arrangedO3 Patient dischargedO4 OtherO5

O7 What other action has been taken as a result of this referral? Please tick all that apply

No action Referred to CMHT GP Informed Other

R1

Date of referral

R2

Referring ward

R3

Speciality code

Profession/Name of referrer

R4

Profession code

R5

Name code

O1

Date referral received O1a Number of working

days lapsed since referral made

O1b Number of actual days lapsed since referral

made

O2a If advice given over the telephone, please state what this was and reasons for this:

06 Please state any other outcomes arising from this referral:

O8 If any other actions taken as a result of this referral, please state what this was:



Section D Assessment outcome and discharge from service

A4 Were there any delays between receipt of referral and assessment date?

Yes No

A5 Reasons for delays Please tick all that apply Patient not available Patient refused

Staff clinically busy Staff on annual leave/study leave Staff sickness Other

A7 Was the patient visited by the assessor? Yes No

A8 What was the outcome of the assessment? Please tick all that apply

Behaviour management plan Nursing management plan Medication

recommendation Review arranged Referral elsewhere

Other

A11 Has the patient been reviewed in hospital following the assessment?

Yes (if yes, please go to question A12) No (if no, please go to question 13)

A1

Date of assessment A1a Number of working days lapsed between

referral and assessment date

A1b Number of actual days lapsed between

referral date and assessment date

A1c Number of working days lapsed between referral receipt and assessment date

A1d Number of actual days lapsed between referral receipt and assessment date

Profession/Name of assessor

A2

Profession code

A3

Name code

A12Review number and date

Number of working days lapsed

Number of actual days lapsed

1(a)

A9/A10 If referred elsewhere – please state where to. If there is an outcome of the assessment other than those listed above, please state what these are:

A6 If delays were due to reasons not mentioned above, please state what these are:



A13 If action is required is it carried out? (review acute trust case notes)

Yes No Not applicable

A15 Arrangements on discharge from service Transfer CMHT referral O/P clinic GP Other

A17 Mental health problem Please tick all that apply



Drug related Capacity assessment Other

A19 Outcome of capacity assessment

Has capacity Does not have capacity Don’t know A20 How would you rate the quality/breadth of psychiatric case notes?

Section E Admission details

D6 How long has the patient been in hospital during this admission and what has been their care pathway (i.e. transfers) prior to referral?

2(b)

3(c)

4(d)

More than 4(e)

Average number

Average number

D1

Date of admission

D1a

Number of days between admission and

referral

D1b

Number of days between admission and

assessment

D2

Admitting ward

D3

Speciality code

D4

PCT area/ postcode

D5

Type of admission

A14 If actions required have not been carried out, please state reasons for this:

A16 If other arrangements have been made following discharge from the mental health service, please state what this is:

A18 If a mental health problem is indicated that is not listed above, please state what this is:



D7 Reasons for admission

Chest pain Cancer Collapse COPD Stroke Heart failure Pneumonia Abdominal pain UTI Broken

Bone Other

D10 Are any of the medications listed above used for psychotropic use?

Yes (If yes, please go to question D11) No (If no, please go to question D13) D11 If answered yes to D10, which conditions are these medications prescribed for:



Drug related Other

D14 Charlson rating

D9 Medication on admission:

D13 Please list concurrent medical conditions:

D8 Please describe reasons for admission if not shown above:

D12 If prescribed medication are used to treat a mental health condition that is not listed above, please state what this is:



D15 Previous hospital admissions within the last 12 months

Date Length of stay

Reason Reason code

1(a)

2(b)

3(c)

4(d)

4 or more(e)

Average Most common reason

D16 Previous psychiatric history noted within acute hospital notes Yes (If yes, please go to question D17) No (If no, please go to section F) D17 Please tick if any of the following conditions are mentioned in previous admissions

notes:



Drug related Capacity assessment Other Section F Social details S1 Marital status

Married/ Co-habiting Single Widowed Divorced Separated

S2 Housing

Owner/Occupier Council/HA Tenant Private Landlord Other

S4 Residential Classification:

S3 If other housing arrangements to those listed above, please state what these are:

D18 If a mental health problem is indicated that is not listed above, please state what this is:



Living alone Living independently with spouse/partner Living with

relative/friend Sheltered accommodation Residential home Nursing home

Hospice/Hospital

S5 Does the patient have an existing care package? Yes (If yes, please go to question S7) No (If no, please go to section G) S6 If patient has an existing care package, please state what this consists of

Care package Hours per month Social care Family care Home care Nursing care S7 Other (please state)

Section G Consent to participation – Part 1 - patients C1 Patient still in hospital at time of first research assessment visit?

Yes (If yes, please go to question C3) No (If no, please go to section I)

C3 Patient has capacity to give consent? Yes (If yes, please go to question C5) No (If no, please go to question C4)

C4 If incapicitious, is this due to a mental health problem?

Yes (If yes, please go to question C10) No (If no, please go to question C5) C6 Patient agreement to participate? Yes (If yes, please go to question C8) No (If no, please go to question C7)

C8 Patient consent form signed?

Yes (If yes, please go to part 2, question C14) No (If no, please go to question C9)

C5 If patient is incapacitious which is not due to a mental health problem, please state what incapacity is related to:

C2 If patient is no longer in hospital, please state reasons for this including dates:

C7 If patient has not agreed to participate, please state reasons given for this:



C10 If patient is incapacitious, has assent been sought?


C12 Patient assent form signed?

GDS (Yesavage J et al 1983) No Question Yes No Score 1 Are you basically satisfied with your life? 0 1









1 0







Total x x T8


2 Changes in habits


C11 If assent is required but has not been sought, please state reasons for this:



Yes (If yes, please go to section

G) No (If no, please go to question C13)

Section G Consent to participation – Part 2 – relatives/carers

C14 Has a relative/carer been asked to consent to participation?


C16 If approached, has a relative/carer consented to participation?


C18 Relative/carer consent form signed?

Yes (If yes, please go to section I) No (If no, please go to question C19)

Section H Symptom assessment – Time 1 T1 Patient still in hospital at time of first research assessment visit?


T10 All assessment tools completed?


T12 Do the results of these assessments need reporting to care staff?


4 Information test

5 Memory

6 Concentration

Total T9

T3

Date of assessment

T3a

Number of days between assessment

and referral date

T3b

Number of days between assessment and admission date

T4

MMSE score T5

DRS score T6

Barthel score

T7

Self rated health

T11 If all of the above assessment tools have not been completed, please state reasons for this below:

T13 If yes, please state reasons for this below. Please also state what action you have taken:

C17 If consent by relative/carer has not been agreed, please state reasons for this:

C19 If a relative/carer has not signed a consent form, please state reasons for this:

C15 If a relative/carer has not been approached to participate, please state reasons for this:

T2 If patient is no longer in hospital, please state reasons for this including dates:



Section I Case note and medication chart review N1 Evidence of assessment of mental health needs during this admission by general hospital staff Nothing Mentioned Unstructured history taking Structured assessment

N3 Evidence of actions taken by general hospital staff as a result of above assessments Please tick all that apply Referral to services Changes to medication (If yes, please go to question N5) Other

N5 Please state what if any changes have been made to medication as a result of any mental health assessments undertaken by general hospital staff New prescription Existing dosage increased Existing dosage decreased Other

N7 Is there any evidence in the case notes indicative of mental health needs not already mentioned above? Yes (If yes, please go to question N8) No (If no, please go to question N10)

N8 Please state what evidence indicates mental health needs not already mentioned Please tick all that apply Wandering Poor appetite Poor sleep Confusion Memory loss Other

N10 Are there any mental health needs protocols in place on this ward? (please ask staff on ward if not

sure)

Yes (If yes, please go to question N11) No (If no, please go to question N13) N11 If there are protocols in place, is there any evidence for these protocols being used for

this patient?

Yes (If yes, please go to question N12) No (If no, please go to question N13)

T14 Please document the main comments, if any, made by patients (and/or their relatives/carers) on the quality of care they receive whilst in hospital:

N2 If structured assessment undertaken, please state what was used:

N4 If other actions taken as a result of the above assessments, please state what these are:

N6 If other changes to medication noted as a result of mental health assessments, please state what these are:

N9 If other evidence of mental health needs, please state what this is:



GDS (Yesavage J et al 1983) No Question Yes No Score 1 Are you basically satisfied with your life? 0 1









1 0







Total x x P8

BDS (Blessed G et al 1968) No Event Score 1 Changes in performance of everyday

activities

2 Changes in habits


4 Information test

N13 Any other comments on case notes/nursing notes contents:



Section J

Symptom assessment – Time 2 (To be completed for patients assessed at Time 1)

P1 Patient still in hospital at time of second research assessment visit?


P10 All assessment tools completed?


P12 Do the results of these assessments need reporting to care staff?

Yes (If yes, please go to question P13) No (If no, please go to question P14) Section K Discharge E1 Has the patient been discharged within the evaluation period?


E7 Is there any evidence of delays in discharge experienced due to non-medical need?


5 Memory

6 Concentration

Total P9

P3

Date of assessment

P3a

Number of days between first and

second assessment

P4

MMSE score P5

DRS score P6

Barthel score

P7

Self rated health

E2

Date discharged E3

Length of stay E4

Where discharged to E5

Discharge code

E6 If the patient has not been discharged within the evaluation period, please give reasons for this:

P2 If patient is no longer in hospital, please state reasons for this including dates:

P11 If all of the above assessment tools have not been completed, please state reasons for this below:

P13 If yes, please state reasons for this below. Please also state what action you have taken:

P14 Please document the main comments, if any, made by patients (and/or their relatives/carers) on the quality of care they receive whilst in hospital:



E9 Have these delays been related to a mental health need?


E12 Are any of the medications listed above used for psychotropic use?

Yes (If yes, please go to question E13) No (If no, please go to question E15) E13 If answered yes to E12, which conditions are these medications prescribed for:



Drug related Other

E15 Does the patient have a discharge care package? Yes (If yes, please go to question E16) No (If no, please go to question E18) E16 If patient has a different care package on discharge, please state what this consists of:

Care package Hours per month Social care Family care Home care Nursing care E17 Other (please state)

Section L Patient/relative feedback This section should be completed only for those patients and/or relatives/carers

for whom consent or assent has been obtained

Date due to be contacted

Date questionnaires

sent

Date questionnaires

returned Patient F1

F3 F5

E11 Medication on discharge:

E18 Any other comments on discharge:

E10 If no, what was the reason for this delay?

E14 If prescribed medication are used to treat a mental health condition that is not listed above, please state what this is:



F8 Patient interview: Has the patient agreed to telephone interview?


F10 If yes, please state date/time arranged

F11 Has the interview been carried out?



F14 Relative/carer interview: Has the relative/carer agreed to telephone interview?





This data should not be returned with any documentation sent to the main site at The University of Leeds. Please ensure contact details are removed and shredded at the point of form completion. Patient name

Patient address

Relative/ Carer

F2

F4 F6

F7 Reasons for any delays in follow-up:







Patient tel no

Relative/carers name

Relationship to patient

Relative/carers address

Relative/carers tel no



Appendix 25: Evaluation – Key stakeholder interview schedule

Mental Health needs of Older People in General

Hospital Ward settings

Context of service Write-up guidelines

Purpose: To provide a description of the local service to set it in context with the data obtained throughout the evaluation period. Most of this information should be obtained through informal discussion with hospital based and mental health service staff. In the event that this information has not been obtained, a short interview with a key clinician in a general hospital ward should be conducted using the key points as question guidelines Key points to include: Are there any champions or colleagues with special interest in liaison work? Have there been any developments/changes in the way in which the mental health service operates within the general hospital within last 3 years? What has led to these developments/changes? Are there imminent plans to change the way in which the mental health service operates within the general hospital? What has led to these plans? What are viewed as the main barriers and drivers to service development? Are there changes that you would like to see, if so what are these and what is the rationale for this? Describe the interface of management between the hospital trust, mental health trust and PCT? What other services are there available for this group of people? How do their referral criteria differ/overlap? Do you know what national guidelines and policies there are for helping to manage this group of patients? How do you influence policy? Examine local documentation to see where the service fits into the local commissioning framework If in doubt about what these are, speak to key clinicians providing the service Report on: Size of hospital(s), local population, other hospitals not included in the evaluation, number of elderly admissions, number of designated CE beds, number of medical/surgical beds



Appendix 26: Evaluation – Routine hospital admission data variables Admission Date Hospital Age Gender Ethnicity Admission type (emergerncy/elective) Place of residence at admission Speciality admitted to Primary diagnosis Secondary diagnosis Tertiary diagnosis Discharge destination Discharge date Length of stay



Appendix 27: Evaluation – Chief Investigator invite to potential evaluation sites Tel e-mail

06 December 2006 Dear Dr Mental Health Services for Older People in General Hospital Settings – Formal Evaluation

Our research team have been commissioned by the NHS Service Delivery and Organisation (SDO) R&D Funding Stream to carry out a project evaluating liaison mental health services for older people. This builds on our previous mapping work, which has led to the development of liaison mental health services for older people in many parts of the UK. This stage of our project process requires us to identify 12 sites across the UK in order to carry out on-site, in-depth pragmatic evaluations of different service models currently in use. The evaluation will run for a 3 month period. Data collection will be facilitated by full-time researchers based at each site. We would like to involve the services based at We would be very grateful for your assistance with this. Please could you indicate whether you would be interested in becoming involved in this valuable research by contacting the project manager as soon as possible. If you have any queries regarding this request, or about the project in general please contact either the project manager or Dr John Holmes (principal investigator) and we will be happy to help. We look forward to hearing from you soon. Yours sincerely Carolyn Montaňa Project Manager



Appendix 28: Evaluation – Timetable to completion

Formal sites - timescale updated 24/06/08

Sheffield Huddersfield Manchester Wansbeck Liverpool Kingston Walsall Cambridge Leeds Newcastle Southend Mth w/c

TSM LPN TSM HMHTsmall HMHTlarge LPN LPN HMHTsmall HMHTlarge HMHTlarge TSM

w/c

08/01/2007 08/01/2007

15/01/2007

15/01/2007

22/01/2007

22/01/2007 Janu

ary

29/01/2007

PI: Dr Eric Gehlhaar appl PI: Dr Joy Ratcliffe

29/01/2007

05/02/2007 05/02/2007

12/02/2007

appl

PI:

Dr D

ave

Ande

rson

12/02/2007

19/02/2007

appl

PI:

Dr P

eter

Bow

ie

19/02/2007

Febr

uary

26/02/2007

appl

PI:

Dr C

hris

Aus

tin

Staf

f rec

ruitm

ent 5

2.5h

p/w

appl

PI:

Dr U

sman

Kha

lid

26/02/2007

05/03/2007 R (1) training 05/03/2007

12/03/2007 1 12/03/2007

19/03/2007 2

appl

PI:

Dr C

hooi

Lee

appl

PI:

Phil

Wal

msl

ey

appl

PI:

Dr D

ebor

ah G

irlin

g

19/03/2007

Mar

ch

26/03/2007

Staff recruitment 30h p/w

3

appl

PI:

Dr A

Car

mic

hael

26/03/2007

02/04/2007 R (1&2) R (2) training 02/04/2007

09/04/2007 2 5.1

appl

PI:

Dr T

ony

Hol

ton

09/04/2007

16/04/2007 3 6.2

LREC

and

R&D

app

l PI:

Iain

Kee

nan

16/04/2007 April

23/04/2007 4.1 (access) 7.3

appl

PI:

Dr R

uth

Adam

s

23/04/2007

30/04/2007 5.2 8.4 30/04/2007

07/05/2007 6.3 9.5 07/05/2007

14/05/2007 7.4 10.6 14/05/2007

May

21/05/2007 8.5 11.7 21/05/2007

28/05/2007

Add

staf

f rec

ruitm

ent 1

5h p

/w

9.6 12.8 28/05/2007

June

04/06/2007

Staf

f rec

ruitm

ent 4

5h p

/w

10.7 R (3) training ext (r1) 13.9

staf

f rec

ruitm

ent 5

2.5h

p/w

appl

: Dr C

hapl

in

Staf

f rec

ruitm

ent 6

0h p

/w

Staf

f rec

ruitm

ent 3

4h p

/w

Staf

f rec

ruitm

ent 3

5h p

/w

Staf

f rec

ruitm

ent 3

5h p

/w

appl

PI:

Dr D

unca

n Fo

rsyt

h

Staf

f rec

ruitm

ent

MH

app

l PI:

Dr E

lizab

eta

Muk

aeto

va

Staf

f rec

ruitm

ent 5

6.5

h p/

w

PI: D

r Dav

id T

ulle

tt

04/06/2007



11/06/2007 11.8 14.10 11/06/2007

18/06/2007 12.9 15.11 18/06/2007

25/06/2007 13.10 (end R3) 16.12 25/06/2007

02/07/2007 R (1/2) training 14.11 17.13 R (1/2) training 02/07/2007

09/07/2007 1 15.12 18 1 09/07/2007

16/07/2007 2 16.13 2 16/07/2007

23/07/2007 3.1 HRC cleared Staff recruitment 9hrs

p/w 3 23/07/2007

July

30/07/2007 4.2 17 R (4) training R (1/2) training 4.1 HRC cleared)

PCT

PI: D

r Sim

on K

err

30/07/2007

06/08/2007 5.3 18 1 5.2 06/08/2007

13/08/2007 6.4 19 2 6.3 13/08/2007

20/08/2007 7.5 20 4 7.4 20/08/2007

Augu

st

27/08/2007 8.6 21 4.1 HRC cleared 8.5 27/08/2007

03/09/2007 9.7 22 5.2 9.6 03/09/2007

10/09/2007 10.8 23 6.3 10.7 R (1/2) training 10/09/2007

17/09/2007 11.9 24 7.4 11.8 1 17/09/2007 Sept

embe

r

24/09/2007 12.10 25 8.5 12.9 2 24/09/2007

01/10/2007 13.11 26 9.6 13.10 3 R (1)

training 01/10/2007

08/10/2007 14.12 27 10.7 14.11 (R2 end) 4 1 R (1) training 08/10/2007

15/10/2007 15.13

Addi

tiona

l sta

ff re

crui

tmen

t 15h

p/w

28 11.8 15.12 5 2 1 15/10/2007

22/10/2007 29 R (5) training 12.9 16.13 6 3 2 22/10/2007

Oct

ober

29/10/2007 30.1 13.10 7 4 3 29/10/2007

05/11/2007 31.2 14.11 8 5 4 05/11/2007

12/11/2007 32.3 15.12 9 6 5 12/11/2007

19/11/2007 33.4 16.13 10 7 6 HRC cleared 19/11/2007 Nov

embe

r

26/11/2007 34.5 11 8 7 26/11/2007

03/12/2007 35.6 12 9 8 03/12/2007

10/12/2007 36.7 13 10 9 10/12/2007

Dec

embe

r

17/12/2007

37.8

Acce

ss m

issi

ng d

ata

Acc

ess

mis

sing

dat

a

Acce

ss m

issi

ng d

ata

Acc

ess

m

iss

ing

d

ata

11 10

Acut

e ap

pl: P

.I. D

r Low

e

17/12/2007



24/12/2007 38.9 12 11 24/12/2007

31/12/2007 39.10 (no cost ext) 13 12 31/12/2007

07/01/2008 40.11 13 07/01/2008

14/01/2008 41.12 14/01/2008

21/01/2008 42.13 21/01/2008

Janu

ary

28/01/2008 28/01/2008

04/02/2008 04/02/2008

11/02/2008 11/02/2008

18/02/2008 18/02/2008

Febr

uary

25/02/2008

staff recruitment

25/02/2008

03/03/2008 R (1,2,3) training R (1/2) training 03/03/2008

10/03/2008 10/03/2008

17/03/2008 17/03/2008

24/03/2008

staf

f rec

ruitm

ent

24/03/2008

Mar

ch

31/03/2008 R (1) training 31/03/2008

07/04/2008

HR

C c

lear

ance

R off sick 07/04/2008

14/04/2008

Acc

ess

mis

sing

dat

a

1 1 14/04/2008

21/04/2008 2 2 21/04/2008

April

28/04/2008 3

Researcher off sick/terminate contract/recruit researcher time

3 end) 28/04/2008

05/05/2008 4 05/05/2008

12/05/2008 5 12/05/2008

19/05/2008 6 clear 19/05/2008

May

26/05/2008 7.1 26/05/2008

02/06/2008 8.2 02/06/2008

09/06/2008 9.3 09/06/2008

16/06/2008 10.4 16/06/2008

23/06/2008 11.5

HRC clearance

staf

f rec

ruitm

ent

23/06/2008

June

30/06/2008

Acc

ess

mis

sing

dat

a

Acc

ess

mis

sing

dat

a

Col

lect

mis

sing

da

ta

Col

lect

mis

sing

da

ta

Col

lect

mis

sing

da

ta

Col

lect

mis

sing

da

ta

Acc

ess

mis

sing

dat

a

12.6 1 1 30/06/2008



07/07/2008 13.7 2 2 07/07/2008

14/07/2008 14.8 3 3 14/07/2008

21/07/2008

Site report

15.9 4 4 21/07/2008

July

28/07/2008

collect missing data


Collect missing data

16.10 5 5 28/07/2008

04/08/2008

Site report

17.11 6 6 04/08/2008

11/08/2008

Site report Site report Site report

18.12 7 7 11/08/2008

18/08/2008

Site report

19.13 8 8 18/08/2008 Au

gu

st

25/08/2008

Site report

9 9 25/08/2008

01/09/2008 10 10 01/09/2008

08/09/2008 11 11 08/09/2008

15/09/2008 12 12 15/09/2008

22/09/2008 13 13 22/09/2008

Se

pte

mb

er

29/09/2008


29/09/2008

06/10/2008 06/10/2008

13/10/2008 Data input /cleaning

Data input /cleaning Data input /cleaning

13/10/2008

20/10/2008 20/10/2008

Oct

obe

r

27/10/2008

Site report Site report Site report

27/10/2008



Appendix 29: Evaluation – List of key people within NHS trusts


Formal evaluation process

Notification checklist

Purpose To ensure that all personnel/services that influence and are influenced by the mental health service for older people in general hospital are aware of the study and have the opportunity to contribute towards the data. Method 1. Identify key personnel within the general hospital setting. Ensure that they have

received a copy of the information sheet E2. Key personnel includes: Chief executive Clinical directors Medical directors Director of Nursing Nursing management (i.e. Matrons/Wards Managers) Occupational Therapy management Physiotherapy management Social Worker management Discharge liaison team A&E liaison PALs (identify any existing patient/carer groups that can be involved in

the study)

2. Identify key personnel within the mental health services setting. The majority of personnel should already be aware of the research. Please check this with the project manager. Other personnel that may need to receive a copy of the information sheet E3 include:

Community Mental Health Team leads Community Mental Health Team Psychiatrists and other medics Mental Health Service Manager for Older People



Appendix 30: Evaluation – Information for key people within NHS trusts

Academic Unit of Psychiatry and Behavioural Sciences Leeds Institute of Health Sciences


Information for NHS General Hospital Staff

A research study to look for ways of improving the services for older people admitted to general

hospital who may also have a mental health need Our research team have been commissioned by the NHS Service Delivery and Organisation (SDO) R&D Funding Stream to carry out a project evaluating liaison mental health services for older people. This builds on our previous mapping work, which has led to the development of liaison mental health services for older people in many parts of the UK. This stage of our project process requires us to evaluate the different service models currently being used. This will allow us to produce detailed knowledge that will inform service development and also provide evidence for the effectiveness of services on the quality of care received. We are in the process of carrying out parallel research at 12 different sites, consisting of a nationally representative sample. What is required? We would be very grateful for your assistance with this. The project consists of 3 main phases: 1. Information will be collected about patients aged 65 years and over who are admitted to the general hospital wards at Wansbeck Hospital and supporting Community Hospitals. This will involve carrying out brief mental health assessments on patients that have been recognised as requiring mental health specialist care. This will also involve data collection from their medical and nursing notes held on the general hospital wards and within the mental health service. We may also ask these patients and their relatives/carers to participate in a post-discharge questionnaire and telephone interview to discuss their views on the care they receive. We would also like to involve in-patients that may not have been identified as having a mental health need. We will be collecting similar data from a cohort of 100 recently admitted patients. We may also ask local carers/patients groups to contribute to the study through satisfaction questionnaires and focus groups. This part of the study should not infringe upon your regular duties. Researchers will adhere to your service policies and priorities at all times. 2. The second part of the study involves asking what support you may require in order to facilitate improvements to the quality of care of older people with mental health needs in general hospital settings. This involves asking all staff directly involved in providing care for older people at Wansbeck Hospital and supporting Community Hospitals to complete a questionnaire designed to elicit views on what support could be available to you to assist in improving care. These questionnaires will be available to you within the next few weeks. There is also the opportunity to share experiences and thoughts on how care can be improved through informal discussion groups held with care staff, or



through individual meetings with members of the research team if preferred. This will require no more than one hour of your time. Further information about the format, dates and times of these will be available to you in due course. 3. Researchers will also be collecting routine data that indicates national benchmarking targets and current policy adherence. This will help to set the above data in context of your local services.

Participation in the study is entirely voluntary. You do not have to become involved if you do not want to.

How will this information be used? The information you provide will help us identify what factors contribute to the quality of care provided for older people with mental health needs who are in general hospital. This will inform future service development. Any information collected from you will be strictly confidential. Anonymity and confidentiality will be adhered to at all times. All staff involved in the study are subject to confidentiality clauses contained within honorary NHS contracts and The University of Leeds staff conditions of employment. This study has been granted local NHS ethical approval and is subject to scrutiny by research governance for the mental health trust and the hospital trust. Information collected about your services will be available for dissemination in December 2007. If you have a particular interest in receiving this information, please do not hesitate to contact the Honorary Researchers – contact details below. What happens next? A member of our research team will visit hospital wards to collect patient data and leave questionnaires for each member of staff to complete. Staff do not have to complete these if they do not want to. Staff will also be invited to participate in an informal discussion about care for this group of patients. Again, attendance is entirely voluntary. If you have any questions about the information contained here or about the project in general, please do not hesitate to contact any member of the research team – contact details below. May we take this opportunity to thank you for your interest in our research

Carolyn Montaňa Project Manager Liaison Mental Health Services for Older People Project LIHS, The University of Leeds Charles Thackrah Building 101 Clarendon Road Leeds, LS2 9LJ Telephone: 0113 343 1964 email: [email protected] Dr John Holmes Chief Investigator LIHS, Telephone: 0113 343 2469 email: [email protected]



Appendix 31: Evaluation – Number of participants recruited into the study

Core data report 23/10/08

evaluation period routine data

patient cohort general hospital mental health services

referred pts admitted pts

feedback - pts feedback -

rels feedback - pts feedback - rels

Site

characteristics Q interview Q interview characteristics Q interview Q interview

staff Q

referrer feedback

focus groups ints

ward obs

focus groups ints TCI characteristics

admissions national targets

researcher journal

Manchester 37 0 0 1 1 80 3 1 0 0 85 0 1 1 0 0 1 0 yes yes yes 2

Huddersfield 61 0 0 0 0 76 0 0 0 0 137 2 3 2 0 1 2 0 yes yes yes 2

Sheffield 24 0 0 1 1 100 1 0 2 1 95 0 0 1 1 4 1 0 yes yes yes 2

Wansbeck 58 3 0 1 0 97 8 4 2 2 68 17 0 1 2 1 1 0 yes yes yes 2

Walsall 75 2 0 1 0 100 18 0 10 0 177 0 0 1 2 0 0 1 yes yes yes 1

Kingston 20 0 0 0 0 98 9 0 5 1 20 2 1 0 0 0 1 0 yes yes yes 2

Liverpool 173 0 0 4 1 100 1 1 6 1 109 3 2 0 0 1 0 5 yes yes yes 1

Cambridge 0 0 0 0 0 0 0 0 0 0 38 0 0 1 0 0 4 0 yes 0 yes 1

Leeds 199 2 1 2 2 124 2 1 1 1 0 0 2 2 1 0 1 3 yes yes yes 1

Southend 16 0 0 0 0 100 0 0 0 0 30 0 0 wip 2 0 2 0 yes yes yes 1

Newcastle 38 0 0 0 0 95 0 0 0 0 58 0 0 wip 2 0 2 0 yes yes yes 1

Total 701 7 1 # 5 970 42 7 26 6 817 24 9 9 10 7 15 9 11 0 12 16

Disclaimer: This report presents independent research commissioned by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, the NIHR SDO programme or the Department of Health. The views and opinions expressed by the interviewees in this publication are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, the NIHR SDO programme or the Department of Health” Addendum: This document is an output from a research project that was commissioned by the Service Delivery and Organisation (SDO) programme, and managed by the National Coordinating Centre for the Service Delivery and Organisation (NCCSDO), based at the London School of Hygiene & Tropical Medicine. The management of the SDO programme has now transferred to the National Institute for Health Research Evaluations, Trials and Studies Coordinating Centre (NETSCC) based at the University of Southampton. Although NETSCC, SDO has conducted the editorial review of this document, we had no involvement in the commissioning, and therefore may not be able to comment on the background of this document. Should you have any queries please contact [email protected].

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