OBJECTIVE: This study examined the effects of collaboration between an internist and psychiatrists on the processes and cost of care among psychiatric inpatients. METHODS: A randomized controlled study was performed on the psychiatric inpatient units of an academic medical center. All inpatients who were admitted to the units between March 2001 and January 2002 were asked to participate in the study. Patients in the intervention group met with an internist who participated in their care by communicating with the patients' primary care physicians, assessing needs, updating appropriate health maintenance services, managing chronic and acute medical problems, and attending hospital work rounds. Patients in the usual-care group received usual care. The processes of care were measured by examining 17 categories that involved assessment of needs, coordination of care, and completion of health maintenance services. Resource use was measured by examining hospital charges and length of stay. RESULTS: A total of 139 adults participated in the study: 55 were in the intervention group and 84 were in the usual-care group. Patients in the intervention group showed significant improvement in 12 of the 17 categories of the processes of care. Overall, no differences were found in hospital charges or length of stay. CONCLUSIONS: Adding an internist to an inpatient psychiatric team is an effective way of improving care for this traditionally underserved population without increasing cost.
AIM: Pragmatic approaches to integration of medical care and substance abuse treatment are desired. We assessed the effectiveness of a novel multi-disciplinary clinic for linking patients in a residential detoxification program to primary medical care. PARTICIPANTS: We enrolled patients undergoing in-patient detoxification from alcohol, heroin or cocaine who had no primary care physician into a randomized controlled trial. The intervention consisted of a clinical evaluation at the detoxification unit in the health evaluation and linkage to primary care (HELP) clinic by a nurse, social worker and physician and facilitated referral to an off-site primary care clinic. The primary outcome of interest was attendance at a primary care appointment within 12 months. Secondary outcomes assessed over 24 months were addiction severity, health-related quality of life, utilization of medical and addiction services and HIV risk behaviors. FINDINGS: Of the 470 subjects enrolled, 235 were randomized to the HELP clinic intervention. Linkage to primary medical care occurred in 69% of the intervention group compared to 53% in the control group (P = 0.0003). The clinic was similarly effective for subjects with alcohol and illicit drug problems. Randomization to the HELP clinic resulted in no significant differences in secondary outcomes. CONCLUSIONS: The HELP clinic, a multi-disciplinary clinic located in a detoxification unit, effectively linked alcohol- and drug-dependent individuals to primary medical care. This intervention utilized a 'reachable moment', the period of addiction care, as a window of opportunity for linking substance abusers to medical care.
BACKGROUND: This randomized trial evaluated an integrated model of primary medical care for a cohort of patients with serious mental disorders. METHODS: A total of 120 individuals enrolled in a Veterans Affairs (VA) mental health clinic were randomized to receive primary medical care through an integrated care initiative located in the mental health clinic (n = 59) or through the VA general medicine clinic (n = 61). Veterans who obtained care in the integrated care clinic received on-site primary care and case management that emphasized preventive medical care, patient education, and close collaboration with mental health providers to improve access to and continuity of care. Analyses compared health process (use of medical services, quality of care, and satisfaction) and outcomes (health and mental health status and costs) between the groups in the year after randomization. RESULTS: Patients treated in the integrated care clinic were significantly more likely to have made a primary care visit and had a greater mean number of primary care visits than those in the usual care group. They were more likely to have received 15 of the 17 preventive measures outlined in clinical practice guidelines. Patients assigned to the integrated care clinic had a significantly greater improvement in health as measured by the physical component summary score of the 36-Item Short-Form Health Survey than patients assigned to the general medicine clinic (4.7 points vs -0.3 points, P<.001). There were no significant differences between the 2 groups in any of the measures of mental health symptoms or in total health care costs. CONCLUSION: On-site, integrated primary care was associated with improved quality and outcomes of medical care.
CONTEXT: The prevalence of medical disorders is high among substance abuse patients, yet medical services are seldom provided in coordination with substance abuse treatment. OBJECTIVE: To examine differences in treatment outcomes and costs between integrated and independent models of medical and substance abuse care as well as the effect of integrated care in a subgroup of patients with substance abuse-related medical conditions (SAMCs). DESIGN: Randomized controlled trial conducted between April 1997 and December 1998. SETTING AND PATIENTS: Adult men and women (n = 592) who were admitted to a large health maintenance organization chemical dependency program in Sacramento, Calif. INTERVENTIONS: Patients were randomly assigned to receive treatment through an integrated model, in which primary health care was included within the addiction treatment program (n = 285), or an independent treatment-as-usual model, in which primary care and substance abuse treatment were provided separately (n = 307). Both programs were group based and lasted 8 weeks, with 10 months of aftercare available. MAIN OUTCOME MEASURES: Abstinence outcomes, treatment utilization, and costs 6 months after randomization. RESULTS: Both groups showed improvement on all drug and alcohol measures. Overall, there were no differences in total abstinence rates between the integrated care and independent care groups (68% vs 63%, P =.18). For patients without SAMCs, there were also no differences in abstinence rates (integrated care, 66% vs independent care, 73%; P =.23) and there was a slight but nonsignificant trend of higher costs for the integrated care group ($367.96 vs $324.09, P =.19). However, patients with SAMCs (n = 341) were more likely to be abstinent in the integrated care group than the independent care group (69% vs 55%, P =.006; odds ratio [OR], 1.90; 95% confidence interval [CI], 1.22-2.97). This was true for both those with medical (OR, 3.38; 95% CI, 1.68-6.80) and psychiatric (OR, 2.10; 95% CI, 1.04-4.25) SAMCs. Patients with SAMCs had a slight but nonsignificant trend of higher costs in the integrated care group ($470.81 vs $427.95, P =.14). The incremental cost-effectiveness ratio per additional abstinent patient with an SAMC in the integrated care group was $1581. CONCLUSIONS: Individuals with SAMCs benefit from integrated medical and substance abuse treatment, and such an approach can be cost-effective. These findings are relevant given the high prevalence and cost of medical conditions among substance abuse patients, new developments in medications for addiction, and recent legislation on parity of substance abuse with other medical benefits.
BACKGROUND: Medically ill alcoholics often do not respond to conventional alcoholism treatment or decline physician referrals. Integrated outpatient treatment (IOT), a new treatment specifically designed for this population, combines comprehensive medical care with alcoholism interventions. OBJECTIVE: To compare the efficacy of IOT with that of standard treatment approaches. METHODS: One hundred five male veterans with severe medical complications caused by alcoholism and recent drinking were randomly assigned to receive IOT or referral to standard alcoholism and medical treatment and were evaluated over 2 years. Integrated outpatient treatment patients received medical care and alcoholism interventions once or twice monthly. Patients in the control group were referred for alcoholism treatment, but few accepted. However, patients in the control group did engage in outpatient medical care. RESULTS: At baseline, the mean +/- SD age of the control group was 57.2 + 10.0 years, compared with 52.8 +/- 11.5 years in the IOT group (P= .04). The groups were well matched in other respects. The mean +/- SD number of visits over 2 years for the IOT patients was 42.2 +/- 29.1, compared with 17.4 +/- 15.6 for the control patients (P<.001); the frequency of hospital use was similar in both groups. After 2 years, 28 (74%) of 38 surviving IOT patients and 17 (47%) of 36 control patients were abstinent (P=.02). Nearly twice as many control patients (30% [n = 16]) as IOT patients (18% [n= 9]) died, but the results of Cox survival analysis were not significant. There were no differences in symptoms of alcohol dependence, quality of life, or life problems. The incremental cost of IOT was approximately $1100 per patient per year. CONCLUSIONS: Standard medical care alone was surprisingly effective in inducing abstinence in surviving medically ill alcoholics. Integrated outpatient treatment significantly increased both engagement and abstinence for a modest annual cost. Further refinement and testing of IOT is indicated.
OBJECTIVES: Intravenous drug users are at high risk for medical illness, yet many are medically underserved. Most methadone treatment programs have insufficient resources to provide medical care. The purpose of this study was to test the efficacy of providing medical care at a methadone clinic site vs referral to another site. METHODS: Patients with any of four target medical conditions were randomized into an on-site group offered medical care at the methadone treatment clinic and a referred group offered medical care at a nearby clinic. Entry to treatment and use of medical services were analyzed. RESULTS: Of 161 intravenous drug users evaluated, 75 (47%) had one or more of the target medical conditions. Fifty-one were randomized. In the on-site group (n = 25), 92% received medical treatment; in the referred group (n = 26), only 35% received treatment. CONCLUSIONS: Providing medical care at a methadone treatment program site is more effective than the usual referral procedure and is a valuable public health intervention.
This study examined the effects of collaboration between an internist and psychiatrists on the processes and cost of care among psychiatric inpatients.
METHODS:
A randomized controlled study was performed on the psychiatric inpatient units of an academic medical center. All inpatients who were admitted to the units between March 2001 and January 2002 were asked to participate in the study. Patients in the intervention group met with an internist who participated in their care by communicating with the patients' primary care physicians, assessing needs, updating appropriate health maintenance services, managing chronic and acute medical problems, and attending hospital work rounds. Patients in the usual-care group received usual care. The processes of care were measured by examining 17 categories that involved assessment of needs, coordination of care, and completion of health maintenance services. Resource use was measured by examining hospital charges and length of stay.
RESULTS:
A total of 139 adults participated in the study: 55 were in the intervention group and 84 were in the usual-care group. Patients in the intervention group showed significant improvement in 12 of the 17 categories of the processes of care. Overall, no differences were found in hospital charges or length of stay.
CONCLUSIONS:
Adding an internist to an inpatient psychiatric team is an effective way of improving care for this traditionally underserved population without increasing cost.
