Addressing Access to Care in Geriatric Psychiatry through Outpatient Consultation

Abstract

<h3>Introduction</h3> Article 31 clinics, under the regulation of the Office of Mental Health, have limitations in the patients that are able to be seen. In particular, patients with a primary diagnosis of neurocognitive disorder are considered ineligible for admission to such a clinic. Furthermore, many of the patients that would seek treatment at Montefiore Medical Center's Outpatient Psychiatry clinic, an Article 31 clinic, would not be able to afford private practice psychiatrists. Nevertheless, older adults with neurocognitive disorder experience symptoms that are typically managed by psychiatrists. In response to this gap in care, the Outpatient Geriatric Psychiatry team at Montefiore Medical Center developed an outpatient psychiatric consultation service to increase access to care and meet the mental health care needs of older adults living in the community. This service is provided under an Article 28 clinic, which is regulated by the Department of Health like any other medical specialty clinic. In this study, we aimed to identify which patients benefited from this service, what types of interventions were made and the impact on referring providers. This was done by collecting demographic data on patients referred for consultation and the format, frequency, and outcomes of these consultations. We also plan to collect feedback from referring providers. <h3>Methods</h3> The Geriatric Psychiatry outpatient consultation service started in December 2019 and conducted visits in person for 3 months, stopped during the 3 months of lockdown due to the COVID-19 pandemic (March to June 2020), restarted with virtual visits in July 2020 and then resumed with in person visits. Patients are referred by other providers in the Montefiore Health System or through self-referral. Patients are then screened for appropriateness for outpatient consultation. Patients who are ≥65 years old or have an underlying medical condition that contributes to their frailty, and who have a psychiatric concern are scheduled for an appointment. Efforts are made to direct those who are not appropriate for the service to more appropriate resources. In a retrospective chart review, data was gathered on patient age, referral source and reason for referral, diagnosis, format and number of visits, and outcomes of interest including medication changes, supportive services, and higher level of care. <h3>Results</h3> From December 2019 through September 2021, 38 patients were scheduled, 32 of whom presented to clinic for psychiatric evaluation. Patients ranged from 61 to 93 years old with a mean age of 79 years. A majority of patients were from ethnically diverse backgrounds with 59% Hispanic, 12.5% Black, 3% Asian and 3% American Indian. 50% of patients were Spanish speaking. About half the visits were conducted in person, with the remaining visits about evenly split between phone and video. Patients on average were seen for about 2 visits with a range from 1 to 11 visits. Most of the referrals came from primary care providers and among the reasons for referral were decline in function or cognition, behavioral concerns, depressed or anxious mood and psychosis. About 87.5% of patients had a diagnosis of major or minor neurocognitive disorder diagnosis. The most common interventions included medication changes, referral to support services, behavioral interventions, transfer to the outpatient department or sending for evaluation in the emergency department. <h3>Conclusions</h3> The Geriatric Psychiatry consultation service provided through an Article 28 clinic was primarily used by patients with neurocognitive disorders who would otherwise not be seen in Article 31 outpatient psychiatry clinics and would not be able to afford private practice. Through this service we were able to address a gap in care for a diverse and underserved patient population. In order to further assess the impact of this service, we plan to ask referring providers for feedback about the process of referral, the evaluations conducted and the recommendations received for their patients. Future studies would be helpful to collect prospective data on patients being followed by consultation service and additionally obtain patient and caregiver feedback. <h3>This research was funded by</h3> N/A Chart: https://apps.aagponline.org/abstracts/uploads/2022/gpn8zt4h8w464zu.pdf