The HOME Study Reveals Modest Benefits of Integrated CL Psychiatry for Older Inpatients

PICLP has been called “an inpatient corollary to the outpatient collaborative care model,” as the CL psychiatrist is embedded within the inpatient care team (as opposed to merely serving in a consultative role), and the team proactively seeks out patients with complex needs (as opposed to responding to needs as they arise). Principal investigator Michael Sharpe, M.D., received the APA Adolf Meyer Award during the APA Annual Meeting in 2022, at which he introduced the study and the PICLP model. He is a CL psychiatrist and emeritus professor of psychological medicine at Oxford University.

“In the traditional model, the CL psychiatrist waits until he or she receives a request for a consultation, does the consult, gives advice to the team, and goes away,” Sharpe told Psychiatric News. “If you have a population of patients with a very high level of need, that’s not a very efficient model. You want to be really looking for patients that you need to help—that’s being proactive; and you need to stay involved with the treatment team—that’s integrated.”

In The HOME Study, a consultant psychiatrist interviewed a patient soon after their admission to the medical ward, and an assisting clinician gathered information from the patient’s family, ward team, and medical records. The psychiatrist then made a comprehensive list of the patient’s problems, including any psychiatric diagnoses; this information was used to identify and prioritize the problems most likely to increase the time the patient spent in the hospital.

A total of 1,373 patients were randomized to PICLP and 1,371 to usual care between May 2, 2018, and March 5, 2020. The average age was 82.3. The primary outcome was time spent as an inpatient in the 30 days after randomization. Secondary outcomes included rate of discharge per day as well as a wide range of other clinical variables.

The average time spent in the hospital in those 30 days was 11.37 days for patients receiving PICLP and 11.85 days with usual care, a difference that was not statistically significant. “It looks like people who get this intervention spend on average about half a day less in hospital, but we can’t know that the difference didn’t happen by chance,” said co-author Jane Walker, M.B.Ch.B., Ph.D., CL psychiatrist and senior clinical researcher at Oxford University. “We didn’t have enough patients in the trial to be sure—we had to stop recruiting because of COVID.”

However, the authors also looked at the rate of discharge over the entire hospitalization period. There they found that patients receiving PICLP had an 8.5% higher daily discharge rate than those receiving usual care—a difference most pronounced among patients staying longer than two weeks. “It could be that the intervention is having an effect a bit later,” Walker said. “That makes sense, because a lot of what happens with the patient and the family during the intervention takes a while to take effect.”

Finally, compared with usual care, PICLP was estimated to be modestly cost-saving and cost-effective, at least over the first three months after randomization. “Because PICLP seems to reduce time in the hospital even just a little bit, it is enough to pay for the intervention and a little bit more,” Walker said.

Why didn’t the study get a clearer signal about reducing length of stay? “The PICLP team encountered barriers that were hard to overcome,” Sharpe said. “These included finding placements for older patients in the community, but also barriers within the hospital.

“Hospitals are quite risk averse and err on the side of keeping people longer,” he said. “The PICLP psychiatrists’ view was that keeping older patients in hospital often wasn’t in their interest in terms of their well-being or autonomy.”

Sharpe and Walker emphasized that PICLP was specifically designed for older medical inpatients who typically have extensive, interacting medical and psychiatric disorders. “The new challenge for medicine is that older people don’t just come into the hospital with one illness, they come with lots of illnesses,” Sharpe said. “What we have today is a system still largely devised for treating single acute illnesses, not older people with multiple illnesses, including dementia, delirium, and depression, as well as social needs.”

Sofia Matta, M.D., instructor in psychiatry at Harvard Medical College, called The HOME Study groundbreaking and said the findings highlight the importance of social determinants of health—housing instability, loneliness, lack of social support, inadequate transportation, and other social and structural factors—that impact care of older people. Matta is also senior director of medical services at Home Base, a Red Sox Foundation and Massachusetts General Hospital program.

As part of the Proactive C-L Psychiatry Special Interest Group of the Academy of Consultation-Liaison Psychiatry, Matta is leading a systematic review of social determinants among medically hospitalized patients that will include Sharpe and past APA President Dilip Jeste, M.D. “At least a third of patients admitted to medical or surgical services have psychiatric comorbidities, and over half face social factors that impact their care,” she said. “In consultation-liaison psychiatry, understanding and addressing modifiable social determinants of health is essential due to their significant impact on disease prevalence, economic costs, and the disproportionate burden on vulnerable populations.”

Sharpe and Walker emphasized that one of the most encouraging aspects of The HOME Study is that patients, psychiatrists, and medical staff found the PICLP model and the involvement of psychiatrists as partners in care to be appealing. “Our psychiatrists really found it professionally rewarding,” Sharpe said. “And the medical team really liked having them on the team. It is really healing the rift between medicine and psychiatry.”

Walker added: “When we started this study, some people said that no one would want to take part because older medical inpatients wouldn’t want to see a psychiatrist. That was not the case at all. Very few people refused to take part, and those that had PICLP really appreciated having a CL psychiatrist involved in their care. Patients want them there.”

The HOME study was supported by the UK National Institute for Health Research along with the Thames Valley at Oxford Health NHS Foundation Trust. ■