Sp. Segal et al., QUALITY OF CARE AND USE OF LESS RESTRICTIVE ALTERNATIVES IN THE PSYCHIATRIC EMERGENCY SERVICE, Psychiatric services, 47(6), 1996, pp. 623-627
Objective: The study examined factors affecting clinicians' decisions
in the psychiatric emergency service about referring patients to less
restrictive alternatives to inpatient care. Indicators of quality of c
are and the severity of the patient's condition were a particular focu
s. Methods: Trained mental health professionals observed the evaluatio
ns of 425 patients in seven California county general hospitals. Multi
variate modeling was used to examine variables thought to predict disp
osition to alternative care. Results: Less restrictive alternatives we
re available for 61 percent of the 425 patients and were used for 39 p
ercent; they were overlooked by clinicians in 14 percent of cases and
considered but not used in 8 percent. Patients' need for a controlled
hospital setting, as indicated by the severity of their condition, was
most important in determining use of hospital alternatives. Quality o
f care, especially the clinician's ability to engage patients in treat
ment at a level appropriate to their functioning, was also a significa
nt predictor of whether alternative care was considered or used. Concl
usions: Under managed care, clinicians are under extreme economic pres
sure to use less restrictive alternatives, thereby reducing costly inp
atient care. To ensure quality of care in general hospital emergency s
ervices, the development of supervised hospital alternatives is crucia
l. Clinicians should be encouraged to engage patients in treatment if
appropriate use of alternative care is a goal.