QUALITY OF CARE AND USE OF LESS RESTRICTIVE ALTERNATIVES IN THE PSYCHIATRIC EMERGENCY SERVICE

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.