Consultative Intervention to Improve Outcomes of High Utilizers in a Public Mental Health System

PURPOSE. To examine the effectiveness of anacademic consultation on outcomes amongconsumers in a public mental health system andto compare outcomes between high-cost/high-utilizer and midcost consumers. METHODS. Participants (N = 36) completed allquestionnaires during three semistructuredinterviews. Using a repeated-measuresexperimental design, the outcomes of globalfunctioning, quality of life, service use and need,costs, and consumer satisfaction were examined.FINDINGS. The hypothesis that consultationwould change medication practices and reducecosts was supported. CONCLUSIONS. Consultation with a seniorclinician helped change medication practices andreduced costs. Consultation may lead torecognition of a new diagnosis (medical,neurologic, or psychiatric) or suggestions formodifying a treatment regimen that couldimprove functioning and QOL. In a busy publicmental health system, there is often little time forconsultation and little thought to secondopinions. For clients who cost the system thegreatest amount, the small additional cost of aconsultation is a good potential investment. Search terms: Consultation, mental healthsystems, patient satisfaction, quality of life,service use and costs

Perspectives in Psychiatric Care Vol. 40, No. 2, April-June, 2004 53

Terry Badger, PhD, RN, Alan J. Gelenberg, MD, and Michael Berren, PhD

Terry Badger, PhD, RN, is Professor, College of Nursing, andAlan J. Gelenberg, MD, is Professor and Head, Department ofPsychiatry, College of Medicine, The University of Arizona,Tucson, AZ; Michael Berren, PhD, is Director of Research andEvaluation, Community Partnership of Southern Arizona,Tucson, AZ.

The impetus for this study came from discussions be-tween providers in one southwestern public mentalhealth system and university faculty about how to pro-vide cost-effective services to those most in need and stillachieve quality health outcomes. In a previous issue thequalitative findings from this study were discussed(Badger, McNiece, Bonham, Jacobson, & Gelenberg,2003). This article presents the results from the repeated-measures experimental study. The authors hypothesizedthat a careful evaluation and consultation with an aca-demic team focused on patients with the greatest finan-cial cost to the system (�high utilizers�) would be cost-effective, improve services, and increase consumer satis-faction and quality of life. The effects of the consultativeintervention were examined for the outcomes of globalfunctioning, quality of life, service use and need, costs,and consumer satisfaction. Consultation was provided tocommunity providers and outcomes examined overtime, comparing those participants who received the in-tervention to those who did not and comparing partici-pants who had the hightest cost of care to those withcosts in the middle range.

Methods

This study used a repeated-measures experimentaldesign with participants assigned to either an interven-tion or a control group. The intervention group receivedan in-depth evaluation and consultation, plus usual care.The control group received only usual care. Participantswere recruited from a list of 240 consumers with seriousmental illnesses who used the regional public mentalhealth system. This system provides public behavioralhealth services in a five-county area to approximately

Consultative Intervention to Improve Outcomes ofHigh Utilizers in a Public Mental Health System

54 Perspectives in Psychiatric Care Vol. 40, No. 2, April-June, 2004

tion between the senior research psychiatrist and nurses,the psychiatrist of record, other personnel (e.g., casemanager), and the consumer to review the history andcurrent treatment. Diagnoses and medications weremodified or added, and additional diagnostic tests andconsultations recommended after the intervention. Thetypes of tests and consultations recommended wereneurology consultations, EEGs, CT scans, sleep studies,liver function tests, and other routine blood and urinaly-sis tests. All were completed during the course of thestudy. The research team coordinated the logistics ofscheduling, arranged for transportation to and from alltests and referrals, and provided a research nurse to ac-company each person during the recommended tests orconsultations.

Measures

The Structured Clinical Interview for Diagnosis(SCID) and Global Assessment of Functioning (First,Spitzer, Gibbon, & Williams, 1997) measured diagnosisand global assessment of functioning. Interrater reliabil-ity was ≥90%.

The Brief Quality of Life Index (BQOLI) (Lehman,1995; Lehman, Kernan, DeForge, & Dixon, 1995;Lehman & Postrado, 1995) measured quality of life. Par-ticipants were asked to rate their satisfaction on health,safety, finances, social relations, family relations, dailyactivities and hobbies, and general life satisfaction. Par-ticipants also were asked to determine frequency of so-cial contacts, family contacts, daily activities, and finan-cial adequacy.

The OARS Multidimensional Functional AssessmentQuestionnaire (OMFAQ) (Badger, 1998; Fillenbaum,1988) measured service use and need. Participants wereasked about their use of and need for 24 generic services:medical help (mental health services, psychotropic medi-cations, nursing care, medical/psychiatric services, sup-portive services and prostheses, physical therapy), trans-portation, financial (financial assistance food, groceries,housing), home help (personal care services, continuoussupervision, checking, homemaker-household, meal

16,500 consumers annually. The list contained 40 con-sumers who used the most services and who, therefore,were most costly (≥$40,000 per annum). Another 200consumers were randomly selected from those withmidrange service costs ($10,000�$15,000 per annum).After giving informed consent, participants completedquestionnaires during three semistructured interviews:baseline at enrollment (T1), 6 to 8 weeks after the inter-vention (T2), and 9 months after baseline (T3).

Sample

Of the 240 potential participants, 139 were contacted bythe research team and 58 were enrolled. About half thosecontacted chose not to participate in the study, citing lack ofinterest or of time. Of the 58 participants at baseline, 39 werein the intervention group and 19 in the control group.Twenty-five were high-cost and 33 were midcost utilizers.Dropout rates were roughly equivalent among groups, withno significant differences between the 22 dropouts and the36 completers for demographic characteristics or diagnoses.

Table 1 lists the demographic characteristics of thefinal sample. Two-thirds were intervention participants,with the sample equally divided between high-cost (n =18) and midcost (n = 18) utilizers. There were no signifi-cant differences between groups for demographic char-acteristics, except for lower educational levels for the in-tervention participants and more men among highutilizers. Diagnoses were similar. The most frequent di-agnoses, whether by the Structured Clinical Interviewfor Diagnosis (SCID) or clinical interview, wereschizophrenia (52%) and schizoaffective disorders (26%).Most participants reported onset of their illness in theirlate teens or early 20s, and about half reported a familyhistory of mental illness and substance abuse. Many hadmultiple hospitalizations (1�50), but none was hospital-ized in the year prior to enrollment.

Consultative Intervention

The intervention consisted of extensive review of thepatient�s history and all medical records, and a consulta-

Consultative Intervention to Improve Outcomes of High Utilizers in a Public Mental HealthSystem


= 14.48) had higher GAF scores than did the high-utilizergroup (M = 39.78, SD = 14.60) at baseline, and these GAFscores remained stable over time regardless of cost level.

Quality of Life (QOL)

There were significant differences between the inter-vention and control participants for four QOL subscales:satisfaction with finances, satisfaction with daily activi-ties, and amount of social and family contact. Althoughthe two groups were similar in their satisfaction with fi-nances at baseline, the control participants became sig-nificantly less satisfied over time (p = .04). The control

preparation), administrative, legal and protective, so-cial/recreational, other (employment, remedial training,sheltered employment, educational services, relocationand placement), and assessment and referral. Costswere based on utilization data we retrieved from themental health system�s database. Categories of serviceswere those used by the mental health system (behav-ioral management, case management, MD services, non-MD counseling, residential, inpatient, pharmacy, allother).

The Consumer Satisfaction Survey-Adult Services mea-sured consumer satisfaction (Berren, 1998). Participantswere asked how long they had received services throughthe mental health system, how much they participated inaspects of their treatment, and how satisfied they werewith their case managers/therapists and psychiatrists. Allquestionnaires had satisfactory reliability and validity. Inaddition to the fixed responses, participants� commentsabout each outcome were recorded verbatim.

Findings

Findings for the 36 participants who completed allthree interviews are presented; missing data were ≤1%.Separate analyses were conducted to determine differ-ences between groups at baseline and within groupsover time (T1, T2, T3). Comparisons between the inter-vention and control groups were analyzed separatelyfrom the high-utilizer and midcost groups due to thesmall sample size. Equality of variance assumptions wasexamined, and if violated, the appropriate results are re-ported. Significance level was set at ≤.05.

Global Assessment of Functioning (GAF)

GAF scores were not significantly different betweenthe intervention and control participants at baseline. Al-though not significant, control participants evidenced alarger drop in GAF scores from T1 (M = 51.67; SD = 13.23)to T3 (M = 40.67, SD = 20.80) compared to the interventionparticipants (M = 43.91, SD = 15.95; M = 43.68, SD =20�52). As predicted, midcost participants (M = 50.83, SD

Table 1. Demographic Characteristics for Midcost andHigh-Utilizer Participants

Midcost High Utilizers (n = 18) (n = 18)

Age■ M 44.33 39.83■ SD 10.55 8.68■ Range 27�76 20�51

Gender Na (%) N (%)■ Male 7 (38) 10 (55)■ Female 11 (61) 8 (44)

Ethnicity N (%) N (%)■ Anglo 12 (66) 13 (72)■ Hispanic 5 (28) 3 (17)■ Native American 1 (5) 2 (11)

Marital Status N (%) N (%)■ Single, never married 10 (56) 15 (84)■ Married/partnered 1 (5) 1 (8)■ Widowed 2 (11) 0 (0)■ Separated/divorced 4 (22) 2 (11)

Education■ M 11.53 11.61■ SD 3.62 2.15■ Range 0�16 8�14

aDoes not reflect missing data.


tions at T3, particularly for antipsychotics (t [33] = �2.07, p = .04). Intervention participants had higher use of atypi-cal antipsychotics and used fewer typical antipsychoticsthan did control participants. Although a similar patternof increase in atypical antipsychotic prescriptions wasfound for both groups over time (F [1,32] = 5.21, p = .02),the intervention group showed a sharper increase. Atypi-cal antipsychotics increased from baseline (44%) to T3(62%) for the intervention group compared to the controlgroup (22% to 25%). The intervention group had a greaterdecline in typical antipsychotics than the control group (F[1,32] = 10.73, p = .003). There also were significant differ-ences between groups for other medication categories.The intervention group used more mood stabilizers, an-tidepressants, and other medications, and fewer antianxi-ety, anti-EPS, and sleep medications than did controls.

Significant differences were found over time betweenmidcost and high utilizers for transportation (p = .03) andsocial/recreational (p = .02) services. At T3, 47% midcostand 61% high utilizers reported needing more transporta-tion services than was available. High utilizers used(64.7%) and needed (76.5%) more social/recreational ac-tivities than midcost participants did (use was 33.3% vs.need 58.8%). Midcost participants had greater unmet need(service need � service use = unmet need) for social/recre-ational activities at every time period. High utilizers re-ported using and needing more of the following servicesover time: sheltered workshops (p = .02), legal services (p = .05), checking services (p = .04), medications (p = .01),nursing care (p = .01) and physical therapy (p = . 01). Thefinding about medications was expected. At baseline,more high utilizers (64%) were prescribed atypical an-tipsychotics than midcost participants (24%), and fewerhigh utilizers (16%) were prescribed typical antipsychoticsthan midcost participants (21%). Both groups showed anincrease in atypical antipsychotic prescriptions and a de-crease in typical antipsychotic prescriptions over time.

Costs

Table 2 presents the mean costs for the interventionand control group over time. There were significant dif-

group had a large drop in satisfaction (�1.04) comparedto the intervention group (�.17).

There was a significant time by group effect for satis-faction with daily activities (p = .05). The intervention groupincreased its satisfaction with daily activities (.34) over time,while the control group decreased its satisfaction (�.66). Theincreased satisfaction of the intervention participants may,in part, be because they initiated some of the changes in-creasing appropriate daily activities recommended by theresearch team during the intervention and assessments.

The intervention and control participants differed forsocial and family contact at baseline (p = .05). The interven-tion group had less social and family contact than did thecontrol group. However, over time the intervention groupincreased, and the control group decreased in their contact.

Although midcost and high utilizers rated their QOLsimilarly for most QOL subscales, two significant differ-ences were noted. The high utilizers were more satisfiedwith their finances than were the midcost group, butboth groups became more dissatisfied over time (p =.004). The high utilizers evidenced a greater decrease(�.63) in satisfaction over time than did the midcostgroup (�.22). There was also a significant group by timeeffect for social contact (p = .02), with the midcost groupreporting less contact over time (�.63). The high utilizersdid not evidence this same pattern but increased theircontact. Although all participants were generally satis-fied with their QOL, participants� two areas of greatestdissatisfaction were for general health and social func-tion (Badger et al., 2003; McDonald & Badger, 2002).

Service Use and Need

Significant differences were found between the inter-vention and control groups for medical help (need formedications [p = .05]), home help (using household help[p = .01]), and regular help with meals (p = .02). Controlparticipants used more household help and meal helpthan did intervention participants, but intervention par-ticipants reported more need for medications.

As seen in Figure 1, there were significant differencesbetween the intervention and control groups for medica-



Consumer Satisfaction

Consumer satisfaction was the final outcome exam-ined. Over time, there were significant differences be-tween the intervention and control groups for satisfac-tion with the amount of input into the services received(p = .01). The control group had greater decreases (�1.37)in satisfaction than did intervention participants (�.38)over time. This finding may be because in the consulta-tive intervention, participants were asked about theirtreatment needs. There also were significant time effectsfor time spent with the case manager/therapist (p =.002), understanding and interest of the casemanager/therapist (p = .001), and overall satisfactionwith the case managers (p = .002). Over time, bothgroups decreased in satisfaction in each area by almostone point.

Midcost participants at baseline were more dissatis-fied with the amount of time spent with the case man-ager/therapist to develop the treatment plan (p = .02)and for the satisfaction with the amount of input into the

ferences between groups at baseline for case manage-ment costs. Regardless of group assignment case man-agement costs decreased over time, but less for the inter-vention than for the control group. Over time, totalpatient costs decreased significantly (F [1,33] = 4.43, p =.04). Total costs decreased over time for both groups,with the largest decrease in the intervention group($9,228). Control participants had a modest cost reduc-tion ($1,166).

There was a significant difference between the mid-cost and high utilizers at baseline for behavioral man-agement/psychosocial costs (F [1,26] = 36.60, p = .000),and over time these specific costs were reduced. Highutilizers had a greater drop in mean costs for behav-ioral management ($8,541) than did midcost partici-pants ($4,380). Both groups decreased in their casemanagement costs over time, with the largest decreasefor high utilizers. Total costs decreased over time,with total costs for the midcost group dropping to67% of baseline compared with an 82% drop for highutilizers.

Figure 1. Medication Type for Intervention and Control Groups at Time 3

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services received (p = .02). Over time, however, high utiliz-ers reported less input and less satisfaction with the amountof input (�1.20) than did midcost participants (�.20).


There were significant differences over time forcase manager/therapist time (p = .001), case man-ager/therapist understanding and interest (p = .004),


Table 2. Means and Standard Deviations for Costs for Intervention and Control Groups Over Time

Time 1 Time 3

Control Intervention Control InterventionCost Categories (n = 19) (n = 39) (n = 12) (n = 24)

Behavior management/Psychosocial■ Mean 25,377.33 26,948.40 22,451.40 18,383.63■ SD 17,877.67 26,207.74 17,988.44 18,456.80

Case management■ Mean 2,240.64 2,327.79 1,606.64 1,818.13■ SD 221.99 237.83 237.70 498.50

MD/Services■ Mean 417.84 736.90 349.11 431.45■ SD 269.16 802.59 293.53 381.40

Non-MD counseling■ Mean 189.88 390.69 156.42 513.53■ SD 68.20 621.02 83.11 767.49

Residential■ Mean 0 2,100.00 0 525.00■ SD 0 0 0 0

Inpatient■ Mean 1,013.66 720.00 0 410.90■ SD 0 235.930 0 505.02

Pharmacy■ Mean 4,931.48 4,476.53 4,842.39 4,809.19■ SD 3,641.72 2,639.49 3,884.18 2,844.64

All other■ Mean 106.70 872.35 281.49 517.50■ SD 177.40 2,203.18 342.65 1,595.28

Total Encounter Amount■ Mean 28,690.17 32,310.40 27,524.13 23,082.39■ SD 21,917.35 25,922.00 21,884.43 18,028.36

All amounts in dollars

and overall satisfaction with the case manager/thera-pist (p = .004). High utilizers reported a greater de-crease in overall satisfaction with the case managers(�1.15) over time compared to midcost participants(�.78). This same decrease in satisfaction was notfound for psychiatrists.

The qualitative findings validated case managers�/therapists� service dissatisfaction (Badger et al., 2003).Most participants had two to three case managers dur-ing the study, and about half experienced a change inpsychiatrists. Participants voiced dissatisfaction aboutthe psychiatrist turnover, but not as strongly. It was notsurprising that the psychiatrists and case managers alsovoiced similar dissatisfaction.

Discussion

The goal of this project was to examine the effective-ness of consultation on selected outcomes: quality of life,global assessment of functioning, service use and need,costs, and consumer satisfaction. The use of both quanti-tative and qualitative methods allowed for findings to bevalidated with different, but complementary, methods,strengthening the confidence of the findings. Participantswere typical of people with serious mental illness whouse public behavioral health systems (Lehman, 1995;Lehman et al., 1995; Miller, Dasher, Collings, Griffiths, &Brown, 2002; Noble, Douglas, & Newman, 2001; Segal,Hersen, & Van Hasselt, 2001). Although the sample sizedecreased over time, the low attrition rate (38%) in thislongitudinal study also increases confidence in the find-ings. The attrition rate among groups was similar.

The findings about medications are especially note-worthy. As expected, there were significant differencesbetween the two groups (intervention vs. control, mid-cost vs. high utilizers) at baseline for antipsychotic medications. Intervention participants showed sharp in-creases in some medication types (atypical antipsy-chotics) over time compared to controls, but the sharpdecreases in other medication types (e.g., anti-EPS medi-cations) were not expected. These findings are not sur-prising, because the intervention often targeted medica-


tion issues. Also, during the study, providers were con-sistently changing from older to newer antipsychotics,conforming to best practices. Perhaps the consultative in-tervention facilitated this process.

Costs were reduced for all participants regardless ofinitial cost level or group assignment over time, but twofindings are notable. First, the hypothesis that by provid-ing a consultative intervention costs would be reducedwas supported by these data. As seen in Table 2, totalcosts for the intervention group dropped by more than$9,000, compared with a modest $1,100 for the controlgroup. At the same time costs were reduced, the inter-vention participants reported increased satisfaction anddecreased service use and need. Although these findingsmust be interpreted with caution because the mentalhealth care system was constantly changing services(which ultimately affect costs) during the study, the dif-ference found between intervention and control groupssuggests it is an important and true finding.

Second, the reduced case management costs were theresult of reducing services, yet the number one servicedissatisfaction was related to this reduction. Participantsand providers alike consistently identified the criticalneed for case management/therapist services, and dis-cussed their dissatisfaction with the current case man-ager/therapist system. This finding provides an interest-ing system issue and may require increases in bothservices and costs before satisfaction can increase.

Staff turnover and case load issues dominated discus-sions. Participants complained about frequent turnoverin staff who must make decisions about their care withlimited knowledge. Case manager turnover was about75%. Turnover is costly in recruiting and training, butalso in the time it takes new staff to become acquaintedwith new cases. During this study, one of us spoke of�the cost of chaos.� Overstretched systems with over-worked staff have insufficient time, let alone the moralspirit and emotional energy to invest in the most needyand ill clients. Staff turnover from stress and burnoutfurther compounds the problem.

The primary reason for dropping out of the study andthe care system was dissatisfaction with the services and


a dissonance in expectations about improvement. Per-haps this finding can help clinicians engage their clientsby asking about satisfaction and expectations to decreasepremature terminations from treatment.

Finally, two future studies are suggested by this re-search. One is a replication of this study with largernumbers of participants who are not switching medica-tions. Another could examine optimal caseloads andother factors that influence case manager burnout andturnover. A number of lessons were learned while con-ducting this study in a rapidly changing system, espe-cially that time was the enemy for both researchers andproviders. However, these time problems, typical of real-world contexts, increase the validity of our findings andtheir applicability to similar systems.

Application to Practice

These findings provide practice implications. First, itis clear that advanced practice mental health nurses(APRNs) must negotiate with systems to hire suchnurses to provide more direct client services in the com-munity. APRNs have the knowledge and skills to pro-vide cost-effective quality care as well as the expertise toprovide consultation to reduce costs.

Further, APRNs can provide counseling and educa-tion to address many of the QOL and health issuesfound in this study. Although participants were gener-ally satisfied with their overall QOL, two problem areaswere frequently discussed at length. Preventive healthcare was lacking, health care was often delayed, and un-healthy lifestyles were predominant. Most structuredprograms did not address poor health habits, and themajority of activities on the treatment plans were seden-tary in nature. Many participants suffered from obesityand a general lack of fitness, had poor nutrition, andoften smoked. These physical health issues are of partic-ular concern as participants� age and chronic illnesses in-crease, which will ultimately increase costs to the health-care system (Dixon, Postado, Delahanty, Fischer, &Lehman, 1999; McDonald & Badger, 2002). APRNs canaddress these issues.


It also was clear that vocational, social/recreational,and intimacy issues were serious concerns. The impor-tance of psychosocial function in keeping consumers inthe community is consistent with previous research(Aquila & Korn, 2002; Bengstsson-Tops, & Hansson,1999; Patrick & Erickson, 1993) and provides clear direc-tion for APRN practice. As the newer, albeit more expen-sive, antipsychotic medications help clear thinking andimprove social abilities, these more functional patientswill have different rehabilitation needs. APRNs can de-velop and implement educational and activity programsto increase daily activities that are sufficiently stimulat-ing, interesting, and challenging, to improve employabil-ity, and to address intimacy and social function. Ulti-mately, clients who receive more individualized carethat addresses their needs may require less care andfewer hospitalizations, and might fulfill their usual socialroles (e.g., employees, homemakers).

Conclusion

Consultation with a senior clinician helped changemedication practices and reduced costs. Consultationmay lead to recognition of a new diagnosis (medical,neurologic, or psychiatric) or suggestions for modifyinga treatment regimen that could improve functioning andQOL. In a busy public mental health system, there isoften little time for consultation and little thought to sec-ond opinions. For clients who cost the system the great-est amount, the small additional cost of a consultation isa good potential investment.

Acknowledgments. Funding for this study was pro-vided by Community Partnership of Southern Arizona,Tucson, AZ, and St. Luke�s Charitable Health Trust,Phoenix, AZ. The authors thank the consumers andproviders of CPSA, and the research nurses, Cheryl Mc-Niece, MS, RN; Carol Bonham, MS, RN; and Jennifer Ja-cobsen, MS, APRN, BC for their assistance on this project.

Author contact: [email protected], with a copy tothe Editor: [email protected]

continued on page 69

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Consultative Intervention to Improve Outcomes of High Utilizers in a Public Mental Health System