Geriatric Triage: Organizational Guidelines for Mental Health Systems

Sam Herman

Increasing longevity as well as the aging of both "chronic" (inpatient) and "deinstitution- alized" (outpatient) populations, make geriatric services a growth area in the future of mental health systems.' Triage at entry points is criti- cal; referrals often are medically problematic or simply better-served within the community, "the least restrictive setting."-"

Geriatric screenings, admissions, and screen- outs (SOs) were subject to chauvinism at Creed- moor Psychiatric Center since autonomous units were involved, i.e., one unit screened; a differ- ent one admitted; a third provided long-term care; and a fourth handled aftercare. This frag- mented system was catchmentized but eventu- ally consolidated within a unified geriatric service. It appeared worthwhile to review the changes longitudinally, to learn from the evolutionary process. Unfortunately, exhaustive centralized data were not collected. Several gaps are pres- ent, few cross-checks are possible, some errors and incompleteness were obvious. Nonetheless, based on what was available, several conclusions can be drawn.

Table 1 illustrates the chronology of the ger- iatric triage teams and their relative ability to effect clinically sound diversions (screenouts). There are three "natural" break-points: 1. October 1980: The geriatric admission unit

was relocated from the short-term care di- vision to the geriatric division. However, screenings remained centralized with the community linkage unit (CLU).

2. July 198I: Geriatric screenings were redis- tributed geographically among OPDs, car- ried out by existing mobile crisis teams (MCTs) based on residence.

3. April 1982: Geriatric screenings were recon- solidated via a single triage team, the ger- iatric division's mobile geriatric outreach team (MGOT).

Table 2 summarizes activity within these break points: community linkage unit's (CLU) func- tioning, gross annual (fiscal year) figures for screenings and admissions, and partial data for the 1982-83 fiscal year. Note that admissions are from triage sources only; patients admitted via court orders, police, etc., are not included, as these are not clearly accounted for.

As for CLU, there were no major shifts in triage performance, admissions vs. screenouts, during its entire functional period. It hovered around 70% SOs, which falls between the ex-

tremes shown in Table 1 (range = 47 - 100%). On an annual basis, there were considerably more screenings in 1980-81 than 1981-82 (449, 314), but approximately equal degrees of diversion (69%, 75%). Simply increasing resources (triage teams) did not yield any increase in service de- livery. Comparison of high vs. low screenings on a monthly basis supports the lack of rela- tionship between number of screenings and de- gree of d i v e r s i o n . On the o the r hand , strengthening the clinical ties between the triage and treatment units does appear to affect both overall services and diversions. Projecting the 4- 7/82 data to annual figures suggests that screen- ings will increase, along with substantially higher diversions than under either previous approach.

As Table 1 shows, the six different groups that were screening concurrently had vastly dif- ferent SO rates. The lowest (central Queens) is to some degree a reflection of its large marginal population and the inclusion of a major city hospital in its catchment. The geriatric admis- sion unit diverted more than half of its potential admissions. Since this patient pool includes court orders, inter-hospital transfers and most bona fide emergencies Cwalk-ins"), this figure is quite respectable. The eastern and western Queens teams submitted data approaching total diver- sion, which is surprising, considering their lack of experience with geriatric triage. Since the numbers are small for western Queens, these data are likely to be accurate. However, since many potential sources of geriatric admissions are in the eastern Queens area, e.g., placement sites, review of individual admissions confirmed that a significant portion from this area some- how bypassed the team, via local hospital emer- gency rooms, thereby inflating its SO rate.

Figure I illustrates the influence of the hid- den admissions; despite the high SO rate re- ported during the period of multiple triage teams, the overall admission rate rose sharply. In ad- dition, the two factors used to calculate this rate (mean screenings and admissions) clearly show that both efficiency (screenings) and effective- ness (diversions) were at their lowest during this period of decentralization. Both were at their highest during MGOT's operation and some- where in the middle under CLU's tenure. The MGOT covered the vast majority of screenings during the most recent period and presented an extraordinary SO rate (97%) during the first four months of operation. Considering that this team

Monthly Geriatric Screenin( TOTAL

ADMISSIONS*

1980

1981

1982

APR MAY JUNE JULY AUG SEP

**OCT NOV DEC JAN FEB MAR APR MAY JUNE JULY AUG SEP OCT NOV DEC JAN FEB MAR

***APR MAY JUNE JULY

1 5 5 7 8 8

15 9 6 7 8

10 9

13 15

8 15 19

8 6 6 3

Table 1 s and Admissions

WO CO CLU MCT MCT

27/11 38/9 36/15 44/10 46/18 36/9 48/19 15/4 33/6 35/11 43/17 48/8 29/8 22/5 26/2 11/1

6/0 9/4 3/0 4/0

10/2 3/3 6/5 8/6 4/3

SCREEN-OUT 73 RATE (% SO) ****

Source (#Screened/#Admitted) EO

MCT

3/0 5/0 7/1

1/1 2/0 10/5 11/0

2/0 5/2 6/0 1/0 5/1 13/1 3/0 6/0 7/3 3/0 8/5 3/0 1/0 7/3 4/0 4/0 7/5 5/1 5/0 13/10 4/0 2/0 2/2 2/0

100 47

GER.ADM. STAFF MGOT

* To Geriatric Admission Unit (Geriatric Division) ** Relocation of Geriatric ~,dmissions (To Geriatric Division) *** Transfer of Geriatric Screenings (To Geriatric Division) **** See Table 2 for More Detailed Breakdown

5/4 5/3 3/1 8/5 5/0 210 0/0 4/1 2/1

91 56

30/0 38/2 35/3 43/0

97

Table 2 Geriatric Screenings and Admissions by Selected Periods of Time

TIME PERIOD

4/80-9/80 10/80-6/81

7/81-4/82 FISCAL 80-81 FISCAL 81-82

4/82-7182

SCREENER(S)

CLU CLU CLU CLU

CLU, OPDs, GER. ADM. MGOT (ALL)

# OF PTS. SCREENED

227 299

64 449

314 146 (164)

# ADMITTED*

72 80 24

137

77 5 (12)

% SO

68 73 62 69

75 97 (93)

*From Screening Sources Only

Figure 1

(X) Mean# Patients

Per Month

Average Monthly Admission Rates (%) Under Different Screeners (Rate = ~X # ADM/X#SCR x 100)

50

40

30

20

i0

(33.2)

(21.4)

(41.o)

�9 -.. / Y

1)

SCREENED ~- - 4

ADMISSION

RATE (%) :

~~ "Qi o

(7. i) �9 (5.8)

ADMITTED i ....... �9

I I I

CLU CLU/OPDS MGOT

(10/80-6/81) (7/81-3/82) (4/82-7/82)

PRIMARY SCREENER (S)

also provided aftercare for most discharges from the geriatric division and developed its own self- referral community case load (diversions), its success at preventing unnecessary hospitaliza- tion is not due to having fewer clients or more staff than either CLU or the OPDs. Similarly, the dramatic performance improvement can't be attributed to differential levels of skill, since tile core personnel of the M G O T were reassigned from the CLU.

Performance shift can be ascribed to the change in the nature of the relationship among the triage, inpatient and aftercare teams; they became part of the same division and were mutually account- able. The implication of these data in terms of administrative organization is deceptively sim- ple; the more closely inpatient and outpatient components function, the greater the service de- livery and the higher the proportion of pre- ventable admissions. "Continuity and assurance ofconnectedness ''-~ through "unified clinical tc~ams responsible for in and out patient care ''a are nec- essary. In addition, appropriate services must be readily available to the triage team, particularly nonpsychiatric beds in general hospitals and long- term care facilities and a wide variety of spe-

cialized community-based programs? Rarely does such integration develop at even tile county level; Rhode Island is a notable exception, perhaps because of its size. 6'v

REFERENCES

1. "The Elderly Remain In Need of Mental Health Services." U.S. General Accounting Office: Gaithersburg, Md., Sept, 1982, p. 11.

2. Ibid, pp. 12-14. 3. "'Outcomes of Admission Screening Studied," This

Month in Mental Health. N.Y.S. OMH: Al- bany, N.Y., Sept., 1982, p.5.

4. Ibkt. 5. Op. cit., p. 19. 6. Ibid., p. 20. 7. "State Plan for Mental Health Services for the

Elderly." Governor's Council on Mental Health: Cranston, R.I., June, 1984.

BIOGRAPHICAL SKETCH

SAM HERMAN h the unit chief of the geriatric division of Creedmoor Ps)chiatric Center, Queens Vil- lage, NY.