Youth hub-and-spoke model

To the Editor

We would like to thank Ilchef (2013) for his helpful commentary on our ‘Youth consultation-liaison psychiatry’ viewpoint (Allison et al., 2013). He neatly summarises the clinical problem: ‘Everyone who works in public mental health services has experienced the jarring discontinuities in care that can occur when a patient moves from a child and adolescent care model to an adult service, with the move triggered not by the patient’s changing needs but simply by leaving school or turning 18’ (Ilchef, 2013). He rightly goes on to challenge us to more clearly identify a service model for the coordinated care of young people with both medical and psychiatric needs. In the accompanying editorial, Jorm (2013) calls for ‘a more detailed and specific proposal for how it would actually work’.

This call goes to the heart of the consultation-liaison psychiatry (CLP) project. Consultation-liaison psychiatrists often notice structural problems in the hospital system, but how can CLP lead a process of clinical improvement? The consultation work is so busy that there is little opportunity for liaison programs. However, CLP is a low-cost outreach model that can be ideally suited to service improvement. CLP works on a simple hub-and-spoke model. The CLP team is the psychiatric service hub that outreaches to other hospital departments (the spokes). The hub-and-spoke model is relatively low cost because a small specialist team is able to consult with patients across the whole hospital. The cost is lower than embedding mental health staff in each hospital department. Furthermore, cost–benefit analyses suggest that CLP might actually save money for hospitals by decreasing inpatient bed days while benefiting patient care: cost per quality-adjusted life year might be negative (Parsonage and Fossey, 2011).

In terms of a specific proposal for a workable model of youth CLP, the CLP project could assume the care coordination role in specialist hospital programs for chronic illness. It is likely that transition coordination and enhanced follow-up can improve youth health outcomes for diabetes mellitus and other chronic conditions. CLP liaison coordinators could follow the transitions of young people in the specialist medical system; screen and ensure health monitoring; assertively follow up those who drop out of care; and organise multidisciplinary case conferences.

Locally, we have the opportunity to implement the youth CLP model for anorexia nervosa. As Ilchef (2013) notes, anorexia nervosa is a psychiatric/medical condition that is especially well suited to the youth health approach. These young people can face abrupt service transitions from paediatric to adult care and this ‘sudden change in treatment ethos, towards increased individual responsibility, can be bewildering and dangerous for patients and their families’ (Treasure et al., 2005). In South Australia, the State government has recently funded a new Eating Disorders Hub that will be linked with Flinders Medical Centre in Adelaide and integrated with the hospital CLP service. The CLP hub-and-spoke model will be used to improve specialist transitional care for older adolescents and young adults. The Flinders Hub will have statewide reach, and local community spokes will form the bedrock of the transitional program. It is well recognised that general practitioners (GPs) deliver most of the combined youth mental health medical care. GPs have the great advantage of remaining constant figures that young people can see throughout their developmental years. In several key locations, Headspace is also well placed to provide psychotherapy for disadvantaged young people who struggle with various eating disorders.