Anticipating Care: Proactive Consultation-Liaison Psychiatry

SPECIAL REPORT: CONSULTATION-LIAISON PSYCHIATRY

It is an all-too-familiar scenario—one many clinicians recognize from clinical practice and personal experience with ill and/or aging relatives. An older adult hospitalized for something as common as a urinary tract infection or pneumonia is deemed medically ready for discharge yet remains in a hospital for days or even weeks longer than expected. The barrier is not medical but contextual. Cognitive impairment, unsafe discharge plans, housing instability, or the absence of a reliable caregiver often shape what happens next. Sometimes it is as simple as managing stairs: A patient recovering from a fall, now deconditioned, is unable to safely climb the steps awaiting them at home. The COVID-19 pandemic brought renewed attention to these realities, highlighting how social context shapes hospitalization and patient outcomes, as well as the global impact on health care worker burnout, depersonalization, and emotional exhaustion.¹

At its core, hospital care has always been about more than just treating disease. If the COVID-19 pandemic taught us anything, it is that hospitals are places where people confront mortality and, in doing so, reflect on what it means to be alive. Questions of dignity, meaning-making, connection, and vulnerability move to the foreground, often alongside medical decision-making, highlighting how deeply human relationships and social context shape the experience of illness.² In this sense, hospital care inevitably touches on what Aristotle described as eudaemonia: human flourishing, understood not as the absence of illness or adversity but as the capacity to preserve function, purpose, and dignity even in their presence.³

Social Determinants of Health

Long before we formalized concepts such as social determinants of health (SDOH), clinicians understood, often intuitively, that recovery involves more than symptom resolution alone. In this pragmatic sense, consultation-liaison (C-L) psychiatry has never been solely about managing psychiatric symptoms but about supporting function and preserving dignity in the midst of medical illness. As Lipsitt observed, attempts to marry “psyche” and “soma” have historically been elusive, and if true integration is to succeed, it is most likely to occur in the hospital setting, where the biopsychosociocultural approach can be meaningfully operationalized.⁴

At least one-third of patients admitted to medical or surgical services have psychiatric comorbidities, and more than half face social factors that affect their care.⁵ Patients with psychiatric illness who are hospitalized for medical or surgical care have poorer hospital outcomes, including longer length of stay (LOS), increased need for observation and restraint, higher care costs, and are more likely to be readmitted.⁵ In C-L psychiatry, understanding and addressing modifiable SDOH is essential due to their significant impact on disease prevalence and economic costs and the disproportionate burden on vulnerable populations. SDOH describe the conditions that influence a person’s socioeconomic status, education, neighborhood environment, access to resources, food insecurity, health care access, and social isolation.^6,7 Though these inequities can compound the health-related challenges facing patients who are hospitalized, the systematic addressing of social factors on psychiatric comorbidity and outcomes has received limited attention.⁸

Proactive C-L Psychiatry

Proactive C-L psychiatry is an integrative care model for medical and surgical inpatients that aims to enhance the value provided to patients, clinicians, and health care systems. The ASPIRE framework highlights key components of proactive C-L psychiatry (Figure): Advocacy addresses unmet psychiatric needs and promotes mental health awareness in medical settings, screening systematically identifies psychiatric illness through collaboration between the C-L team and other medical staff, proactive review of identified patients with primary medical teams ensures that interdisciplinary interventions are tailored to patient needs, real-time coordination integrates psychiatric care with care from primary teams, and evaluation assesses service metrics such as LOS, consultation volume, satisfaction, and care delivery improvements.⁹

The HOME Study represented a groundbreaking effort as the first multicenter randomized controlled trial of proactive integrated C-L psychiatry (PICLP), specifically targeting older adults.¹⁰ The form of proactive C-L psychiatry examined in the HOME Study, though sharing some similarities with proactive C-L psychiatry as generally practiced in the US, differed in some significant ways, including that interventions occurred on the patient level instead of entire units (as often occurs in the US) and that direct assessment by a psychiatrist of randomly assigned patients in the active study arm was performed instead of routine screening of all patients for psychiatric need, as is generally found in the US.¹¹ Conducted across 24 medical wards in 3 English hospitals, this large-scale study involved 2744 participants 65 years or older who were randomly assigned to either PICLP or usual care. Key findings highlight that the majority were older than 75 years, mostly White, and living alone, with over 90% experiencing multimorbidity and many facing severe psychiatric impairment, including neurocognitive disorders. Despite these complex social and health issues, the study results found that PICLP led to an 8.5% higher discharge rate, particularly for patients hospitalized for more than 2 weeks.¹⁰ This underscores the importance of addressing social determinants in interventions and highlights how early detection, combined with PICLP, can improve patient outcomes in complex, prolonged hospital stays.¹¹

In contrast, US-based data highlight how proactive C-L models may function differently across health care systems and patient populations. Triplett et al examined a large retrospective cohort from a tertiary academic hospital, comparing a proactive C-L service with a traditional on-request model over a 6-year period.¹² The proactive service managed more than 4 times as many initial consultations as the on-request service (7592 vs 1762) and was associated with shorter lengths of stay, earlier psychiatric engagement, and higher rates of eventual transfer to inpatient psychiatry services. Patients served by the proactive model were more likely to be female, Black, and publicly insured and generally had lower medical acuity, whereas the on-request service disproportionately managed medically complex patients requiring critical care, surgical services, or multiple hospital unit transfers, with higher rates of in-hospital mortality or ultimate discharge to rehabilitation services.¹²

Together, findings from these studies demonstrate that although proactive models reliably improve access and timeliness of psychiatric care, their downstream impact is contingent upon health system design, including health insurance coverage, universal access, and pathways to postacute care. These findings suggest that proactive C-L psychiatry is not a one-size-fits-all intervention but rather a flexible framework that can be tailored to local contexts to address equity, access, and social complexity across diverse global health care systems.

Workforce Flourishing as a Quality Metric

Proactive C-L psychiatry is not only patient centered; it is also clinician protective, with evidence demonstrating improvements in staff safety, perceived support, and satisfaction when proactive psychiatric teams are embedded in general medical settings.¹³ By embedding psychiatric expertise earlier and more predictably into care delivery, proactive models reduce moral distress, burnout, and the fragmentation that often characterizes reactive consultation. Medical and surgical teams are better supported in managing complex social and ethical dilemmas, leading to improved psychological safety and shared responsibility for care. These features align closely with the American Psychiatric Association’s vision of empowering the psychiatric workforce and fostering collaborative, team-based care environments.¹⁴ In articulating this vision, Miskimen Rivera has emphasized the importance of expanding integrated care models, leveraging emerging technologies such as artificial intelligence (AI) to reduce administrative burden, ensuring the sustainability of telepsychiatric services, and supporting legislation that strengthens training pathways for the future workforce.¹⁴ Within this framework, psychiatry functions not as a consultant of last resort but as an integrator—supporting clinicians across disciplines, enhancing clinical decision-making, and improving outcomes in increasingly complex health care systems. As health systems confront rising acuity, burnout, and retention challenges, proactive C-L psychiatry offers a scalable, systems-level strategy that advances both quality of care and workforce flourishing.

Proactive C-L Psychiatry as a Learning Health System

Looking ahead, the evolution of proactive C-L psychiatry increasingly intersects with advances in digital health infrastructure, including electronic health records (EHRs), data analytics, and emerging AI-enabled tools. Within contemporary health systems, these technologies are not intended to replace clinical judgment but rather to support earlier identification of risk, improve recognition of inequities in care delivery, and reduce cognitive and administrative burden on clinicians. SDOH are now routinely integrated into EHRs, with standardized fields capturing social domains such as housing instability, food insecurity, employment status, and social support across patient encounters.^15,16 When aggregated through reporting tools and dashboards, these data can inform proactive consultation, population-level risk stratification, and targeted care planning, including linkage to community-based resources. Patra et al found that both structured EHR strategies and natural language processing approaches can enhance the extraction and clinical use of SDOH data at scale.¹⁷ In this context, digital tools function as analytic and operational supports that strengthen equity-focused, systems-aware, globally relevant models of proactive C-L psychiatry that are adaptable across health systems rather than as substitutes for clinical expertise.

Where the Field Is Heading

As the psychiatrist’s role continues to evolve toward integrated, measurement-informed, and digitally enabled practice, proactive C-L psychiatry offers a pragmatic pathway to anticipation, integration, and sustainable excellence.¹⁸ Realizing the full potential of proactive C-L psychiatry will require ongoing investment in longitudinal, interventional research that moves beyond feasibility and process metrics toward patient-centered, workforce, and system-level outcomes. Parallel efforts are needed to train and support a workforce skilled in equity-based, trauma-informed, and culturally responsive models of care.

The principles of proactive C-L psychiatry are highly adaptable across clinical settings, health care systems, cultures, and the lifespan, offering a unifying framework for addressing complexity where medical and psychiatric needs intersect. Advancing this work will depend on international collaboration, enabling shared learning, comparative effectiveness research, and the development of globally relevant standards for integrated psychiatric care. As health systems confront increasing medical complexity, social vulnerability, and workforce strain, the proactive approach offers a framework that aligns clinical effectiveness with equity, efficiency, and professional well-being. The future of proactive C-L psychiatry will be defined not by how quickly we respond but by how thoughtfully we anticipate.

Dr Matta serves as the senior director of medical services at Home Base National Center of Excellence, a Red Sox Foundation and Massachusetts General Hospital program. She has extensive experience in military psychiatry, having served within the Defense Health Agency and the Department of Veterans Affairs. She is also an instructor of psychiatry at Harvard Medical School.

Dr Triplett is the codirector of the Johns Hopkins Proactive Hospital-based Intervention to Provide Psychiatric Services and an associate professor of clinical psychiatry at Johns Hopkins University School of Medicine.

References

1. Macaron MM, Segun-Omosehin OA, Matar RH, et al. A systematic review and meta analysis on burnout in physicians during the COVID-19 pandemic: a hidden healthcare crisis. Front Psychiatry. 2023;13:1071397.

2. Grassi L, Nanni MG, Riba M, Folesani F. Dignity in medicine: definition, assessment and therapy. Curr Psychiatry Rep. 2024;26(6):273-293.

3. Book X. In: Aristotle. Nicomachean Ethics. Ross WD, trans; Brown L, rev-ed. Oxford University Press; 2009:1177a1-117a13.

4. Lipsitt DR. Psychiatry and the general hospital in an age of uncertainty. World Psychiatry. 2003;2(2):87-92.

5. Oldham MA, Desan PH, Lee HB, et al; Council on Consultation-Liaison Psychiatry. Proactive consultation-liaison psychiatry: American Psychiatric Association resource document. J Acad Consult Liaison Psychiatry. 2021;62(2):169-185.

6. Jeste D, Lu F, Gibbs T, et al. Report of the Presidential Task Force on the Social Determinants of Mental Health. December 2022. Accessed January 27, 2026. https://www.psychiatry.org/getmedia/b73d3f7b-94dd-4a52-9267-e83328247325/2022-APA-TFSDMH-Board-of-Trustees-December-Report.pdf

7. World Report on Social Determinants of Health Equity. World Health Organization. 2025. Accessed January 27, 2026. https://www.who.int/teams/social-determinants-of-health/equity-and-health/world-report-on-social-determinants-of-health-equity

8. Matta SE, Feldman H, Lydston M, et al. Social determinants of health among medically hospitalized patients and the potential role of proactive consultation-liaison psychiatry: a scoping review. Open Science Framework. February 9, 2024. Updated January 13, 2026. Accessed January 27, 2026. https://osf.io/5j43e/overview

9. Proactive C-L Psychiatry SIG. Academy of Consultation-Liaison Psychiatry. Updated 2025. Accessed January 24, 2026. https://clpsychiatry.org/sigs/proactive-cl-sig/

10. Sharpe M, Walker J, van Niekerk M, et al; HOME Study Team. Proactive integrated consultation-liaison psychiatry and time spent in hospital by older medical inpatients in England (the HOME Study): a multicentre, parallel-group, randomised controlled trial. Lancet Psychiatry. 2024;11(9):684-695.

11. Oldham MA, Triplett P, Lee HB. Evaluating the proactive C-L model: insights and unanswered questions from the UK HOME Study. J Acad Consult Liaison Psychiatry. 2024;65(5):411-416.

12. Triplett PT, Prince E, Bienvenu OJ, et al. An observational study of proactive and on-request psychiatry consultation services: evidence for differing roles and outcomes. J Acad Consult Liaison Psychiatry. 2024;65(4):338-346.

13. Afriyie-Boateng M, Loftus C, Wiesenfeld L, et al. Proactive psychiatry intervention using a nurse-led behavioral response model for hospitalized patients with behavioral disturbances. J Healthc Qual. 2019;41(5):267-273.

14. Miskimen Rivera T. Empowering our psychiatric workforce. Psychiatric News. May 29, 2025. Accessed January 24, 2026. https://www.psychiatryonline.org/doi/10.1176/appi.pn.2025.06.6.17

15. Gold R, Cottrell E, Bunce A, et al. Developing electronic health record (EHR) strategies related to health center patients' social determinants of health. J Am Board Fam Med. 2017;30(4):428-447.

16. Focus areas. Massachusetts General Hospital. Accessed January 24, 2026. https://www.massgeneral.org/community-health/cchi/programs/focus-areas

17. Patra BG, Sharma MM, Vekaria V, et al. Extracting social determinants of health from electronic health records using natural language processing: a systematic review. J Am Med Inform Assoc. 2021;28(12):2716-2727.

18. Potash JB, McClanahan A, Davidson J, et al. The future of the psychiatrist. Psychiatr Res Clin Pract. 2025;7(2):80-90.