Evaluating the Proactive C-L Model: Insights and Unanswered Questions From the UK HOME Study

Abstract

The HOME Study is the largest and among the most important trials in the history of consultation-liaison psychiatry, and its study team is to be commended for this landmark study. In this article, we provide context for the HOME Study and consider several aspects of the study critical to understanding the nature of the intervention and interpreting its results. First, we compare the model of proactive integrated consultation-liaison psychiatry as implemented in the HOME Study with versions of proactive consultation-liaison psychiatry as commonly practiced in the US. Key distinctions of proactive integrated consultation-liaison psychiatry include a direct assessment of all study arm participants by a consultation-liaison psychiatrist rather than the use of initial screening for acute psychiatric issues, the unique inclusion of an occupational therapist as a member of the proactive integrated consultation-liaison psychiatry team, and patient-level randomization as opposed to unit-based approaches as commonly practiced in the US. Next, we consider several characteristics of the HOME Study sample relevant to its generalizability. These include an average age of 82 years, limited ethnic and racial diversity, and a high prevalence of both cognitive and functional impairment. Third, we review how study methodology informs study interpretation. These include early trial termination due to COVID, which limits power to detect a 1-day reduction in hospital, a mean 3.5-day delay from hospital admission to study enrollment, and the exclusion of patients who had already received a psychiatric consultation, which likely reduced the acuity of mental health issues addressed in this study. Despite these considerations, the HOME Study is a truly remarkable contribution to the literature, and its results will be discussed for years to come. In view of the aging global population, the HOME Study set about to tackle an especially ambitious and forward-looking question by focusing exclusively on older hospitalized adults. Like all good studies, this trial raises many important questions. As the first randomized trial of proactive consultation-liaison psychiatry of any form, the HOME Study is an encouragement to the field to consider the range of potential benefits of providing proactive, integrated mental health care to medical and surgical inpatients with mental health needs.