Restrictive Alternatives in the Psychiatric Emergency Service

Objective: The study examined factors affecting clinicians ’ decisions in the psychiatric emergency service about referring patients to less restrictive al-ternatives to inpatient care. Indicators of quality of care and the severity of the patient’s condition were a particular focus. Methods: Trained mental health professionals observed the evaluations of 425 patients in seven Cali-fornia county general hospitals. Multivariate modeling was used to examine variables thought to predict disposition to alternative care. Results: Less re-strictive alternatives were available for 61 percent of the 425 patients and were used for 39 percent; they were overlooked by clinicians in 14 percent of cases and considered but not used in 8 percent. Patients ’ need for a controlled hospital selling, as indicated by the severity of their condition, was most im-portant in determining use of hospital alternatives. Quality of care, especial-ly the clinician’s ability to engage patients in treatment at a level appropriate to their functioning, was also a significant predictor of whether alternative care was considered or used. Conclusions: Under managed care, clinicians are under extreme economic pressure to use less restrictive alternatives, thereby reducing costly inpatient care. To ensure quality of care in general hospital emergency services, the development of supervised hospital alterna-tives is crucial. Clinicians should be encouraged to engage patients in treat-care is a goal. (Psychiatric Service