High Referral Success Rates in a Crisis Center HOWARD

S. SUDAK,

Associate

M.D.

Psychiatric Emergency Evaluation Referral Service, we can provide evidence of the success of the more active method of referral. A number of other authors have reported on referral rates from and to various mental health programs. Bogard studied 138 individuals who attempted suicide and initially were seen in psychiatric consultation in an emergency room. He found that only five of the 44 patients specifically referred to the outpatient department actually showed up, and that only 35.6 per cent of his total sample followed up on the recommended treat-

Professor

JOHN B. SAWYER, Assistant Professor

M.D.

GOTTFRIED K. SPRING, M.D. Assistant Professor Department of Psychiatry Case Western Reserve University

Cleveland,

Ohio

CAROLINE M. COAKWELL, Suicide Prevention Center Cleveland, Ohio

M.S.W.

The standard method of referral used by workers at the Cleveland Suicide Prevention Center Is to call the facility or therapist

and

then

to make

an appointment

for

the

client

to follow

up to see if the client kept the appointment. Three different patient samples were studied to find what percentage of patients were actually seen at the resource to which they were referred. The success rates were 69.5 per cent, 63.4 per cent, and 62.3 per cent. The authors review some of the literature on referral rates and report that their rates are significantly higher than those reported by screening agencies that merely direct clients to another resource. problem confronting any mental health facility involved in screening is how to successfully refer clients to other resources for more definitive care. Whether the triage program is an emergency ward, a hotline, or a social agency, the rate of successful referrals generally is less than 50 per cent. There is a growing body of evidence that the traditional approach of merely providing the client with the name of an agency is insufficient, and that the more active approach of a worker’s actually making the arrangement and then following up on the recommendation results in greater success. Using data from the Cleveland Suicide Prevention Center, also known as UA

Dr.

Sudak’s

Circle, and

vention

mailing

address

Cleveland, Dr.

Sawyer

Center.

Ohio is

Dr.

44106.

medical Spring

at

Case

Western

Reserve

is

University

chief medical consultant to of the Cleveland Suicide Prewas a staff psychiatrist at the

He

is also

director formerly

center.

530

HOSPITAL

&

COMMUNITY

PSYCHIATRY

Similar data have been reported by others. Chameides reported that only 55 of 153 patients seen in a hospital emergency ward kept a single appointment in the outpatient department to which they had been referred.2 More recently, Paykel reported on 78 mdividuals who attempted suicide and were seen in emergency rooms in New Haven. Only 13 of the 29 specifically referred to outpatient departments kept one appointment.3 There are two reports, however, indicating that higher success rates can be obtained if the referring agency arranges the referral directly rather than simply providing the client with information. Kogan reported on the follow-up of 195 short-term cases from a social casework agency. He divided 105 cases who were given referral into steered cases, in which the client was merely provided with a name or number to call, and referred cases, in which the worker made the appointment for the client. Approximately 73 per cent of the 105 clients were steered; the others were referred. Only 37 per cent of the steered group made contact with the referred-to resource, while 82 per cent of the referred group kept at least one appointment.4 Bogard,

‘ Follow-Up Study of Suicidal Patients Seen in Consultation,” American Journal of Psychiatry, Vol. 126, January 1970, pp. 1017-1020. 2 W. A. Chameides and J. Yamamoto, “Referral Failures: A OneYear Follow-Up,” American Journal of Psychiatry, Vol. 130, October 1973, pp. 1157-1158. $ E. S. Paykel et a!., “Treatment of Suicide Attempters,” Archives of General Psychiatry, Vol. 31, October 1974, pp. 487-491. L. S. Kogan, “The Short-Term Case in a Family Agency,” part 1, Social Casework, Vol. 38, May 1957, pp. 231-238.

‘H.

Emergency

M.

Room

Rogawski reached a similar conclusion in his followup study of 334 patients referred from an emergency evaluation unit to longer-term outpatient resources. He considered referrals as complete only if the patient kept at least two appointments with the referred-to facility. A total of 141 of the 334 were completed, which is in keeping with the usual success rates of less than 50 per cent. However, if the therapist made the call for the patient, 85 of 153 referrals were successful, as compared with 49 out of 160 instances when the patient was only steered. The difference reached statistical significance.3 Both Rogawski’ and Paykel7 cite the difficulties posed for the physician on emergency night duty; the physician is not in a position to make contact with the referred-to resource after hours. There is nothing, however, that precludes the physician or his delegate from making the call for the patient the next working day, as is done at the Cleveland center. A certain consistency can also be found in attrition rates of clients once they are established in ongoing therapy. Kogan studied 250 new cases in a social agency and found that 56 per cent did not return after their initial interview, 69 per cent dropped out before a third interview, and 78 per cent dropped out before five interviews. Jacobson studied patients in a brief treatment center that allowed a maximum of six visits. He found that 57 per cent, or 419 of 735 patients, made three or fewer visits.9 On the other hand Chameides, in a one-year followup of 51 patients who failed to keep one outpatient appointment following an emergency ward visit, found thit 40 of the patients had received some type of professional care during the year.1#{176} Since the Cleveland Suicide Prevention Center almost always actively refers rather than steers, we were prompted to examine our data to find what proportion of our clients actually are seen at the resource to which they have been referred, how long they stay with the resource, and how helpful the resource found the contact.

THE

CLEVELAND

STUDY

There is a standard method of referral used by workers at the center, whether they are responding to a telephone call or to a walk-in client. The worker calls the referred-to resource to make an appointment for the client and then subsequently follows up to see if the client kept the appointment. Three separate reviews and samples were considered A. S. Rogawski and B. Edmundson, “Factors Affecting the Outof Psychiatric Interagency Referral,’ American Journal of Psychiatry, Vol. 127, January 1971, pp. 925-934.

come

#{149} Ibid. Paykel et a!., op. cit. L. S. Kogan, “The Short-Term Case in a Family Agency,’ part 2, Social Casework, Vol. 38, June 1957, pp. 296-302. #{149} C. F. Jacobson et a!., ‘The Scope and Practice of an Early-Access Brief Treatment Psychiatric Center,” American Journal of Psychiatry, Vol. 121, June 1965, pp. 1176-1182. ‘#{176} Chameides and Yamamoto, op. cit. $

We were most successful when we persuaded the client to return to a therapist or agency he had been to before. We were least successful when we felt that personal contact at the center itself might resolve the crisis. for the study; the first was over-all data from the center for the period July 1, 1973, through June 30, 1974. As shown in Table 1, the center made 1921 referrals. Of those, 1336, or 69 per cent, were confirmed by the center to have been successful. Thus 585 were considered unsuccessful referrals. An additional 198 clients called but made their own arrangements without the center’s making a recommendation, and another 54 dispositions could not be classified under our usual list of dispositions. Even if those 252 cases were considered unsuccessful referrals and were added to the 585, then 61.5 per cent of the total possible dispositions (2173) were successful. There were 758 individuals who telephoned the center but who refused to provide sufficient information for further processing of the case. Consequently, the total pool of callers to the center was 2931 ; of those 36 per cent were male and 64 per cent were female, and 67 per cent were self-referred and 33 per cent were referred by others. We were most successful in cases where the client had been active with a therapist or agency previously and was persuaded to return to the same resource. In such instances, our follow-up calls indicated that 97.2 per cent of the time the client had actually returned. We were least successful in those instances when we felt that personal contact at the center itself might resolve the crisis without further referral. In such cases, 417 of 826 clients refused further contact. The second study included only those individuals contacting the center during the one-year study period TABLE 1973

1

through

Dispositions June 1974

made

by

Total referred 1921)

the

center

from

Total confirmed (N = 1336)

confirmed

Percent

Disposition

(N

Hospital

146

129

88.4

78

66

84.6

182

130

71.4

283

207

73.1

406

395

97.2

826

409

49.5

Emergency ward Outpatient clinic Other resources Back to private therapist or agency Further contact with center

VOLUME

28

NUMBER

=

7 JULY

1977

July

531

2

TABLE

Disposition

of cases

reporting

a recent

suicide

attempt

Disposition Hospital Emergency ward Outpatient clinic Further contact with center Cases lost or unknown

Total referred (N = 246)

Total confirmed (N = 156)

44 36 94

44 18 82

65 7

12 0

Percent confirmed 100.0 50.0

87.2 18.5 -

who reported a recent suicide attempt; there were 246 such cases. Successful, confirmed referral was made in 156 cases, unsuccessful referral was made in 83 cases, and the outcome of seven cases was unknown. A more detailed breakdown of the dispositions is shown in Table 2. Whenever center staff recommended hospitalization, that disposition was effected. Although most of the contacts were initially “emergency’ phone calls, there were some walk-ins. A total of 36 out of the 246 clients were actually seen at the center; 25 of them were successfully referred to other resources. Seventy-two of the callers were male, 174 were female. Eighty-seven initiated the contact themselves; in the other 159 cases the call was made by someone else on behalf of the patient. The proportion of self-referrals and referrals by others in this group is the reverse of the proportion for callers in general to the center. The third study covered a different time periodNovember 1, 1970, through September 30, 1971-and a different population. Only walk-ins or patients actually seen at the center and then referred were considered; most of the referrals were to private therapists, social agencies, or hospital outpatient departments. ‘

TABLE ter and

3 Outcome of patients initially successfully referred to nonhospital

seen at the conresources

Private

Variable Number of times 1 2 to 5 6 to 9 10 or more How contact Problem Problem

Active

therapists: per cent

Clinics: per cent

of N (13)

of N (32)

Social agencies: per cent of N (23)

seen

15.4

15.6

53.8

50.0

18.2 40.9

15.4

15.6

22.7

15.4

18.8

18.2

46.2 53.9

25.0 68.7

27.3 63.6

ended resolved unresolved

6.3

or unknown

9.2

We were able to follow up 130 cases. Questionnaires mailed to the referred-to resource revealed that 81 clients kept at least one appointment. A total of 68 clients were successfully referred to nonhospital resources: 13 to private therapists, 32 to clinics, and 23 to social agencies. We were interested in making comparisons among the three nonhospital resources of the number of times the clients were seen at each resource, whether the contact was terminated as resolved or not, and whether the therapist viewed the contact as helpful. It can be seen from Table 3 that regardless of the nonhospital disposition, approximately 66 per cent of the patients were seen only one to five times. That figure held even when further visits were offered and when financial considerations were not paramount. One might have expected that the patients referred to private psychiatrists would have been seen more frequently since the decision to make such referrals was predicated both on the client’s ability to pay and on his motivation. However, the social agencies had the highest percentage of clients coming more than six times; clinics were next, followed by private therapists. Of the three groups, private therapists felt that their clients had the highest percentage of problems resolved. Kogan has suggested that such results may be due to the social workers’ tendency to underestimate their own abilities.” It is also possible that private therapists overestimate their abilities. Thus the conclusions drawn by the referred-to resources about whether the patient was improved at the time of termination might be biased, since this judgment was also a subjective one made by the therapist. A comparison of the data from our three studies of the results of active referrals with data from the three studies by Bogard, Chameides, and Paykel of the results of merely steering a client clearly reveals the greater success rate of active referral. Pooling the success rates from our three studies (1336 out of 1921, 156 out of 246, and 81 out of 130) and comparing them to pooled success rates of Bogard, Chameides, and Paykel (49 out of 138, 55 out of 153, and 13 out of 29) gave a chi square of 125 (p < .001). Our pooled success percentage was 68.5, and the other three studies had a pooled success percentage of 36.6. These data support Kogan’s and Rogawski’s contention that active referral is more successful than steering, and they cast considerable doubt on the wisdom of continuing a traditional, more passive referral approach in crisis situations. While it may be reasonable for the neurotic patient to be expected to take the initiative in his own referral, for the patient in crisis it is more practical for the therapist to be active and to refer rather than just steer.U 11

Patient’s condition at termination

532

Social

Improved

69.2

62.5

45.5

Unimproved Active or unknown

30.8

31.2

45.4

6.3

HOSPITAL

& COMMUNITY

9.2

PSYCHIATRY

L. S. Kogan,

Casework,

“The

Vol.

Short-Term

38,

Case

in a

Family

July 1957, pp. 366-374.

Agency,”

part 3,

High referral success rates in a crisis center.

High Referral Success Rates in a Crisis Center HOWARD S. SUDAK, Associate M.D. Psychiatric Emergency Evaluation Referral Service, we can provide e...
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