The impact of referral letter quality on timely access to specialised mental health care: a quantitative study of the reliability of patient triage.

BACKGROUND: Patients referred to specialised mental health care are usually triaged based on referral information provided by general practitioners. However, knowledge about this system's ability to ensure timely access to and equity in specialised mental health care is limited. We aimed to investigate to the degree to which patient triage, based on referral letter information, corresponds to triage based on a hospital specialist's consultation with the patient, and whether the degree of correspondence is affected by the quality of the referral letter. METHODS: We gathered information from three specialised mental health centres in Norway regarding patients that were referred and offered health care (N = 264). Data consisted of triage decisions for each patient (i.e., the hospital specialist's assessment of maximum acceptable waiting time), which were determined on the basis of a) referral information and b) meeting the patient. Referral letter quality was evaluated using the Quality of Referral information-Mental Health checklist. The reliability of priority setting and the impact of referral letter quality on this measure were investigated using descriptive analyses, binary logistic regression and Nadaraya-Watson kernel regression. RESULTS: In 143 (54%) cases, the triage decision based on referral information corresponded with the decision based on patient consultation. In 70 (27%) cases, the urgency of need for treatment was underestimated when based on referral information compared with that based on information from patient consultation. Referral letter quality could not explain the differences between the two triage decisions. However, when a cut-off value of 7 on the Quality of Referral information-Mental Health scale was used, low-quality letters were found more frequently among patients whose urgency of need was underestimated, compared with those whose need was overestimated. CONCLUSIONS: Deciding the urgency of patient need for specialised mental health care based on referral information is a reliable system in many situations. However, the possibility of under- and overestimation is present, implying risks to patient safety and inappropriate use of resources. Improving the content of referral letters does not appear to reduce this risk when the letters are of acceptable quality. TRIAL REGISTRATION: NCT01374035 .

Defining when specialised mental health care is needed: a focus group study.

BACKGROUND: Shared understanding between GPs and hospital specialists concerning when patients need specialised mental health care is important to ensure patients receive appropriate care. The large amount of rejected referrals often indicates a lack of such shared understanding. AIM: To explore how patient representatives, GPs, and mental health specialists understand 'need for specialised mental health care', meaning that primary care is no longer sufficient. DESIGN & SETTING: This qualitative study was conducted in western Norway. The study has a service user-involved research design in which GPs and patient representatives participated in all stages of the research process. METHOD: Six semi-structured focus group interviews were conducted. The groups were homogenous as they included only the perspectives of either GPs, mental health specialists, or patient representatives. Data were analysed using thematic analysis. RESULTS: The need for specialised mental health care was assessed using two continuums: (a) the patient's level of functioning and symptoms; and (b) characteristics of the healthcare system and the patient's informal support networks. Assessment along these continuums were often overruled by the evaluation of expected usefulness of specialised mental health care. In addition, all participants reported they often adapted their definition of need to fit other stakeholders' interpretations of need. CONCLUSION: Evaluation of need for specialised mental health care is complex and depends on several factors. This may explain some of the current challenges that exist with regard to equity and timely access to appropriate healthcare interventions.