Photo by Jaye Haych | Unsplash
The COVID-19 pandemic has been associated with increased strain on mental health and substance use resources. Even as telehealth has increased the capacity of and access to behavioral health care, these gains have been largely outstripped by demand, which has brought increased wait times for patients. Furthermore, some therapists and clinicians are overwhelmed and fighting burnout.
Recently, the Institute for Healthcare Improvement (IHI) innovation team completed a 90-day research project focused on identifying and testing a care model that improves access (as defined by patients) to behavioral health services: simplified scheduling; reduced wait times; and successful matching of patients to behavioral health treatments or services. The methods for the project included a literature review, interviews with more than a dozen behavioral health clinicians and systems design experts completed in partnership with a large integrated health system to evaluate potential tests of change that would be both feasible and impactful.
We have four recommendations for health systems and community organizations interested in taking steps to improve access to behavioral health services.
- Understand how your patients define access — We found that patients and providers often had different perspectives on how and where care “begins.” For example, providers might consider the intake or administrative process as the beginning of care, whereas patients might view the post-intake visit with a clinician as the starting point. Additionally, while some patients might prefer to wait longer to see a therapist who is a certain gender, race, or ethnicity, others just want an appointment as quickly as possible. Insights like these may help to redesign, simplify, or change the order of steps in your current process.
To gain this understanding, you might survey or interview patients, asking questions such as:
- How do you define access to behavioral health services?
- What does an ideal access system look like?
- What is most important to you when choosing a behavioral health provider?
- What was the scheduling process like for you?
- Test a model of brief assessment and intervention — In our synthesis of the literature, interviews, and expert consultations, we found that many evidence-based and promising practices to improve access to behavioral health services included a care pathway for briefer interventions while achieving exemplary outcomes. The design and staffing of this pathway varied across settings, but these shorter interventions are typically 20 to 30 minutes in length, conducted by a motivated therapist who is solutions-focused, and often include testing new intake and assessment tools which emphasize functional outcomes in addition to symptoms.
Many organizations that have implemented brief behavioral health visits have been surprised to find that many patients are able to make rapid progress by using tools and team-based support to “solve today’s problems today” with briefer, on-demand visits emphasizing evidence-based psychosocial interventions. Once health systems have tested the staffing, referral process, and operations of these models, some have then moved to utilize virtual care to improve access in rural clinics and for more seamless clinician cross-coverage.
- “Break the Rules” for better access — Organizations should consider what institutional “rules” might inadvertently create barriers to access. Can those rules be broken, changed, or removed entirely? IHI’s work on Breaking the Rules starts with bringing staff together and asking the question: If you could break or change one rule in service of a better care experience for patients or staff, what would it be and why? Then, gather the ideas and categorize them as: 1) rules that need clarity; 2) rules that need redesign; and 3) rules that need advocacy.
For instance, can the call center patients use to request a behavioral health appointment operate with expanded hours or make appointments at the point of first contact? Does your organization have a “no-show” policy in place that penalizes missed appointments? Can the intake process be more flexible for patients? For example, would it be possible to offer daily walk-in office hours when patients can be assessed by a staff member allocated (on a rotating basis) to client intake? Might you think flexibly about how much time needs to be allocated for a behavioral health visit? Once you have collected and categorized your team’s suggestions, think about which rules might be feasible and impactful for some pilot tests of change.
- Plan for sustainability — We learned that financial concerns are one of the biggest perceived barriers in implementing new care pathways. The flexible model we recommend involves moving away from individual therapeutic visits or sessions in which mental health clinicians are compensated based on a “the more the better” productivity to an integrated, team-based model that meets patients’ needs through multiple and varied potential points of contact.
When looking at best practices in financing integrated behavioral health care models, much can be learned from federally qualified health centers (FQHCs) and community mental health centers (CMHCs). FQHCs are reimbursed via Prospective Payment System (PPS) and can bill for a same-day behavioral health encounter, while CMHCs can contract with managed care organizations and bill in accordance with the terms of those contracts. This can include funding for mental health services and case management in some cases. Additionally, in many integrated models, behavioral health clinicians can bill in partnership with a primary care provider (PCP).
Experts’ tips for getting started include seeking funding from wherever possible (e.g., Medicare/Medicaid, private insurance, philanthropy, federal waiver) and starting any pilot test by considering what services you want to offer (same day access, telehealth, or briefer visits) rather than what you know will lead to payment.
The increased need for mental health care has provided an impetus for health systems to innovate. Systems will never be able to hire enough therapists to address their ever-growing waitlists without rethinking the “one-size-fits-all” therapy pathway. Additionally, with the proliferation of on-demand therapy platforms appealing to many different segments of the population, it is more important than ever for health systems to understand what patients want and need, break the “rules” establishing barriers to seamless care, test different ways of providing great behavioral health care, and work with a systems-view to create sustainable change.
Marian Johnson, MPH, is an IHI faculty member. Marina Renton, MPhil, is an IHI Project Manager.
You may also be interested in:
A Guide for Health Systems to Save Lives from “Deaths of Despair” and Improve Community Well-Being