Brief Report
Eliminating the Wait for Mental Health Services Marian E. Williams, PhD James Latta, LCSW Persila Conversano, PsyD Abstract Timely access to mental health services is critical to successful treatment of adults with severe and persistent mental illness, and timeliness is a key quality indicator in calls for improvement to the health care system. Waiting weeks for a psychiatric appointment results in increased psychiatric hospitalizations, decompensation, and risk for suicide. However, many community mental health administrators assume that waiting lists for services are inevitable given the high demand for services. The present study evaluates the successful efforts of a large urban community mental health center to eliminate the wait for psychiatric services in an adult outpatient setting. Through systematic changes in the service delivery system, the wait time for a psychiatric appointment was reduced from 13 days to 0 days, and the no-show rate dropped from 52 to 18%. Furthermore, these changes were associated with reduced psychiatric hospitalizations and improved staff morale and teamwork. The change processes implemented can be successfully applied to other systems problems confronting mental health agencies.
Introduction Over the past decade, calls for improvements in the American health care system have served to focus healthcare providers and agencies on the importance of quality improvement and systems change for the benefit of consumers.1,2 Community mental health centers struggle to meet demand, and even people with severe problems face lengthy delays to obtain services.3,4 For people with serious mental illness, substance abuse, and homelessness, having to wait for a psychiatric appointment can mean the difference between regaining stability and relapse, crisis hospitalization, or even suicide attempts. Soumeri et al.5 found that restricting access to prescription medications for people with schizophrenia led to a significant increase in psychiatric
Address correspondence to Marian E. Williams, PhD, General Pediatrics, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd., MS#53, Los Angeles, CA 90027, USA. Phone: +1-323-3618525; Fax: +1-3236713843. Email:
[email protected]. James Latta, LCSW, Division Director, Didi Hirsch Community Mental Health Center, 4760 S. Sepulveda Boulevard, Culver City, CA, USA. Persila Conversano, PsyD, Licensed Psychologist, Childrens Hospital Los Angeles, 4650 W Sunset Blvd., Los Angeles, CA, USA.
) 2007 National Council for Community Behavioral
Journal of Behavioral Health Services & Research, 2008. c Healthcare.
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hospitalizations; similar outcomes may occur if clients are unable to obtain psychotropic medications because of delays in accessing psychiatric services. Accessing mental health services is critical for homeless people, who generally do not keep calendars or return for appointments scheduled in the future.6 Timeliness was identified as a primary aim for improvement in the health care system by the Institute of Medicine.2 In addition to the human costs of psychiatric decompensation while awaiting care, waiting lists lead to higher no-show rates and reduced efficiency of mental health agencies. Typical no-show rates of 39 to 50%7,8 for first mental health service appointments waste resources. In an experimental study varying waiting times, Folkins et al.9 found a significant relationship between waiting times of 1 to 2 weeks and a higher rate of no-shows. People referred for psychiatric care in primary care clinics10 or community mental health centers11 are more likely to miss their appointment the longer they wait. Waiting for care was identified as a key area of waste leading to inefficiency in the Institute of Medicine report.2
The Setting and Previous System The present project was carried out in a large community mental health center in an urban setting, serving more than 30,000 children, adults, and older adults annually at 13 sites. This article focuses on a model quality improvement effort to eliminate the waiting list for psychiatric services for adults with serious and persistent mental illness served at the largest outpatient clinic within the agency. The program annually serves approximately 800 low-income adults with mental illness, primarily schizophrenia, bipolar disorder, and major depression. The ethnic background of clients served is 50% Caucasian, 26% Latino, 18% African American, 2% Asian, and 4% other ethnicities. Approximately 40% of the clients have coexisting substance abuse disorders, and 10% are homeless. Ninety percent of clients are prescribed medication by agency psychiatrists, in addition to case management services. Time-limited individual or group psychotherapy is available to approximately 25% of clients. Before implementation of the access improvement model, clients often waited 3 to 4 weeks for the intake appointment, and three more weeks for a psychiatric appointment.
Quality Improvement Model to Reduce Wait Times for Services The agency’s mission is to provide quality behavioral healthcare services in a setting that is accessible and client centered. Regular quality improvement reviews are carried out in partnership with the agency’s primary funding source, the Los Angeles County Department of Mental Health (LAC-DMH). Based on input from stakeholders (advisory board, consumer surveys), LAC-DMH identified long wait times for appointments as a primary issue for quality improvement focus. The Department launched an Access Improvement Project to address this aim, beginning with hiring consultants to help implement the pilot project described here. The quality improvement effort to improve timeliness at this community mental health center was carried out in two phases, the second of which is described in detail in this article. In the first phase of the effort, a group of staff was reorganized into a centralized intake program to improve efficiency and consistency across programs. This reorganization improved access in that appointments were scheduled during the initial call, more intake slots were made available, and the average wait time for intakes was reduced to approximately 1 week. However, clients needing a psychiatric evaluation continued to wait 3 to 4 weeks after their intake interview, and the no-show rate for the initial psychiatric appointment was 50 to 60%. Recognizing the costs to client care and efficiency in the existing model, the center volunteered to participate in the Los Angeles County Access Improvement Project pilot. The quality improvement methods built on the “advanced access” model developed by Murray and Tantau12,13
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in medical primary practice settings. Application of the model involves monitoring supply and demand and developing a “continuous flow” system designed to match demand, reducing existing backlogs, developing contingency plans for unusual circumstances, and increasing the availability of bottleneck resources; this model was cited by the Institute of Medicine as an example of strategies for organizations to use to reorganize and thereby improve quality of care2 (pp. 125 and 142).
Specific Change Strategies Develop an Effective Access Team The agency organized an Access Team to meet with the consultants, learn the advanced access model, and develop and implement changes to the access system. Team members included the clinical director, medical director, adult outpatient program director, centralized intake coordinator, psychiatric nurse, and a case manager, therapist, and clerical staff manager. The team participated in several daylong consultation/planning meetings and met weekly to plan and evaluate the implementation of system changes over a period of 1 year. Identify/Track Data Weekly Several measures were used to provide continuous weekly feedback data to the access improvement team: (1) demand and supply (demand: the number of calls per week from all new clients requesting services; supply: the number of available intake and psychiatric evaluation appointments per week); (2) no-show rates (no-shows were tracked for both intakes and initial psychiatric appointments); (3) delay to available appointments (the number of days to the third available appointment was used to measure delay in the system). Evaluate the Current System and Set Goals Several team members “walked through” the existing access system from a client’s perspective, to identify barriers clients faced in accessing the system. Comparison of supply and demand tracking data revealed that an average of ten new clients per week requested adult outpatient services and ten intakes and ten first psychiatric evaluations were provided each week. Therefore, it was noted that demand and supply were already matched (despite the delay between the request for service and the delivery of that service) and that therefore additional staff resources were not needed to meet the demand. Ninety percent of clients were eventually prescribed psychiatric medications, indicating that virtually all clients could benefit from immediate access to a psychiatric evaluation. The no-show rate for psychiatric evaluations was found to be more than 50%, suggesting considerable wasted resources. Brainstorming led to the following goals: (1) All clients will be seen for a joint intake and psychiatric evaluation within 48 h of their initial phone call or walk-in request for services; (2) the no-show rate for intakes and psychiatric evaluations will be reduced to below 15%. Reduce the Existing Backlog Before beginning to offer same-day appointments, the backlog of 20 existing clients waiting for a psychiatric evaluation needed to be quickly reduced. The medical director ran a one-time psychiatric clinic for all clients awaiting a first appointment, and almost all clients in the backlog were seen that day. The remaining clients on the waitlist were seen by parttime psychiatrists who added hours temporarily. Provide All New Clients Evaluations Within 48 Hours All therapists and psychiatrists in the program set aside weekly intake times to meet the typical daily demand identified through initial data tracking. Therapists were required to arrange intake coverage in advance of their vacations, with back-up assistance by the two program managers. On days when demand was temporarily higher than usual, the two program managers completed intakes. Using these procedures, virtually all clients who called or walked in were offered an intake that day. Occasionally, clients who were offered a same-day appointment would ask to be seen at a future date instead and so were scheduled for
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future intake appointments as requested. However, the no-show rate remained very high, and review of phone screening logs revealed that almost all of the patients who no-showed were those who had scheduled appointments in the future. Therefore, the team stopped scheduling appointments into the future, but assured clients that they would be guaranteed an appointment on the day they called back and asked to be seen. Those clients were still included in the study, as when they called back they were given a same-day appointment. Meet Clients’ Immediate Needs Immediately By combining the intake and psychiatric evaluations in the first session, clients were able to tell their story one time, the intake therapists and psychiatrists were able to learn from each other by conducting interviews jointly, and clients’ greatest needs were addressed in their first visit. Clients who requested not to meet with a psychiatrist were seen by an intake therapist alone. Address New Problems as They Arise The weekly access team meetings provided opportunities to develop strategies to address new problems as soon as they arose. For example, when a client could not fill her prescription because her chart had not been opened yet, a new goal was established by the access team to have charts open in the county computer system on the same day that intakes were conducted. The support staff manager reorganized the system by crosstraining, ensuring that only one person handled each chart from start to finish and revising staff schedules to ensure dedicated time after each intake slot to complete the chart opening procedures.
Measures Iterative Measures As described above under “Specific Change Strategies,” the access team tracked several measures on a weekly basis to identify problems and to develop and evaluate change strategies. To evaluate the overall effectiveness of the project, the following additional data from the agency database was analyzed retrospectively. Delay to initial psychiatric appointment Data entry staff (not involved with the access team) entered all appointments into a database, including date of session and type of appointment. Delay to initial psychiatric appointment was defined as the number of days between the first intake appointment and the first appointment with a psychiatrist. No-Show Rates On a weekly basis, the centralized intake coordinator entered data regarding the number of kept and no-show intake appointments into an Excel database, and the psychiatric nurse did the same for all psychiatric intake appointments. Crisis Hospitalizations This measure was designed to determine if the improved system resulted in reduced psychiatric hospitalizations at the time of initial intake. In the agency billing system, the services provided to hospitalize a client are labeled with a “crisis intervention” service code. The database manager (not involved with the access team) provided a list of all clients during the 18month period before the access project and the 18-month period after completion of the access project, with crisis intervention billing code during the first visit. The first author reviewed the intake progress notes for those clients to confirm that a psychiatric hospitalization was described in the intake clinician’s progress note for that session. Office Efficiency The database manager provided a retroactive report from the agency database system, which indicated the number of days from the intake date to the date the client data were entered into the agency database.
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Staff Perceptions of Project A survey was developed by the authors including questions about staff satisfaction and staff perceptions of client care after project implementation, with responses provided on a Likert scale. The survey was distributed to all staff in the centralized intake and adult outpatient teams, and 100% of staff responded (anonymously).
Results Reduced Time Between Intake Appointment and Psychiatric Evaluation Weekly tracking of available appointments revealed that, before access implementation, psychiatric appointments were available 13 days after the request for help; this wait was eliminated with the availability of same-day appointments for all clients after access implementation. The actual number of days between initial intake session and initial psychiatric appointment was compared for all clients seen in the 18 months before starting the access project and the 18 months after access implementation. A one-tailed t-test analysis demonstrated a significant reduction in the average delay between intake and psychiatric evaluation after access implementation, from 11 days to 2 days (pG0.0005). In the period before access implementation, 12% of clients saw a psychiatrist on the same day as their intake. In contrast, after access implementation, 80% of clients were seen by a psychiatrist on the same day as their first intake appointment. No-Show Rate Reduced For the 6 months before implementing the access program, the no-show rate for initial psychiatric evaluations averaged 52%. Over a 7-month period, after full implementation of the access model, the no-show rate averaged 18%. This was slightly above the 15% goal but nonetheless represented a significant improvement over the previous system of care (pG0.01). An analysis of the costs involved in providing psychiatric services indicates a significant cost savings associated with the reduced no-show rate. Cost savings were estimated based on the amount billed for a psychiatric appointment, multiplied by the average number of appointments per week represented by the reduced no-show rate. With ten psychiatric evaluations provided per week at a cost of $250 in potential billings per evaluation for psychiatrist time, the 52% no-show rate was costing $1,300 per week, or $67,600 per year. The reduction to an 18% no-show rate meant an estimated cost savings of $850 per week, or $44,200 per year, in billable psychiatrist time. Reduced Crisis Hospitalizations An important consequence of long wait times for treatment is the risk of clinical decompensation while awaiting treatment. Review of billing records revealed that intake psychiatric hospitalization rates were significantly reduced after implementation of same-day access to psychiatric evaluations. In the 18-month period before implementing the access program, there were 13 clients hospitalized at intake (out of a total of 138 intakes completed). These were clients who presented for intake with acute psychosis or suicidal ideation, and the intake therapist initiated a voluntary or involuntary psychiatric hospitalization to stabilize the client and ensure their safety. In contrast, in the 18-month period after implementation of the access program, only one client was hospitalized at intake (out of a total of 175 intakes), indicating a significant decrease in hospitalization rates (Chi-square test; pG0.001). Office Efficiency Increased The access project resulted in a significant reduction in days to create and open a new chart, from an average of 19 days before access implementation to an average of 5 days after implementation of clerical staff changes.
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Staff Perceptions of Project An anonymous staff survey was conducted 1 year after the access project started and was completed by all 28 of the clinical staff involved in the centralized intake and adult outpatient programs. Staff completing the survey included psychiatrists, therapists, phone counselors, care coordinators, program directors, and psychiatric nurses. Responses to the survey indicate positive perceptions of the access project. In terms of client care, 96% of staff agreed that the project improved clinical services to clients, and 87% reported that they received fewer complaints from clients after the project was instituted. Regarding staff working conditions, 75% of staff reported improved morale as a result of the project, and 92% said the program staff works more as a team after implementing the project. Chi-square analyses indicate no difference in survey results for the group of staff who participated in the Access Team and those who did not have a role in designing the project, with both groups expressing high satisfaction.
Discussion This study presents a model quality improvement team approach that significantly reduced wait times for adult psychiatric services without increasing staff resources. Improvements in access to care led to a more efficient system, with less staff time wasted in no-shows and higher staff morale associated with teamwork and higher quality care. Finally, improved access to care led to reduced emergency psychiatric hospitalizations at intake. A key aspect of the quality improvement strategy was the willingness to experiment with change. The team made a commitment to encourage a “brainstorming” approach to problem solving in which all ideas would be considered. New ideas were tried for 2 weeks, and results were analyzed at the weekly access team meetings to determine if the change should be continued or modified. In this way, innovative strategies were attempted and then revised based on feedback. Having successfully implemented change in one major area of a complex system, the managers involved in the programs were more open to addressing other seemingly intractable problems. In addition, managers from other programs within the agency began to implement similar projects aimed at improving other aspects of the system. Thus, there was a ripple effect in which change occurred more broadly across the organization. There are limitations in the present study that may impact its generalizability to other agencies. The initial consultation sessions were funded through a special project, and the same results might not have been achieved without outside consultation. In addition, the agency had made significant changes by reorganizing the centralized intake program before the start of the access project. This two-stage, gradual approach to change may have been critical to success. Furthermore, multiple system changes were implemented in this project, and it is not possible to determine which of these changes were essential to the success of the project. In addition, as no control group or comparison program was included in the study, it is possible that the changes documented were not the result of the quality improvement effort. However, it is notable that 18 months of data before implementation of the model program showed consistent wait times and no-show rates, suggesting that the program was quite stable in its problems with access to care before the access project implementation. Furthermore, other programs in the same agency did not experience reductions in wait time and no-show rates during the period that the access team focused on the program described in this study. Another potential limitation to generalizability is the finding that, in the program studied, there was found to be a match between supply and demand for new psychiatric appointments at the onset of the project. In agencies where supply and demand are not matched, additional system changes (probably including increased personnel resources) would likely be needed to reduce wait times. However, it should be noted that all team members at the outset of this project assumed that the
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agency’s demand exceeded supply; the process of carefully tracking demand and supply revealed that additional resources were not needed. Simply adding new staff without changing the system would not have been successful. In agencies where demand is found to consistently exceed supply, quality improvement strategies that improve efficiency still help to increase supply without adding staff resources. For example, the finding that the no-show rate for psychiatry appointments was significantly reduced meant that more “supply” was made available through the change strategies. The model described was applied within an urban community mental health center serving adults with serious mental illness, with a high incidence of substance abuse and homelessness. Changes to the model would likely be needed for agencies serving different populations of clients. For example, the policy to offer only same-day appointments would probably not be successful with employed adults who plan schedules in advance. The strategy of offering psychiatric appointments and intake appointments jointly would be less appropriate in a population where a smaller percentage of clients needed psychiatric medication. The measure of staff satisfaction was collected after the project was completed, so there were no baseline data for comparison. Therefore, it is unknown to what extent staff satisfaction actually improved, although the questions on the survey did focus on satisfaction specifically related to the access project. Although the surveys were completed anonymously, it is likely that there was a favorability bias. This hypothesis was partially refuted by the finding that staff that were not Access Team members had equal satisfaction with the project as those staff on the team. Finally, the follow-up period measured in this project was 18 months, and it is unknown whether the documented changes would be sustained for a longer period. However, it is notable that the access team stopped meeting weekly before the 18-month post-access measurement period. Therefore, the positive outcomes did continue for at least 18 months beyond the period when the staff was actively meeting to focus on access issues.
Implications for Behavioral Health This study presents a model approach to significantly reduce wait times for treatment for adults with serious and persistent mental illness in a large, urban, community mental health center for a low-income population. The improvement in rapid access to psychiatric services resulted in better patient care, evidenced by reduced crisis hospitalizations and staff reports of improved patient care and fewer complaints from clients. In turn, significant cost savings to the system were realized through reduced no-show rate (estimated cost savings of $44,000 per year in psychiatrist time). In addition to the immediate improvements to the system, managers from other programs used the example of the project to inspire changes to unrelated systems within the agency.
Acknowledgements The authors would like to thank the Los Angeles County Department of Mental Health, Murray & Tantau, Duane McWaine, M.D., Medical Director, Kita Curry, Ph.D., President/CEO, and all the other staff at Didi Hirsch Community Mental Health Center Adult Outpatient Program, who helped us to transform a system.
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