With outpatient mental health clinicians often having weekslong to monthslong waiting lists, people experiencing acute mental health difficulties often find that their only option for care is the emergency room.
But emergency rooms come with their own slew of problems, including high costs, a lack of mental health-specific resources and staff, and an environment that can easily aggravate already-intense stress and anxiety levels.
This gap for those who can’t wait days or weeks for an appointment but don’t yet require emergency attention prompted the recent launch of Butler Hospital’s Express Care service, modeled after the role that urgent care centers play in general health services.
The concept isn’t completely novel at Butler, according to Gretchen Anderson, senior clinical director of ambulatory and outpatient behavioral health. But when offered on an informal basis, the service quickly hit capacity.
“It was pretty heavily used,” Anderson said. “We had 10 scheduled appointments each day, and the appointments were mainly filled.
“So we were looking at how to expand access to those individuals who needed services,” she said. “We really wanted to reduce the wait times in the emergency rooms, so we looked at our workflows and our services in a different way and changed our model a bit so we can accommodate more walk-in volume.”
Through Express Care, Butler can now accommodate walk-ins every weekday from 9 a.m. to 9 p.m., with no specific cap on the number of appointments per day. The psychiatric and substance use hospital saw an immediate stream of walk-in appointments upon announcing the service, Anderson said.
At an Express Care appointment, patients can meet with a mental health clinician for a full evaluation, start prescription medication when appropriate, and receive a referral for ongoing care. If needed, Butler can also provide bridge services in the waiting time between Express Care and referral appointments.
“Our goal is to really prevent mental health [crises],” Anderson said. “We’re wanting to help people target their symptoms and treat their symptoms sooner, so it lessens their [likelihood] of having a crisis event later.”
Butler is ahead of the curve, observers say. While many industry professionals recognize a need for intermediate-level care, the concept of urgent care facilities specifically for mental and behavioral health has yet to take off on a broader scale, said Marnie G. Shanbhag, senior director of the American Psychological Association’s Office of Independent Practice.
“They’re not incredibly common yet,” Shanbhag said. But she’s “thrilled to see more of these clinics because we sorely need them.”
Currently, many patients find themselves in a well-known but distressing dilemma.
“When you end up in a crisis, it might not be at the level where you need hospitalization, but you also don’t want to wait until you can get that first appointment somewhere,” Shanbhag said. “And maybe that appointment is in six weeks or two months from today.”
Without care facilities that can meet these intermediate needs, “emergency rooms have become our urgent care centers,” Shanbhag said. This environment not only lacks specialized providers and resources but also presents a “very chaotic” setting.
“It’s noisy, no soothing lights, it’s busy,” she said. “That’s not something that makes people feel calmer in the middle of a mental health crisis.”
While not common, the urgent care model of mental health isn’t novel to the Ocean State. In late 2018, Rhode Island health consortium Horizon Healthcare Partners opened BH Link, an East Providence behavioral health facility offering 24/7 availability for emergency mental health care, recovery support and help connecting with long-term providers.
Horizon launched BH Link with a goal of providing specialized, non-judgmental and round-the-clock mental and behavioral health services, said James DiNunzio, Horizon CEO and president. People without this access might otherwise end up with long waits and rushed emergency room visits, he said, or even in police stations.
Like Express Care, BH Link can connect patients with longer-term care and provide bridge appointments in the interim. Beyond that assistance, those who visit the facility are welcome to stay for up to 24 hours while they work with staff to figure out next steps.
“We have a whole other level of behavioral health response that takes people away from 911, and away from police and fire rescue,” DiNunzio said, “and away from emergency services.”
Despite demand for urgent care-level resources, DiNunzio said that stigma associated with mental and behavioral health, as well as the service’s relative novelty, made it harder to reach BH Link’s intended audience.
“I think the concept was lost on a lot of people,” DiNunzio said. “I’m not sure the word got out the way it needed to.”
But that seems to be changing, he said, noting an approximately 35% increase in patient volume over the last several months.
Shanbhag said Rhode Island is unusual for having two urgent care centers for mental health in a small area.
As to why more haven’t been established nationwide, Shanbhag said there’s no definitive answer, but the overall fragmented nature of U.S. health care likely plays a role. And while therapist shortages and wait times have improved in the wake of high demand during the COVID-19 pandemic, staffing potential facilities remains a challenge.
Likewise, financial and regulatory barriers stand in the way of some potential locations, according to Mark Covall, CEO and president of the National Association for Behavioral Healthcare.
In addition to paying clinicians, urgent care facilities also need to factor in overhead and facility fees. Insurance typically focuses on traditional therapy practices and lags in setting up structures for newer models, he said.
“This type of facility ... really hasn’t existed, so there’s not really a model of reimbursement,” Covall said. “It’s kind of a chicken and egg” situation.
But time is of the essence in finding new ways to increase accessible mental and behavioral health services.
“We need to come up with other ways [to serve] individuals who need mental health and addiction treatment,” Covall said.
“I think it’s a great concept,” he said of the urgent care model. “But as we always say, the devil’s in the details.”
