Editor’s note: Mind Springs Health (MSH), a community mental health center that serves 10 counties in rural western Colorado, received a 2019 Sherman Award for Excellence in Patient Engagement for its innovative approach to mental health care. Using “phase-based care,” MSH is able to respond to patients’ needs promptly and effectively in its Rapid Recovery Clinic for Depression. MSH and other awardees were recognized for their accomplishments during a ceremony at the Institute for Healthcare Improvement’s Patient Safety Congress in Houston, Texas, on May 16, 2019.
Community mental health centers (CMHCs) in the United States face demands for service far exceeding their capabilities. Following implementation of the Affordable Care Act in 2010, CMHCs experienced 25% greater demand for services from newly insured consumers. If you or a loved one have attempted to access psychiatric care, you might be aware that wait times to engage in treatment can range from 7 to 12 weeks. These delays profoundly impact the lives of patients and families, and potentially contribute to escalating rates of suicide. A tsunami of patients seeking mental health services overwhelms our hospital emergency rooms.
Our mental health system is broken, and communities all across the country are demanding better service to meet society’s needs. Yet, solutions to achieve better service and fix the system are elusive.
Mind Springs Health in western Colorado accepted the challenge. We had to figure out how to engage acutely ill consumers in care without delay and to provide high-intensity treatment at the time of need. We had to be ever mindful of patient and staff satisfaction, as well as the likelihood of reduced financial resources due to federal and state budget adjustments. Phase-based care, a strategy that preferentially directs existing resources towards the patients at the time of their greatest need, was our proposed solution.
Two years and 300 patients later, the significance of this innovation has been recognized through the Sherman Award for Excellence in Patient Engagement. Patients engage in comprehensive treatment within 4 days, instead of 2 to 3 months. At weeks 6 and 12, depression resolution rates are 63% and 78%, far superior to the national norms of 16% and 33%. The average psychiatry and therapy time provided for depression symptoms to resolve (or week 12, whichever comes first) is 1.5 and 2.5 hours respectively. While some patients have received 8 hours of therapy to achieve recovery, others opted for medication management alone. Staff and consumer satisfaction is high and productivity is enhanced, with no additional staff required.
As simple as the concept of providing care to patients when they need it appears, there were formidable challenges.
In traditional CMHC settings, psychiatrists, therapists, and others work independently, without a coordinated patient care plan. Patients are scheduled for routine visits for years on end based on habit and culture rather than need, thus saturating the schedules of mental health providers. As a result, patients presenting in acute, highly symptomatic states (or phases) experience long delays to access care and do not receive timely, intensity-appropriate treatment that would result in rapid improvement.
We developed mathematical algorithms to guide the reallocation of psychiatry, therapy, case management and peer-support resources into a single patient-focused care plan to provide rapid and intense treatment during the acute phase and modify treatment intensity according to the patient’s progress (or lack of progress).
We integrated three simple, scientific principles into one unified approach to achieve these outcomes of phase-based care:
- Medication, psychotherapy and social support/life support skills all contribute to the resolution of depression when offered in a systematic, coordinated manner guided by patient preference. Creating a treatment team that meets weekly to review progress allows coordination of all team members into a single patient-focused care plan.
- Every “touch” (patient contact) provides meaningful therapeutic benefits regardless of the credentialing letters behind staff members’ names. Patients have scheduled appointments with psychiatrists or therapists, or can opt to walk-in to join the weekly clinic.
- Measuring care has a profound impact on outcomes. Measured care, while widely accepted in physical medicine (blood pressure, blood sugar, weight), is a relatively new concept to CMHCs.
Addressing false assumptions and changing culture
To implement these principles, we had to address the culture of traditional CMHCs. Stable patients had to be seen less intensely in order to reduce the bottleneck for new patients seeking care. In most CMHC settings, the “one in – one out” philosophy assumes that when a new patient enters treatment, a stable patient must be discharged to maintain caseload equilibrium and not over-burden staff. This is a false assumption! Far more resources are needed for a new, acutely ill patient compared to those who have reached stability. In fact, according to our algorithm, in order to see one additional acutely ill patient per week, 48 stable patients receiving routine “check-in” care must be seen differently or discharged!
Guided by our algorithms and our belief in the value of a fully integrated treatment team, the use of measurements, and value of each “touch,” we have successfully improved the care for our patients who are engaged in phase-based care without requiring additional resources.
To spread this approach throughout the 10 counties we serve, Mind Springs Health has nine additional clinics in various stages of development. The recognition and honor bestowed by the Sherman Award has motivated us to explore how to share this approach other CMHCs across the U.S. Finally, current Medicaid funding does not provide financial incentives if patients get better quicker. In fact, there is no difference in funding if patients get better or not! PBC could provide an infrastructure for a pay-for-performance strategy in which CMHCs would receive funding for achieving rapid recovery rates based on the principles of phase-based care.