CASE STUDY

Behavioral Health Urgent Care Clinic: Providing Critical Care When and How It’s Needed

An Innovative Model Connecting People with Acute Mental Health and Substance Use Needs to Care

Executive Summary

After reviewing this case study, readers will have an understanding of how Providence Regional Medical Center in Everett, Washington, developed and launched the Behavioral Health Urgent Care clinic (the Clinic) to provide tailored assessment, immediate treatment and coordination of care for patients experiencing a mental health crisis, including issues related to substance use disorder.

The case study summarizes the model and approach, and reviews the outcomes and lessons learned after its first year of operation.

Below is an overview of the program discussed in this report.

Background

Individuals facing mental health and substance use disorder issues increasingly must turn to emergency departments (ED) to seek care, but these patients require a different set of interventions than acute medical crises and are often challenging to administer in busy EDs. ^{1, 2, 3}

“Patients have told me about traumatic experiences sitting in the ED for more than 36 hours waiting to talk to a crisis counselor. It’s horrible to sit there for so long and not get the help you need. Our goal is to keep them out of the ED and bridge them to other support and guidance.”

The Clinic offers a supportive environment where, even when patients aren’t sure what they need, they can find a trusted guide. In addition to addressing immediate care needs, the staff helps patients and families learn the language, chart a path forward and work around roadblocks.

“There are so many ‘no’s’ out there. Patients get to a point where they just stop asking questions – and they might turn to other things that just create more problems. It’s such a big change when people come into our clinic. We are here to help, we understand, and we’re ready to get them on the path of feeling better. You can watch the weight on their shoulders be lifted away.”

The Clinic equips patients and families with the resources they need to overcome barriers to care and take their next steps on the journey to treatment and recovery.

National Behavior Health Challenges

There is a growing, nationwide need for behavioral health services delivered in an urgent care setting that address mental illness and substance use.

According to the National Institute on Drug Abuse, about half of those who experience a mental illness will experience substance use disorder at some point in their lives and vice versa.⁶

The relationship between substance use disorders and mental disorders is bi-directional – the presence of one may contribute to the development or exacerbation of the other.⁴ People who have both disorders together tend to have worse impairment than people with either disorder alone, and they have worse treatment outcomes.⁴ The 2019 NSDUH found a significant increase in the number of adults aged 18 years or older with both mental illness and substance use disorder between 2015 and 2019, from 8.1 million to 9.5 million.⁴

Individuals facing mental health issues and substance use disorders increasingly have to turn to emergency departments (EDs) to seek care.

Insufficient funding for community-based and outpatient programs combined with insurance barriers forces patients to seek care in emergency settings.¹ The problem is not small: about one in eight ED visits involves mental health or a substance use disorder and the proportion appears to be increasing.²

EDs are not designed to meet the needs of these patients, and that often leaves them waiting hours or even days for appropriate care.^1,8 Although treating physical and behavioral health issues together can improve patient experience and outcomes,⁹ mental health and substance use issues require a different set of interventions than acute medical crises and are often challenging to administer in a busy ED.³ The Behavioral Health Urgent Care clinic (the Clinic) at Providence Regional Medical Center in Everett, Washington (PRMCE), the subject of this case study, was designed to provide an innovative model of care to connect those in need to appropriate services in a timely and effective manner. The Clinic has proven to be especially valuable to patients in the midst of a prolonged pandemic, which is increasing stress and isolation.¹⁰

Behavioral Health Needs in Washington State and the Everett Area

Located north of Seattle, Snohomish County, the area that PRMCE serves, has a ratio of 310 patients to one mental health provider, which includes psychologists, licensed clinical social workers, psychiatrists, counselors, marriage and family therapists, mental health providers who treat alcohol and drug abuse, and advanced practice nurses specializing in mental health care.¹¹ This ratio is lower than Washington state’s average of 270 patients per provider.¹¹ In a January 2019 report, the Snohomish County Health District estimated that between 5,000 and 10,000 of its residents had opioid use disorder and up to 80,000 were misusing opioids.¹²

The problem was evident to healthcare administrator Laura Knapp, a licensed clinical social worker who helped spearhead the new Behavioral Health Urgent Care and is PRMCE’s director of behavioral health. “The gap between mental health and substance use needs and available care led to some patients, even those who were already established in an outpatient practice, sometimes having to wait months to see their healthcare provider.” Another barrier is that many practices are limited in insurance they accept – which can exclude Medicaid patients. This leaves many patients who need medical or therapeutic intervention to stabilize a psychiatric crisis with nowhere to turn other than the Providence Regional Medical Center ED.

Providence Regional Medical Center Everett

PRMCE, part of Providence Health & Services-WA, the state’s largest healthcare provider, is a full-service medical center offering cardiology, neurology, cancer treatment, a birthing center and a Level 2 Trauma Center serving patients from several counties in northern Washington. As of July 2021, it also has a 24-bed inpatient psychiatric department that complies with state requirements for psychiatric care. PRMCE is located in Everett, the largest city in Snohomish County and home to approximately 113,000 residents.

Even prior to having an inpatient behavioral health unit, PRMCE has cared for a large number of mental health patients, including individuals with co-occurring medical, mental or substance use needs. In 2019, 15,386 patients with a behavioral health diagnosis (including 3,901 with opioid or other substance use disorder diagnosis) came into or through the ED, which averages approximately 60,000 visits per year. Patients visiting the ED for behavioral health are seen for a variety of clinical presentations which may include treatment for substance use disorders, anxiety, depression or psychosis – challenges which are exacerbated by the environment of a busy Level 2 Trauma Center.

The Behavioral Health Urgent Care Program

Identifying the Service Gap

“It was clear to us that there were not enough access points in our systems for people with behavioral health needs. Our Clinic not only fills this void, but we provide an innovative approach to care once they’re here.”

— Danielle Waldron, ARNP, RN, psychiatric nurse practitioner, Behavioral Health Urgent Care

Goals & Approach

The PRMCE team conceptualized an outpatient urgent care clinic that would provide crisis intervention, initiate treatment, and bridge to community mental health providers for ongoing care. The intention was to serve those who needed same-day care but had nowhere to go besides the ED. Although the team knew there would be some who required ED services, the goal was to reduce the burden on the ED while providing an alternative treatment setting more conducive to mental health crisis intervention.

The Clinic was modeled after the Pediatric Behavioral Health Urgent Care Center at Cohen Children’s Medical Center in New York City, which provides access, engagement, specialty assessment, coordination, and transitional care. PRMCE learned of the Cohen Children’s model through its involvement in the Institute for Health Improvements ED and UP Collaborative to address behavioral health challenges in EDs. At the time the Clinic was conceived, there were very few known behavioral health urgent care clinics in U.S. hospital settings for adults. Knowing that another provider had plans to open a pediatric behavioral health clinic nearby, PRMCE focused on the adult patient population.

Program Elements

Location & Hours

The Clinic is housed on the same campus as the ED, so patients can easily be referred between the two treatment locations based on the type of clinical treatment required.

There are four exam rooms and a large waiting room to allow spacing for patients in crisis. For the first year of operation (November 2019 to November 2020), clinic hours were Monday through Friday, from 10:00 a.m. to 5:00 p.m. The start time was chosen due to low volume in the ED during early mornings and the need for coverage in late afternoons. No appointments are necessary, and patients are seen on a first come, first served basis.

As a result of the COVID-19 pandemic, beginning in April 2020 virtual visits were also offered.

Services

The Clinic was designed to provide a tailored assessment for each patient, prescribe medication to meet immediate needs, referral to treatment services, and ensure coordination of care. If a patient needs medication, the nurse practitioners can prescribe oral medications, including medication-assisted treatment (MAT) for substance use disorder. The Clinic works collaboratively with multiple programs that treat SUD for ongoing treatment, including facilitating access to residential treatment and referring to an ongoing MAT prescriber.

Costs & Fees

The Clinic was established as an outpatient clinic to allow for credentialing with individual payers. PRMCE provides quality care to all regardless of ability to pay. Patients who do not have insurance are referred to the Patient Financial Assistance Program that provides free or discounted services to eligible patients.

Stakeholder Engagement

PRMCE’s Executive Leadership Team and Providence General Foundation were supportive of the creation of the Clinic. PRMCE provided space for the Clinic and the Foundation applied for funding from Purdue as well as paid for the furniture. The team also worked with community providers of mental health services to raise awareness about the Clinic and coordinate care for patients following crisis intervention in the Clinic. These partners come from diverse settings, including treatment and recovery services, behavioral health nonprofits, community mental health programs, psychiatric facilities, health districts, county health and primary care.

Year 1 Implementation

Operations

The Clinic opened its doors to the public on November 4, 2019. The first case of COVID-19 in the U.S. was reported in Snohomish County just over two months later, on January 20, 2020.¹⁴ Despite the challenges the Clinic faced during the pandemic, it remained open throughout its first year. By the end of November 2020, the Clinic had served 1,688 patients – well over what was anticipated.

Most patients were seen in person. Because many community health agencies in the area were not able to offer in-person treatment once the COVID-19 pandemic began, the Clinic became a critical source of services for patients who might have challenges seeking appropriate care virtually. Patients could walk in without an appointment Monday through Friday, from 10:00 a.m. to 5:00 p.m. and were usually seen the same day. Beginning in April 2020, they could also call to make an appointment for a same-day virtual visit. Although virtual visits were encouraged by Clinic staff, very few patients chose this option. Of the 1,881 visits completed in the first year, only 81 (4%) were virtual. In rare cases, visits were conducted by phone for established patients who required follow-up but were not able to connect virtually. According to Providence, the average cost per patient served at the Clinic was $281.36, less than half of the cost of a behavioral health visit in the ED.

Service Utilization

Only about 7% of patients were referred directly by the ED for same-day visits. All patients who seek treatment at the ED are seen by a physician for evaluation. Patients who are not admitted may be walked to the Clinic for coordination of care. When patients have medical issues or are in very acute crisis and out of safety – for themselves or others – they remain in the ED. In addition, the Clinic is also receiving patients from the Swedish Edmonds ED (approximately 18 miles away) for follow-up visits.

During the first year of operations, the Clinic served 1,688 unique patients (in-person and phone visits). Without phone visits (but including virtual office visits), the Clinic served 1,544 unique patients – including 16% of patients with repeat visits.

Patient Count by Number of Visits November 2019 to November 2020

Unique Patient (in-person and virtual office visits only; excluding phone visits)

As more people became aware of the Clinic, there was a steady increase in service utilization, with an average of 11 visits per day in February 2020. When the pandemic lockdowns began in mid-March 2020, patient volume decreased. However, as the pandemic persisted and there was prolonged stress, anxiety, isolation and barriers to community mental health services, there was a slight upswing in patients who needed crisis services in fall 2020. Unlike many community behavioral health clinics that closed or provided virtual visits only, the Clinic stayed open as well as provided virtual visits. Staff also supported a quarantine site for individuals with COVID-19 diagnoses and housing insecurity in Everett during the pandemic, providing support and MAT to patients as needed.

Patient Characteristics

Reasons for visiting the Clinic

Most frequent diagnoses November 2019 to November 2020

This suggests that patients with anxiety and mood disorders were more likely to seek care from the Clinic than those in crisis or dealing with alcohol and substance use disorders.

A separate search of electronic health records revealed that among all patients seen at the Clinic, only 67 had an opioid use disorder diagnosis, which was not necessarily a direct contributing factor to the patients’ Clinic visit. The number of patients with a diagnosed opioid use disorder was lower than expected. This may be due to the severely acute state many patients are in when they seek treatment for opioid use disorders (often requiring ED intervention) as well as the Clinic not being open during evenings and weekends (when there is most need for treatment).

Patient Satisfaction

“Just couldn’t thank them enough for their kindness and resources, suggestions, and allowing me to vent.”

“I felt comfortable enough to express everything I needed to say. ”

“I was able to address everything here at [the Clinic]. In previous visits at other places, I don’t feel people listened like they should.”

Nearly 40% of patients surveyed (from November 2019 to February 2021) reported that they would have gone to the ED if the Clinic were not available. The remainder would likely have not gotten any treatment or had to wait, since finding appointments with providers became even more challenging as the pandemic persisted.

“A lot of the community partners really see us as this space that is able to capture their patients, if they’re falling through the cracks or have fallen off their radar. To get that patient reconnected with their ongoing care.”

— Crystal Blankinship, LICSW, manager of behavioral health, Providence Medical Group

Data from the ED indicate that avoidable behavioral health visits have decreased since the Clinic opened.¹⁶ However, acuity increased with the COVID-19 pandemic, based on admit rate data following a mental health diagnosis.

The average number of avoidable visits per month from November 2018 to October 2019 was 350, compared to an average of 310 avoidable visits in the year following opening of the Clinic in November 2019; representing a 11% decrease in avoidable visits.

Discussion

Balancing the supply of providers with the demand for same-day services was a challenge. Allowing staff to float between the Clinic and ED helped address this but required staff with medical experience. Certain insurance providers also have stringent requirements on the types of providers that can bill in each treatment setting. This was an important lesson learned, as the substance use disorder professional was unable to bill for services in the Clinic outpatient setting. Maximizing cost reimbursement also addressed another key challenge for the Clinic: high cost and low reimbursement for services. The amount of follow- up and coordination of care to ensure patients are connected to necessary treatment was well beyond what is covered by most insurance.

Establishing bi-directional partnerships with community mental health providers was also integral to the success of this model. Community mental health providers – many of whom were not able to see patients in person – connected patients in acute need to the Clinic, which in turn connected patients to ongoing care from community partners once they had been stabilized. Without these relationships in place, the Clinic would not have been able to serve as the intended bridge across service gaps.

Lastly, the central thread through all these factors is the need for a strong team with different types of skills and experiences to serve patients in crisis, work flexibly across treatment settings, and maintain strong relationships with community partners. Given the high intensity and pace of working with patients in crisis five days per week, it is also critical to support staff wellness. Two ways the Clinic does this is by securing budget to hire per diem support when necessary, ensuring adequate coverage for staff on both short-term and long-term leave, and hiring staff who can transition to other roles as needed. For example, the Clinic manager is also a social worker who can see patients when needed.

Conclusion

Looking Ahead

References

^9. American Hospital Association. Issue Brief: Integrated Behavioral Health is High-value Care. 2019. (p3)
https://​www​.aha​.org/​s​y​s​t​e​m​/​f​i​l​e​s​/​m​e​d​i​a​/​f​i​l​e​/​2​0​1​9​/​1​2​/​v​a​l​u​e​-​i​n​i​t​i​a​t​i​v​e​-​i​s​s​u​e​-​b​r​i​e​f​-​i​n​t​e​g​r​a​t​e​d​-​b​e​h​a​v​i​o​r​a​l​-​h​e​a​l​t​h​-​h​i​g​h​-​v​a​l​u​e​-​c​a​r​e.pdf
^10. Washington State Department of Health. Statewide high-level analysis of forecasted behavioral health impacts from COVID-19. DOH 820-101. September 2020. (p1) (1) (1,9)
https://​www​.samhsa​.gov/​d​a​t​a​/​s​i​t​e​s​/​d​e​f​a​u​l​t​/​f​i​l​e​s​/​c​b​h​s​q​-​r​e​p​o​r​t​s​/​W​a​s​h​i​n​g​t​o​n​-​B​H​-​B​a​r​o​m​e​t​e​r​V​o​l​u​m​e​5.pdf
^11. Washington County Health Rankings Health Rankings. Countyhealthrankings​.org. Accessed March 23, 2021. (p2) (1)
https://​www​.countyhealthrankings​.org/​a​p​p​/​w​a​s​h​i​n​g​t​o​n​/​2​0​2​0​/​m​e​a​s​u​r​e​/​f​a​c​t​o​r​s​/​6​2​/data
^12. Snohomish Health District. Opioid use disorder and opioid misuse in Snohomish County. December 2018. (p15)
http://​www​.snohd​.org/​D​o​c​u​m​e​n​t​C​e​n​t​e​r​/​V​i​e​w​/​1​7​7​3​/​B​u​r​d​e​n​-​o​f​-​D​i​s​e​a​s​e​-​R​e​p​o​r​t​-​-​-​D​e​c​e​m​b​e​r​-​2​0​1​8-PDF.
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^15. NAMI. Mental Health by the Numbers. 2019. Accessed Nov 24, 2020. (p 2) (2)
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https://​doi​.org/​1​0​.​1​0​9​3​/​i​n​t​q​h​c​/​m​zx081
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