With long wait times the norm for new behavioral health patients — three months isn’t unusual, according to one doctor — Nebraska Medicine and the University of Nebraska Medical Center have launched a plan to improve access.
The plan, launched July 1, calls for returning most patients — once they’re stable — to their primary care providers for ongoing care, freeing more appointment slots for new patients.
David Cates, Nebraska Medicine’s behavioral health director, said limited access to psychiatric providers is a regional and national problem.
Behind the access crunch are a number of converging trends.
Behavioral health providers are clustered in urban areas, leaving rural areas underserved, particularly in Nebraska, said Dr. Howard Liu, chairman of UNMC’s psychiatry department. And that workforce is aging, with more than half of providers in Nebraska now over age 50 and retiring faster in some cases than they can be replaced.
At the same time, the stigma around seeking behavioral health care has lessened somewhat, he said. Not only is there a greater understanding of such behavioral health problems, today’s younger generation — Generation Z — also is more likely to have access to such care than earlier generations and at the same time to report a greater number of poor mental health days.
On top of that, Cates said, is the way providers practice — and the problem the new plan is specifically designed to address. Providers typically follow patients indefinitely, leaving few openings available for new patients. In the first quarter of fiscal year 2019, some 92% of outpatient psychiatry visits at Nebraska Medicine were return ones.
“We tend to keep patients forever,” Cates said.
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The plan calls for new patients to come via referrals from their primary care provider, with some exceptions.
After an evaluation, patients will follow one of two tracks. Those on a consultation track will go through several more visits and, once stable, be referred back to their primary care provider for ongoing management.
Those with more persistent or severe conditions, such as psychotic disorders or conditions requiring frequent lab monitoring of medications, will stay on a continuity track under the care of psychiatrists or psychiatric advanced practice providers, all of whom can prescribe medications.
The difference between the two tracks will come down to the complexity of the patient’s condition, including stability and history, rather than the diagnosis itself.
But Cates said the team that developed the plan believes that a significant number of patients can be transferred back to primary care providers.
“That’s where we hope to increase access for Nebraska Medicine and the wider community,” he said.
Neither patients nor providers on the consultation track will be cut loose entirely, however. Providers will receive guidance, including recommendations regarding changes they can make in case of side effects or medications they can add if symptoms worsen. Primary care providers can contact psychiatry department providers via a pager for matters requiring urgent attention, or message them through the health system’s electronic health record system for more routine follow-ups. They also can refer patients back to the psychiatry department at any time.
Dr. Thomas Tape, a Nebraska Medicine physician, said he sees the new system as a good thing.
“There is a workforce shortage in psychiatry, so it’s really hard for us to get timely psychiatric advice,” he said. “It’s not unusual for patients to be told it’s a three-month wait or more to get an opening in the psychiatric clinic.”
Tape said he had a similar arrangement with a former psychiatrist and recommended it to Liu. It’s also similar to the relationships primary care providers have with a number of specialists who manage chronic diseases. If he has a patient who’s having difficulty controlling blood sugars, for instance, the patient might see an endocrinologist once or twice and then come back to him for ongoing management.
“It’s making the best use of everyone’s expertise ... in a situation where there aren’t enough mental health (care) providers to go around,” Tape said.
In Nebraska, 88 of the state’s 93 counties met the federal criteria for a Mental Health Professions Shortage Areas designation in 2018, and 32 lacked a behavioral health provider of any kind. Nearly one in five Nebraskans has a mental illness.
A number of partners are working on the problem. The state saw a nearly 15% increase in its behavioral health workforce between 2010 and 2016, according to a 2018 report compiled by the Behavioral Health Education Center of Nebraska. The center was established by the Nebraska Legislature in 2009 to increase residents’ access to behavioral health care by bolstering that workforce. Liu is the center’s former director.
The biggest gains, he said, have come in the number of psychiatric nurse practitioners, who can prescribe medications.
Liu said the new plan follows a concept known as population health, which is focused on treating the health of a community rather than that of individual members. Providers can either go deep and treat a few patients for 25 or 30 years — and those with serious illnesses will still need that — or go wide and see many more for a few visits before sending them back to primary care providers.
“For the great majority, we think we can go wide, rather than deep,” he said, noting that most systems are moving in that direction.
There are a number of models. Nebraska Medicine, for instance, also has behavioral health providers embedded in primary care clinics. Those providers can provide therapy, but they typically can’t prescribe medications.
But Cates said all of the models are focused on supporting primary care providers’ efforts to provide behavioral health care. “Overall,” he said, “they are excited about the prospect of being able to get their patients seen more quickly.”
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