Implementing Help Now, a Case Study
Tyler Booth, Chief Operating Officer, InterCommunity, Inc.
This article was originally published in National Council Magazine
InterCommunity is a private, non-profit, behavioral health center located in an impoverished urban community. We serve an indigent population with severe and persistent mental illness.
As of 2011, despite our best efforts, patients had significant delays in accessing care and no-show rates were 30–50 percent. Faced with projected cuts to grant funding, insurance reimbursement rates insufficient to cover service delivery costs, and increasing demand for services, InterCommunity had two options — turn away referrals or find a different way of delivering services.
Inadvertently, we had been choosing the first option. Individuals faced a 2-week wait between their first call requesting services and an intake assessment. Then after completing a 2.5-hour intake assessment, they were told that they’d be contacted to schedule follow up care. When contacted to start services, they often did not show up for their appointments. Medication evaluation no shows were common, and given the financial detriment, InterCommunity required patients prove engagement before they could schedule a medication evaluation. No shows were also common among those already on medication.
Psychiatrists had a productivity rate of only 47 percent despite having schedules that appeared to be full at the beginning of each clinic day. With psychiatrist schedules booked multiple weeks out, individuals who didn’t show up for appointments needed medication refills to bridge the time until their psychiatrist’s next opening. Although patients were getting their medications, they were not getting good care. The psychiatrists were frustrated and worried about continuing medications without consistent evaluations. InterCommunity was not delivering billable services. Everyone was losing.
Committed to an alternative, InterCommunity consulted with MTM Services and implemented, starting in December 2011, the three-pronged Help Now model comprising:
- Same-day access for intake assessments.
- Daily walk-in therapy.
- Medication management appointments within 72 hours.
The switch from scheduled intake appointments to same-day access eliminated the delay to obtain services as well as the 51 percent no-show rate for intake assessments. Figure 1 provides graphical support for the significant change in actual service capacity provided with the same staff compared to the old scheduled model.
The initial intake process was shortened and included an individualized treatment plan and appointments for follow-up care within one week. Providing immediate access to services also decreased the likelihood that the presenting problem would escalate into a crisis.
The benefit of same day access, however, could only be realized if ongoing care was easily accessible. InterCommunity started offering daily walk-in groups that used a combination of crisis management and motivational-interviewing techniques to serve patients who were
- In pre-contemplative and contemplative stages — to build engagement as a first step of treatment.
- Too vulnerable to wait for the next scheduled group or individual therapy appointment — to get immediate support.
- Experiencing exacerbated symptoms or needing additional support — to get supplemental clinical services.
- Out of regularly scheduled therapy services but still involved with medication management or community support services — to address occasional clinical issues or re-engage in services.
These walk-in groups ensured that patients had access to therapy services that met their varied needs and levels of engagement. Providing immediate access to therapy resulted in a 90 percent increase in demand for services. Figure 2 provides an actual comparison of the number of completed initial intakes each month before and after the Help Now model was implemented.
If InterCommunity had continued to operate under the old model, this increased demand for services would have been overwhelming. However, with Help Now, InterCommunity has been able to meet the demand without increasing staffing levels. Help Now has led to significant decrease in no-show rates, which has helped to more fully realize the service capacity of each direct care staff. As clinicians no longer devote hours to managing no shows, their productivity has risen from 54 percent to 71 percent of paid time. And with productivity levels above 60 percent, InterCommunity is positioned to have the financial resources to hire additional clinicians as the demand continues to grow — a shift from surviving to thriving.
We created a rapid scheduling model where all psychiatric appointments are booked within 72 hours. With the traditional scheduling model, a patient might have received a 30-day supply of medication plus one refill and been given an appointment with their psychiatrist 55 days later. With Help Now, patients receive the same amount of medication. However, instead of being given an appointment, they are given a reminder card to call back in 52 days. When they call, they are usually offered a same-day appointment. If their psychiatrist is fully booked for that day, clients are offered an appointment within the next two days. By limiting appointment scheduling to 72 hours, Help Now has decreased the no show rate for medication appointments from 46 percent down to 6 percent. Figure 3 provides a comparison of no show percentages for clinical services (initial assessments plus therapy) and medical services for the comparative period August 2011 and August 2013.
In addition, Help Now enables rapid scheduling of new medication evaluations (initial psychiatric evaluations). Figure 4 provides a comparison of the number of days from first call for help to the initial Medication Evaluation in June 2011 compared with June 2013.
To support this scheduling, we hired a registered nurse to assist the psychiatrists and advanced practice registered nurse medication managers. This RN triages patients who present with unexpected medication issues or have a medication emergency.
Despite the changes, some patients still fail to show or do not initiate follow-up care until days after they have run out of their medications. To best resolve these issues, those who call for an appointment after a no show or who want to be seen on a day when their psychiatrist is fully booked are encouraged to walk in. Working with the RN, these clients are either seen when their psychiatrist has an opening on account of other no shows or are seen during the designated walk-in hour the psychiatrists have built into their daily schedules. This has enabled InterCommunity to use the psychiatrists’ previously unrealized capacity.
The psychiatrists’ productivity has risen from 47 to 72 percent of paid time, resulting in a 66 percent increase in services delivered. Figure 5 provides a six month comparison of medical service events delivered in 2011, 2012 and 2013 respectively.
The implementation of such major changes in scheduling and productivity could have resulted in staff turnover and dissatisfaction. However, InterCommunity avoided this outcome by educating staff on the rationale for Help Now and involving them in its design. In addition, leadership provided consistent staff support and supplied outcome measurements to track the effectiveness of changes.
Help Now has helped to realize InterCommunity’s four core aims of better patient experience, improved health outcomes, financial viability, and positive staff experience:
- Surveys indicate a 94 percent customer satisfaction rating with 80 percent asserting that InterCommunity’s timely services have prevented a need to seek inpatient psychiatric care.
- Improved capacity to provide access to treatment has led to a decrease in ER visits/ hospitalizations at a savings of over $3.7 million.
- Staffing has been able to stay flat despite a 90 percent increase in intakes, 66 percent increase in medical services delivered, and 45 percent increase in clinical services delivered
- The significant increase in billable services, without increased staffing, has led to a 48 percent increase in third party revenue.
Staff feels so positively about the Help Now experience that they voted InterCommunity a Top Work Place in the state for the past three years.
Help Now has shown InterCommunity a way to migrate into integrated health settings and ensure that we can meet the demand for quality behavioral health services.
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