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Scott Lloyd

President, MTM Services

Giving Consumers the Access They Deserve

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Teams in 11 states have implemented Just-in-Time Prescriber Scheduling (JIT), an offshoot of same day access. This process moves a consumer from a diagnostic assessment to a psychiatric evaluation on the same day in some versions, or within three to five days in others. This speed has greatly increased engagement and reduced the no-shows and cancellations that once plagued the standard medical team.

For 20 years, MTM Services has had the unique opportunity to work with more than 500 teams around the world to help them attain the highest levels of quality care, consumer and staff satisfaction, successful treatment outcomes and financial stability. It has been our pleasure to help teams attain results in all of these areas via the use of consulting techniques that have a positive impact on all areas equally, rather than a singular focus.

JIT is attaining very positive results for teams across the country, when implemented correctly. We are happy to share the results of one of those teams in the case study below and hope it will speak to you about the improvements that you can attain in your service delivery processes via the JIT system.

JIT Access – The same day model it is not.

By: Benjamin Neal Millsap, Vice President of Clinical Services, Monarch


Monarch is a large, not‐for‐profit agency located in North Carolina with more than 50 years of experience providing services to people with mental health issues, substance use disorders or intellectual and developmental disabilities. Monarch currently has 19 outpatient sites across the state that provide outpatient and medication management services in addition to other mental health, substance use and intellectual and developmental disability services across multiple levels of care. We have a staff of over 1,700 and provided services to approximately 23,000 individuals last year.

Monarch is committed to open access, the ability to provide first service without an appointment. Historically in North Carolina, after initial contact, there is a seven to 14 day waiting period for a person to receive behavioral health services with possible delay of an additional week to complete a treatment plan and other paperwork. If the individual would benefit from seeing a psychiatrist, it can be between four and 12 weeks before an appointment is made to see a doctor.

Monarch’s expectation is that an individual that presents for open access will receive a comprehensive clinical assessment (CCA) by a licensed clinician, a treatment plan and be seen the same day by a psychiatrist for a psychiatric evaluation. If it is appropriate, the individual may receive a prescription(s) and appointments for group, individual and/or medication management as soon as the next day. If an individual needs a level of care Monarch does not provide or wants to receive services from another provider, our staff will make referrals to the appropriate, medically necessary level of care.

One of the most difficult parts of moving to an open access system is trying to ensure there is enough capacity to meet daily changing needs. In an attempt to make this work for our various outpatient locations, we created what we call the “hub” concept. A hub is a group of staff members, generally located at an office that is in a relatively urban area. Each hub consists of a minimum of two licensed clinical social workers (LCSWs), a psychiatrist, a nurse and an administrative staff member. The purpose of the hub is to provide open access services, not only the office at which they are located, but to other Monarch outpatient sites across the state.

The four hubs in the state of North Carolina regularly use telemedicine to assist in open access services. The sites connect through a technology installed and maintained by Metro E, a local provider with a secure private network that allows high-speed connectivity among all of Monarch’s outpatient sites. With this technology, our IT department can monitor the flow of the network and work with the telecom provider to solve any problems or connectivity issues.

Armed with the concept of hubs and the use of telemedicine, Monarch has been able to create a tiered process to ensure capacity in our agency.

  • Tier 1: The licensed staff assists in open access services at a location that has an opening (i.e., no one scheduled, no-shows or cancelations).
  • Tier 2: When those clinicians are not available, clinicians who are purposely scheduled as “open access” clinicians are used at the local site (no scheduled appointments and available for walk‐ins).
  • Tier 3: If the Tiers 1 and 2 staff are unavailable, a site reaches out to one of the hub sites to request use of telemedicine to provide open access services.
  • Tier 4: Local management, which consists of licensed clinicians, provide the CCAs to help with capacity issues to ensure that individuals are seen on the day that they present for open access.

How can an agency that traditionally schedules first appointments convert to an open access model? At Monarch, our initial process started with an in-depth analysis of our data. This allowed us to determine the number of assessments needed per week to pay for a part-time or full-time staff and to develop productivity standards for the staff. Start small with something as simple as assigning walk-in slots during certain hours of the day or certain days of the week until the open access model takes off and capacity is increased.

Hiring the right staff for open access cannot be underestimated. Because North Carolina’s telemedicine policy only allows LCSWs or psychologists with Ph.Ds. to provide CCAs via telemedicine, Monarch employs only LCSWs as clinicians in the hubs. Priority is given to individuals who use collaborative documentation, who are comfortable with technology and feel comfortable assessing multiple population groups (e.g., children, adults, MH/SAs).

Monarch developed software designed to help control the flow of open access by tracking where a person is in the process. We then incorporated this software into our Electronic Health Record (EHR) to further increase efficiency.

Our success has been measurable. From July 2014 through January 2015, the number of individuals per day supported through open access at Monarch increased 44 percent. In October 2012, during the beginning stages of introducing open access, Monarch saw 139 individuals for a new assessment, by January 2015; the number grew to 2,694 individuals.

Open access has been transformational for Monarch and continues to gain support across the service delivery system in North Carolina. Improved access provides the opportunity to intervene when an individual is motivated – often before acute care is needed. Since moving to an open access delivery system, Monarch has seen increased revenue as well as opportunities to add additional sites where managed care organization networks need to increase access. An agency that is willing to dedicate resources toward moving to an open access model can start small and grow to a complete open access system.