Urgent message: Offering mental health services in an urgent care setting could facilitate treatment for conditions such as depression and help eliminate the stigma associated with psychiatric care.
Consumers value urgent care for its on-demand access to medical treatment without waiting to schedule a doctor’s appointment and for its cost savings over hospital emergency rooms (ERs). While urgent care centers have historically focused on treating coughs, sniffles, cuts, scrapes, sprains and strains, the convenience and affordability of urgent care can apply to other medical specialties.
This interview with an expert focuses on the provision of psychiatry services as an emerging business model in urgent care and it also addresses how urgent care providers can raise their awareness of mental health issues and develop referral relationships in their communities.
The Couch’s Business Model
Alan Ayers: The Couch has a unique business model. Please describe the services that you offer.
Ora Frankel: At The Couch, we see patients by appointment or on a walk-in basis. They can receive a full psychiatric evaluation, as they would in a private practice, with one of our psychiatric nurse practitioners (NPs). The comprehensive evaluation, which is our main service, takes approximately 1 hour and, if appropriate, a patient will be referred to therapy or started on medication. If, for example, a patient already has a psychiatrist in the community but can’t get into that practitioner in short order, we would see the individual and perhaps evaluate medications. We would then fax a record of the individual’s visit to the psychiatrist of record and recommend follow up with that provider. In essence, we can be an on-call service for psychiatrists.
The second scenario is the patient who has not yet seen a psychiatrist and wants to but is experiencing a delay getting a first appointment. We have quite a few Medicaid patients who pay out of pocket to see us just to get started because they have to wait several months to get an appointment with a psychiatrist in the community. At the conclusion of the evaluation, we promptly fax our evaluation and treatment plans to the patient’s psychiatrist to ensure continuity of care. Some patients choose to continue their care at The Couch, however, we also refer to numerous clinicians in the community, according to a patient’s needs.
Differentiating the Couch
Alan Ayers: What differentiates The Couch from other mental health providers in your community?
Ora Frankel: The main difference is our availability when a patient or their family is in crisis. About 3 years ago when I first started working on this project, we did an informal survey of patient wait time for mental health appointments in our area. We called 42 different offices in the community, including private practices and university clinics, some of which were fee-for-service and others that took insurance. On average, 4 to 6 weeks was the earliest that a patient could be seen for a first appointment. The number one thing about The Couch is that if a patient calls in the morning, they can come in that day.
The other thing that differentiates us from an ER is that if a patient needs treatment right away, we provide it. ERs that see patients with mental health issues tend to make a determination as to whether inpatient or intensive outpatient care is warranted. Patients who only need outpatient services don’t usually get treated at an ER. They may get a couple of days of medication to damp down anxiety, but they don’t actually get mental health care.
The reason that most people seek psychiatric services is because they are in a crisis and need to be seen right away so that treatment can be initiated. We do the triage of an ER but at the same time, also provide patients with the treatment that they need.
Why and How the Couch Operates
Alan Ayers: What led you as a clinical psychiatrist to create The Couch?
Ora Frankel: During my career, I’ve had the opportunity to work with different types of clientele and in a lot of different models of psychiatric care. I have worked in academics as well as private practice. I trained at the Cleveland Clinic as well Washington University where I stayed on faculty as director of the Child Guidance Clinic. I worked in state hospitals, community mental health clinics, as well as private practice. The one thing that all patients have in common is that they usually only seek psychiatric care when they are in crisis. However, very often, they may start in counseling rather than receiving a comprehensive psychiatric evaluation. This is akin to treating a diabetic with a blood sugar of 300 with nutritional counseling and exercise before providing them with insulin.
It isn’t unusual for patients with mania or severe depression to receive weeks of counseling before ever seeing a psychiatrist where they could be stabilized with the appropriate medications. Counseling is hugely important, but unlikely to be beneficial until the patient is stabilized.
For some patients, especially those who are poor, elderly, working, or in school, issues of transportation or being able to take time off work or school often lead to missed appointments and noncompliance with medications. I saw a need for a mental health practice where a patient could come with or without an appointment for a quick medication checkup when she or her child has the day off, or in the evening, or on a Saturday. It would facilitate getting help to individuals when they are really in crisis and when it is convenient for a patient rather than the clinician or the health care system.
Alan Ayers: Why and how do you utilize psychiatric NPs?
Ora Frankel: There are two main reasons: cost and the type of training NPs receive. It is more cost-effective to have a NP rather than an MD on duty for 10 hours. But more importantly, I am impressed by the holistic approach of NPs. Their training emphasizes not only diagnostic skills and pharmacotherapy, but I am impressed by the importance they place on hearing and communicating respectfully with a patient.
Alan Ayers: Do you accept both cash and insurance from walk-in patients?
Ora Frankel: No. We only take cash. We provide patients with a form they can submit to an insurance company to request reimbursement for out-of-network care or at least have the cost of the visit applied towards their deductible. We walk them through the steps they need to take to file with their insurance company and we also provide a Notice of Privacy Practices in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Because The Couch doesn’t accept insurance, we don’t have the overhead associated with the staff that would be required to bill insurance companies.
Alan Ayers: What types of mental health presentations are you seeing in the Louisville suburbs where The Couch operates?
Ora Frankel: We see the same presentations as in private practice or the ER, including depression, bipolar illness, attention deficit disorder (ADD), obsessive compulsive disorder (OCD), family conflict, and substance abuse. One patient with HIV was referred to us by a university program because he was having difficulty getting mental health care. It’s a compliment to us that the head of the university program wants to send us more referrals because the initial patient received such good care. At The Couch, we provide care in essentially the same way as a private practice and we treat patients with respect.
Urgent Care Providers and Mental Health Care
Alan Ayers: Are there medical complaints that an urgent care physician might see that could be manifestations of an underlying, undiagnosed mental health condition?
Ora Frankel: Yes. The classic presentation is the patient with OCD, depression or panic attacks who shows up with recurring, multiple medical complaints for which an underlying medical cause cannot be found. It’s important for a physician is to take a few minutes and just listen to a patient and allow the individual to list all of his or her concerns. An anxious patient feels the need to give great detail in order to be sure that the physician won’t “miss” something. When a patient is depressed, you can sometimes sense the heaviness, sadness, and lack of animation. It almost takes an effort for that patient to speak.
To probe for mental health concerns, urgent care providers can ask questions about a patient’s work and family. When physicians are busy, they often avoid these types of queries for fear of opening Pandora’s Box.
Alan Ayers: What kind of mental health conditions would you expect patients to commonly present with at urgent care centers?
Ora Frankel: Children with ADD are known to be frequent visitors to ERs because of falls, accidents, and broken bones and likely would also come to urgent care centers. Medication-seeking patients with chemical dependency also may present. When I was a very naive intern, I treated an agitated, elderly manic woman who was convinced that she had a contact lens stuck on her eye. I spent an hour trying to suction out a lens that was not there (she did have arcus senilis) and the result of that treatment was a raging corneal abrasion. Urgent care providers should be aware that patients in manic phase can sometimes be very convincing!
Alan Ayers: What strategies can you suggest to urgent care providers to help them better identify, assess, and provide referral for patients with mental health conditions?
Ora Frankel: I think it would be beneficial for urgent care centers to have a psychiatric NP on staff, or a social worker who has been trained in diagnosis of psychiatric conditions and could meet with patients who needed somebody to talk to. It may not be realistic for urgent care providers to do more than a superficial psychiatric assessment due to time constraints. But an NP or well-trained social worker could spend the time needed to listen to patients with mental health issues and get them to really open up about their problems. Fostering Connections with
Mental Health Professionals
Alan Ayers: How would you recommend that urgent care operators identify and cultivate referral relationships with mental health professionals?
Ora Frankel: I would suggest that an urgent care provider have a nurse call several local psychiatry offices and ask if they have a clinician who would be willing to take an immediate referral, should the need arise. Most psychiatrists have the capacity to add on a patient at the end of the day or to bring a patent in on an urgent basis. But that call needs to come from a physician not the patient. I think urgent care providers need to be proactive in reaching out to local psychiatrists so they know who is likely to take a patient with a mental health issue. The other option would be to hire a psychiatrist or a psychiatric nurse to work at an urgent care center one day a week. Patients could then be encouraged to come back on that day to be seen for mental health care.
Alan Ayers: Is there anything else you’d like to share with our readers?
Ora Frankel: The four major hospital ERs in the Louisville area see 10,000 patients per year who leave with a psychiatric diagnosis and the cost for each of those visits is approximately $2,000. A study in Kentucky identified 4,500 patients who had used the ER more than 10 times in a year.1,2 Of those, 80% had a mental health disorder and 45% were substance abusers. To me, it is a waste of time and resources to use the ER to see patients with psychiatric issues that are best treated on an outpatient basis. I think that models like The Couch can free up ERs for treatment of patients with true medical emergencies and help save money in the long run.
The other issue we need to address is the stigmatization of psychiatric care. The Couch is located in a strip mall, next to a high school and we’ve had students come by who say they’ve been feeling suicidal. They can literally look in our window and see a welcoming waiting room with friendly staff. No strait jackets or padded rooms in sight. That kind of accessibility normalizes psychiatric treatment. I think that we as physicians should make it more comfortable for patients to get the mental health care that they need.
Alan Ayers: The things you have mentioned—reducing ER visits and creating a venue that is accessible, convenient, and welcoming—are exactly what urgent care is about.
- Hasselman D. Super-Utilizer Summit: Common themes from innovative complex care management programs. Robert Wood Johnson Foundation, The Atlantic Philanthropies, and Center for Health Care Strategies, Inc. October 2013. Available at http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf407990
- Kim A, Keast R. Kentucky: Focus on emergency room “super-utilizers” could lower health care costs and improve care. Republic 3.0. Available at http://republic3-0.com/kentucky-focus-emergency-room-superutilizers-lower-health-care-costs-improve-care/