Is Your Practice Suffering from Mental Health Care Gridlock?

More than 3.5 million people are awaiting mental health treatment in the United States, with average wait times of 48 days.^1,2 Waiting lists are not only problematic for patients in need of care, but are also leading to increased provider burnout.³

The current shortage of care access is compounded by the preexisting barriers to mental healthcare, including social stigma, lack of adequate insurance coverage, and underdiagnosis in primary care.⁴ Herein, we review these barriers with a fresh eye and discuss potential solutions to this growing bottleneck.

Service Delivery Solutions: What to Try

Multidisciplinary Approaches

An important first step to reduce the mental health care bottleneck is to increase interdisciplinary collaboration of care – a sort of one-stop-shopping approach that includes mental health providers and mental health services in primary care with collaboration on treatment and follow-up.⁵ Research has shown that primary care practices can be successful in offering short-term, time-limited treatments in-house for mental health concerns.⁶ (See also, what’s possible with brief therapy.)

In 2020, the American Medical Association (AMA) and seven leading medical associations established the Behavioral Health Integration Collaborative, a group dedicated to catalyzing effective and sustainable integration of behavioral and mental healthcare into physician practices. Initially focused on primary care, the collaborative has since expanded to include a selection of non-primary care specialties that provide long-term care to patients with chronic illnesses significantly impacted by a comorbid mental health condition.⁷

The Department of Veterans Affairs (VA) has implemented such a model with their Primary Care-Mental Health Integration (PC-MHI) teams. PC-MHI teams now exist in each primary care setting, providing services for depression, anxiety, PTSD, and substance use disorder without the need for a separate referral for mental health services. Mental health providers have also been integrated in other non-primary care specialties within the VA, including in pain management, weight management, and sleep medicine.

While a multidisciplinary approach is a first, important step in reducing the barriers to mental health treatment, it is not a turnkey solution. Systematic changes are also needed and have been shown to help increase service delivery and reduce appointment wait times.

Service Logistics

One study that investigated the impact of systematic changes on time-to-treatment in an adult, outpatient setting found a reduction in appointment wait times and in no-show and drop rates.⁸ This study used the access model developed for primary care settings by Murray and Tantau (2000), who recommend a willingness to be creative with solutions and try and assess new ideas.⁹ In fact, their advanced access model recommends that only 35% of appointments should be scheduled in advance so that practitioners can have 65% of their day available for same-day appointments. The motto of this model is “do today’s work today.” However, before a new system can be put into place, the backlog/waitlist should be reduced. In this study, a one-day clinic was run to offer sessions for all the backlog patients.

Once the backlog was addressed, a group of multidisciplinary staff was reorganized into a centralized intake program in which appointments were scheduled during the initial call, more intake slots were made available, and the average wait time for intakes was reduced to approximately 1 week. The second phase involved monitoring supply and demand, developing a continuous flow system, setting contingency plans for unusual circumstances, and increasing the availability of bottleneck resources. Here, the wait time for an appointment was reduced from 13 days to 0 days, and the no-show rate dropped from 52% to 18%. These changes were also associated with reduced psychiatric hospitalizations, as well as improved staff morale and teamwork. It is important to note that no additional staff were hired to contribute to this improved outcome.

This approach, while effective, requires the development of a new system, and thus, a good deal of initial effort. A more immediate solution may involve the creative use of service delivery methods, such as telehealth treatment delivery.¹⁰

Internet-Based Interventions

There is a growing body of evidence demonstrating the effectiveness of internet-based interventions.¹¹ Several have been developed and tested for common mental disorders with outcomes similar to face-to-face psychotherapy. A recent meta-analysis of 20 studies investigated in-person therapy and synchronous teletherapy. Results indicated no differences in effectiveness at post-therapy and follow-up.¹² Similarly, another study demonstrated reduced no-show rates for teletherapy compared to therapy in-person.¹³

However, there are important considerations when delivering teletherapy. A systematic review of 40 studies identified three key factors, starting with proper screening to determine whether telehealth is an appropriate option for the patient. For example, do they have the technology and ability to use the technology for virtual session? Do they have a private, safe environment to attend virtual sessions, and do they have the capacity to consent to virtual care?¹⁴ The same study identified the need to ensure that the provider has the patient’s emergency contact information, and the need to keep open communication with the patient − informing them of the steps providers take to ensure confidentiality, and checking in after initial sessions to see if the patient is satisfied with virtual care or if they would prefer in-person sessions

Even with the benefits of reduced no-show rates, waitlists may still exist. In these cases, practices can triage patients based on urgency and motivation to attend behavioral health sessions.

Triage

A review of the literature identified five demand-management approaches for waiting lists, and triage was one of the most common strategies used.¹⁰ Two of the most commonly used approaches in agencies were standardizing and centralizing the intake process. Other efforts included combining triage with a brief assessment and scheduled daily triage sessions. Phone triage processes were also adopted.

Phone triage assessments gave clinicians the opportunity to identify clients who were in crisis and offer an earlier appointment.¹⁵ Phone triage also provides an opportunity for providers to recommend alternative services to prospective patients, thereby reducing demand on services.¹⁶

Turn Some Responsivities Over to the Patient

Patient-Led Approaches

The same literature review identified patient-led approaches as a second commonly used demand-management approach for waiting lists.¹⁰ Patient-led approaches involve patients initiating their own appointments, by calling or scheduling them online, as needed as opposed to going to appointments as determined by their provider. This was introduced in a general practice that provided mental health providers 2 days a week, where patients can book a 30-minute session as they need it, rather than follow-up, standing appointments, scheduled at the completion of the previous session.¹⁷ Similar is the partnership approach, which includes efforts such as reallocation of FTEs based on patient demand, quantifying care providers’ capacity, and streamlining referrals.¹⁰

Walk-In Clinics

Walk-in services operate with no appointments and, in some cases, in conjunction with a brief intervention.¹⁰ For example, a walk-in mental health clinic for adults may offer counseling, case management, and psychiatric appointments for medication management. The clinic may be staffed with a team of nurses, social workers/counselors, peer specialists, and advanced practice nurses. Several services may be offered, including immediate assessment and treatment, crisis services, follow-up calls for well-being checks, and peer counseling.

Self-Help and Bibliotherapy

Another strategy practices can use to meet the growing mental healthcare needs is to prescribe self-help treatments, such as digital, web-based, and analog bibliotherapy (ie, reading therapy, book therapy, therapeutic storytelling, podcasts, meditation apps, documentaries/docuseries) commonly referred to as low-intensity treatment (LIT) (see also, a list of apps for mental health).

LITs can be recommended in lieu of formal treatment, in addition to formal treatment, or while a patient is on a waitlist. Despite the effectiveness of LITs and providers’ general positive attitude toward LITs, fewer than 20% of practitioners with patient waitlists reported recommending LITs to their patients.¹⁸

Practitioners can recommend self-help resources that encourage patients to engage in specific behavioral health practices to improve their mental health. These resources can help them manage stress, lower their risk of illness, and increase their energy.

Encouraging even small acts of self-care can have a big impact, such as:

• getting regular exercise

• eating healthy

• increasing sleep hygiene

• trying meditation and/or relaxing activities

• learning how to set goals and priorities

• practicing gratitude and savoring pleasant experiences

• staying present

• staying socially connected

Self-care looks different for everyone, and it is important to offer patients a variety of options. It may take some trial and error to discover what works best. Bibliotherapy can help patients build greater empathy, insight, and self-compassion by exploring stories that relate to their experiences.¹⁹

Consider Group Therapy vs Individual Therapy

Given that one or two behavioral health providers can work with multiple patients at a time, group therapy is another option to help reduce wait time to service delivery. Importantly, it is an empirically supported treatment for a wide range of mental health concerns. Group therapy is an ideal treatment option to address mental health service barriers because it is considered a “triple E treatment” – that is, efficient, effective, and equivalent to individual therapy in terms of outcomes.²⁰ In fact, a recent study demonstrated how increasing group therapy by 10% nationally, particularly in primary care settings, would significantly increase treatment access.¹ (See also, group therapy for geriatric patients.)

Group therapy has its own process that is intended to be different from individual therapy, and is widely regarded as the best option for patients whose distress involves difficulties in relationships with others. The shared space of group allows for greater experiencing of relational dynamics between members, and the processing of these dynamics facilitates healing. Some groups do not have a session limit, making them a wonderful place to take on long-term goals.

Groups can be virtual, generally meet once a week, have an average of six to eight members, and one to two trained therapists. Many groups have rolling admission, meaning you can join at any time of year, and others are closed meaning everyone starts at the same time. In the VA, the PC-MHI clinics offer a variety of groups to veterans focused on grief, anger management, stress management, and more.

In Practice: How to Get Started

National studies demonstrate that most people who could benefit from mental health services are simply not receiving them.²¹ Pre-existing and growing barriers to care access can be even more challenging to overcome for select groups, such as older adults, racial and ethnic minorities, individuals with low socioeconomic status, and those who live in rural areas.

To alleviate these obstacles, clinics/practices can integrate multidisciplinary behavioral health providers in their practice, use the advanced access model/same-day scheduling model to do “today’s work today,” and incorporate telehealth practices to reduce no-shows. Additional solutions include the use of digital and analog bibliotherapy and related self-help practices, and increasing group therapy practices for mental health service delivery. Outstanding patient needs can be triaged to allow those in crisis increased access to care.

The overall goal is to create systems where patients can make mental health appointments when they need them rather than forcing a mental health appointment through a provider referral or following the traditional model of standing, weekly, or biweekly appointments. This way, the patient dictates when and how often they want to meet, reducing no-show rates.