ACCESS TO BEHAVIORAL HEALTH SERVICES

Using an Established Model to Generate Positive Results

Access to behavioral health services is a key driver of both member and employer group satisfaction. With more than 700 members waiting for a behavioral health appointment, this plan felt an acute need to reorganize the way it delivered services.

As early as 1993, leaders from the plan's behavioral health department realized that certain members experiencing an acute crisis could best be served in an outpatient setting, but no such option was available. A quality improvement (QI) team was formed to implement a crisis management system. At the same time, the plan became aware that members had an unacceptably low level of satisfaction with the available access to the plan's behavioral health services. Recognizing the need for improvement in the delivery of these services, the plan decided to undertake a comprehensive quality improvement effort.

The targeted population consisted of all members requesting a behavioral health appointment. The plan chose two performance measures: the percentage of members who received a behavioral health appointment within two weeks of the request, and the percentage of member who received a behavioral health appointment within four weeks of the request.

Baseline measurement, based on 1993 data, showed that 30.9% of members received an appointment within two weeks, and 63% received an appointment within four weeks.

No benchmarks were established for this initiative. Based on information from member focus groups and a "sister" plan, the plan's staff decided on a performance goal of 80% for the percentage of members who received a behavioral health appointment within two weeks.

Not Available - Please note that NCQA requires the establishment of a benchmark or goal for measurement.

The plan identified three barriers to improvement that needed to be addressed:

• There was no efficient crisis management system; the plan determined that this system needed to improve member access to behavioral health services, match services to the individual needs of members, meet current quality standards, and improve satisfaction
• There was no effective procedure for managing initial encounters with behavioral health patients
• With waiting times for standard outpatients services at three to five weeks, patients in an acute crisis situation were limited in their options to either emergency room services or inpatient care

The plan decided that urgent care services needed to be integrated into the services provided by outpatient healthcare teams. This allowed members in crisis to be seen within 48 hours of calling in their local area. It also offered the plan more flexibility in accommodating unplanned visits and avoiding unnecessary use of hospital services.

To choose an appropriate model for the system, the plan invited regional managers, medical directors, and clinical chiefs to a two-day conference on "best practices" in behavioral health. At the end of the conference, the participants agreed to adopt a care delivery model that had been used successfully in another state.

REINVENTING THE WHEEL This health plan decided to model its new program on one that had already been successfully implemented. This can be a successful strategy for plans faced with limited resources and demanding time frames. A review of known best practices, and an analysis of their usefulness in the situation at hand, is an important but often overlooked step in quality improvement.

The new delivery model and the urgent care team concept formed the basis for the initial interventions. A pilot project was initiated at one medical office to test the concept of incorporation of urgent care delivery into teams. Next, the plan collaborated with five other regional plans on member satisfaction measures, alternatives to inpatient treatment, and emergency, crisis, and urgent care programs.

The new delivery model features single-call access to triage and an appointment scheduling system. The concept was to shift practitioner resources to meet demand on the front end. The approach was to take ownership of patients' initial needs and address them at the outset of their interaction with the program. Components of the model included:

• A user-friendly phone system with sufficient hardware, capacity, and staff to answer all calls within 60 seconds
• A customer-focused behavioral health triage team trained to respond to member needs using existing data systems
• Ongoing training of staff on the appointment system, benefits structure, and advanced communication techniques
• Flexible scheduling of appointments and business hours designed to meet customer preferences (such as midday, early morning, and evening hours)
• Standardized clinical information made readily available to practitioners and triage staff
• Consensus that the behavioral health program "owns" the member from the time of the first call, rather than the time of the first appointment

During the fourth quarter of 1994, the plan tested the one-call intake system, and installed a feature on its telephone menu to allow patients to "opt out" during long or frustrating waits. The behavioral health department created lunch hour coverage at outpatient clinics and extended the hours of clerical and phone triage staff to 6:00 PM.

The first measurement, based on 1994 data, showed virtually no change from baseline. The rate of patients receiving appointments within two weeks was 30.8%; the rate receiving appointments within four weeks was 63.1%. The plan was neither surprised nor discouraged. It felt that the interventions had not been in place long enough to produce a change.

Stepping up its interventions, the plan initiated urgent care services at six sites. Daily team meetings were instituted at outpatient clinics to enhance ownership of patients. In February, additional staff members were hired to focus on the needs of at-risk patients and began to provide them with urgent care services. The role of the behavioral health team was expanded to include medication management and urgent response. Staff hours were extended to meet the demand for appointments.

Remeasurements, based on 1995 data, showed that the percentage of patients receiving an appointment within two weeks rose to 48.9%, while the percentage of patients receiving an appointment within four weeks rose to 75.6%. These improvements were statistically significant.

Through the opening of urgent care clinics and the analysis of member surveys, the plan learned that patients respond better in urgent situations when they are treated at a familiar clinic, at the time they requested, and without the restrictions of an inpatient care setting. Therefore, the plan extended the evening appointment hours for behavioral health clinicians. At the same time, behavioral health team supervisors initiated weekly retrospective and prospective monitoring of data in order to coordinate the number of available new appointments with member requests.

MEMBER FEEDBACK When implementing changes to schedules, hours, or staff patterns, it's important to get feedback from members about their preferences. This plan was surprised by preferences expressed by members. Without their input, it wouldn't have considered interventions such as early evening appointment hours.

With these changes, statistically significant improvements continued. Data from 1996 revealed that 54.2% of members received an appointment within two weeks, and 79.2% of members received an appointment within four weeks.

The implementation of the one-call model of service was the driving force in the reduction of waiting time for all appointments. This program had other benefits as well:

• Triage therapists were able to obtain intake information and sort through treatment options at first contact
• As efficiency increased, clinicians were able to see more patients
• Initiating daily staff meetings increased opportunities for collaboration and learning between clinicians
• Measures of throughput and patient satisfaction became important indicators of performance for the behavioral health staff

In 1997, 58.7% and 88.4% of members received appointments within two and four weeks, respectively.

Even after the impressive results of previous years, the plan determined that more progress was needed to meet the initiative's goal. Further actions taken in the second half of 1997 focused on increasing the urgent care and triage staffs. In November 1997, the triage staff conducted a survey of patient preferences for appointment times and concluded that it needed to extend its appointment hours further. In December 1997, emergency psychiatric services were moved to a psychiatric emergency room providing services 24 hours a day, seven days a week.

As the health plan continued its focus on these interventions in 1998, the rates continued to improve as well; for 1998 data, the two- and four-week appointment rates rose to 60% and 90%, respectively.

The plan has continued to conduct monthly reviews of data on member access appointments and other quality measures. It has set a new goal of five minutes for connecting members over the phone with its triage team. It continues to closely monitor its telephone call abandonment rate and has extended its evening appointment hours again.

By making a commitment to service goals that address the specific needs of members, this health plan is creating the internal environment necessary for successfully rethinking its programs.