Community psychiatry -- should it be all walk in clinic and street outreach?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

Doctor Bagel

so cheap and juicy
Moderator Emeritus
20+ Year Member
Joined
Sep 26, 2002
Messages
10,910
Reaction score
1,154
So I've had 3 no shows so far today, which is pretty typical for me in this community job. And it's not because I suck (OK, maybe it is), but I don't think so -- I don't even know most of these people. Anyway, should we move away from actually scheduling SPMI people for clinic appointments because their underlying psychopathology and life chaos make regular attendance at appointments unrealistic? Unfortunately we're tied into a face to face evaluation for compensation type of system, and I'm definitely losing money for my employer by sitting around waiting for patients to show up.

How does community MH work in your community? I think ACT teams are great, but unfortunately enrollment is so limited. What about those people who don't qualify for ACT and yet still can't make a 10:30 appointment in a clinic with any regularity?

Members don't see this ad.
 
Our clinic does a reminder call the day before and sends a cab to their home. Pt usually forgets about their appointment and don't answer their phone or check their voicemail. But when the cab driver knocks on their door they usually come in.

I do not know what the % of shows are at our clinic. My ballpark estimate is 75% come in but it would be a lot lower if we didn't have the cabs.

State is now trying to refuse to pay for the cabs and there has been a huge uproar over this. Pts don't want to take the bus and many won't use the bus passes we give them. Reality is they just won't come in. Case managers may need to do more outreach if this happens.
 
  • Like
Reactions: 2 users
Two to three no shows or cancellations is typical for me and most other psychiatrists.

I don't mind seeing walk-ins some of the time, but I don't want to work in what would essentially become a psychiatric ER full time.

Also, I think it is therapeutic for patients to make and keep regular appointments. It provides some stability in their lives, increases patient ownership and collaboration in their own treatment plan, and increases acceptance of mental illness as chronic conditions we can treat, not just a series of crises.

ACT team type treatment is under utilized, mostly because it's under funded.

In my VA outpatient clinic, which isn't much different than local community mental health, we worked hard to reduce no-show from 19% to 13% these last few months. We did that by calling patients THREE times before their appointment, and then calling them again if they no-showed. Most clinics I worked in during residency had a similar no show percentage range.
 
Last edited:
  • Like
Reactions: 1 users
Members don't see this ad :)
Our clinic does a reminder call the day before and sends a cab to their home. Pt usually forgets about their appointment and don't answer their phone or check their voicemail. But when the cab driver knocks on their door they usually come in.

I do not know what the % of shows are at our clinic. My ballpark estimate is 75% come in but it would be a lot lower if we didn't have the cabs.

State is now trying to refuse to pay for the cabs and there has been a huge uproar over this. Pts don't want to take the bus and many won't use the bus passes we give them. Reality is they just won't come in. Case managers may need to do more outreach if this happens.

Yeah, I imagine if someone actually showed up and picked the patients up via cab, they would be more likely to come. I imagine it saves money in the long run, too, because people actually make appointments and get their needs met instead of showing up in the ED or getting admitted to the hospital because they decompensate.

We sometimes have case managers bring people in, but that's not feasible for most of our patients. Public transit here is OK, but not great. Patients who qualify for LIFT type of services seem to have better show rates.
 
  • Like
Reactions: 1 user
Two to three no shows or cancellations is typical for me and most other psychiatrists.

I don't mind seeing walk-ins some of the time, but I don't want to work in what would essentially become a psychiatric ER full time.

Also, I think it is therapeutic for patients to make and keep regular appointments. It provides some stability in their lives, increases patient ownership and collaboration in their own treatment plan, and increases acceptance of mental illness as chronic conditions we can treat, not just a series of crises.

ACT team type treatment is under utilized, mostly because it's under funded.

In my VA outpatient clinic, which isn't much different than local community mental health, we worked hard to reduce no-show from 19% to 13% these last few months. We did that by calling patients THREE times before their appointment, and then calling them again if they no-showed. Most clinics I worked in during residency had a similar no show percentage range.

Yeah, a full on walk-in clinic could be a pretty miserable experience, and patients don't get the best long term care in those settings because there's no continuity and lots of problems get kicked down the road (sure, they gained 30 lbs on olanzapine, but eh, that's for the long term provider to figure out). I moonlight in a walk in clinic. It's a nice resource for people who really are in crisis or who need a bridge between providers or hospital discharge and community MH intake. It's not great for long term care.

I hear you on taking responsibility, too. I do think, though, that there are people who fall outside of say the ACT definition of care (which requires I think multiple hospitalizations) and the ability to do things like make regularly scheduled appointments. At least that's been my impression in working in the walk in clinic where people in that demographic seem to be falling through the cracks. Now if we could send them a cab ...
 
  • Like
Reactions: 1 user
And the struggle continues -- struggling homeless patient just strolls in 18 minutes late to his 30 minute appointment, and my next appt is already here. I refused to see him. Making him take responsibility or am I being a jerk?
 
My new job is going to be completely community mental health for a few months. I've not done it before. At least not since residents clinic which was kinda the same. But they were telling me today that their no show rate is 25%. Case managers will bring them in sometimes, but don't like to because apparently they're not reimbursed for that.

Anyway. I hope I like it. It's going to be an adjustment. Not the least of which is going back to paper charts after several years of EMR.


Sent from my iPhone using Tapatalk
 
  • Like
Reactions: 1 user
And the struggle continues -- struggling homeless patient just strolls in 18 minutes late to his 30 minute appointment, and my next appt is already here. I refused to see him. Making him take responsibility or am I being a jerk?
No, you're not being a jerk. You are setting reasonable limits. You are being therapeutic and providing the patient with structure he needs.

If my 65 year old Silver Star, 3 Purple Heart recipient with PTSD who is early to nearly every appointment he ever went to in his life is 18 minutes late one day because a moving truck parked behind his car, I see him anyway, and do what I can for him.
If the 20 year old who was discharged after one year of service for what was essentially Conduct Disorder, drug abuse, and I know he just quit his fast food job then misses 5 appointments with me in the last 6 months, and then shows up 18 minutes late, I have him reschedule. It doesn't help this second guy at all if I reinforce his counter-productive behavior.
 
  • Like
Reactions: 4 users
And the struggle continues -- struggling homeless patient just strolls in 18 minutes late to his 30 minute appointment, and my next appt is already here. I refused to see him. Making him take responsibility or am I being a jerk?

I'm making the decision based on the patient. I have an internal triage system where I decide "is not seeing this patient going to cause me more trouble down the line than if I take the time to see them today?"

I already have one where I told him he would have no walk-ins, no exceptions because of his behavior. He fired me.
 
  • Like
Reactions: 4 users
And the struggle continues -- struggling homeless patient just strolls in 18 minutes late to his 30 minute appointment, and my next appt is already here. I refused to see him. Making him take responsibility or am I being a jerk?
Not a jerk. Maybe an irrational decision? He could go on stand-by for another missed appointment or wait until the end of your day. I say that since you said he is struggling, which I presume means he probably needs all the help he can get and arriving to an appointment even if you're late can be a pretty difficult task for some people. I kind of feel like for some people just arriving within a certain amount of time is having completed 99% of the work. I'm impressed though that you are so on time that a patient coming in 18 minutes late actually means he is missing his slot. If I came in 18 minutes late to almost any doctor's office I still would be early relative to when the doctor actually sees me.
 
I handle late visits based on level of acuity. If they are stable or mildly unstable I have them reschedule. If they are moderate to severely unstable I have them wait in the lobby until I can see them.
 
I handle late visits based on level of acuity. If they are stable or mildly unstable I have them reschedule. If they are moderate to severely unstable I have them wait in the lobby until I can see them.

Which in retrospect is what I should have done. I didn't even think about that as an option.

My personal triggers, though, are feeling as if I don't have control over my schedule and being kept late at work due to other people's stuff. Based on that, I'm again wondering if community psychiatry isn't my best long term home.
 
  • Like
Reactions: 1 user
I don't like that either. It's why I didn't like inpatient or CL. I couldn't wake up in the morning with a good sense of what kind of day I'd have. I hated that.

We'll see how this community health gig goes. I'm going to be optimistic. And the bright side is that this organization does more than just community health. That's just where they happened to stick me. If I don't like it, I can switch out after the first of the year. Which I will probably do at least 2-3 days/week just because they have other things going on with a better commute that I kinda want to check out.

I think I want to get more into women's health and primary care integration type stuff. Maybe some psychotherapy. And maybe check out what their physician wellness committee is up to.


Sent from my iPhone using Tapatalk
 
Members don't see this ad :)
Our clinic does a reminder call the day before
Our clinic also does this, but they started out by doing it in a randomized-controlled fashion and found that it didn't actually improve no-show rates.

and sends a cab to their home.
That's a good idea - a cab is probably cheaper than the lost revenue from a no-show. In lieu of this, our clinic usually gets the case worker to personally transport the patient if it's somebody who can't do it independently.

In addition to this, they also implemented a hybrid walk-in/appointment system. If a patient is more than 10 mins late for a new intake or 5 mins late for a follow-up, they'll give their appointment away to a patient who is trying to get in at the last minute.

As a result of these interventions, the show rate increased from ~65-70% to about 85%.
 
  • Like
Reactions: 1 user
Which in retrospect is what I should have done. I didn't even think about that as an option.

My personal triggers, though, are feeling as if I don't have control over my schedule and being kept late at work due to other people's stuff. Based on that, I'm again wondering if community psychiatry isn't my best long term home.

Eh, don't worry too much about it. You will develop your own style and get the hang of things. I also recruit the case managers, nurses and other psychiatrists when I'm in a jam. If the patient is in bad shape I will ask them if they have free time to assess the patient. If I absolutely need to see the pt I will do a drive by since most of the info is already gathered.
 
Cancellations in community psych may be the norm depending on how it's set up. E.g. as a resident I worked in a community place where almost all the people that fit into the demographic of not wanting treatment were referred from the inpatient unit. The inpatient unit in residency was made up of about 60% malingerers on day 1 that were almost always kicked out and referred to that clinic. The no-show rate was over 90%.

Compare that to an outpt clinic where I worked where the people who showed up fit into the demographic of wanting treatment. There the no-show rate was less than 10%.

I don't think the no show rate at the malingerer clinic was the fault of any of the clinicians there.
 
  • Like
Reactions: 1 user
Bearing in mind this is the observations of a clinic patient. At the CMHC I was originally at with my Psychiatrist, it seemed to operate on three levels - there was the Acute Crisis Assessment Team, the outpatient clinic and then inpatient unit connected to the local hospital.

Acute crisis assessment was typically managed by a social worker and Psych nurse for the initial assessment, they allocated the urgency of the case (eg, must be see within 24 hours versus can be seen within a week) and then a registrar under the supervision of one of the lead/consultant Psychiatrists would do the actual intake. I got accepted into treatment at the clinic under a different scheme so I'm not entirely sure what happens if you are considered an acute crisis case in need of immediate stabilisation (I've mentioned before I was unwell and unstable at the time, but not to the level of being considered a crisis case).

From what I did observe:

There was a medication clinic, presumably for those under community treatment orders, that was run 2 days a week by Psych nurses, but the patients had to have their medication particulars checked and signed off by their treating Psychiatrist first. I'd also see some of the Psych nurses and social workers heading out with packs of medication, so presumably they did home visits as well.

Cab vouchers were/are available for those who are legitimately unwell enough to travel any other way, but that was at the discretion of Medicare itself and abusing the privilege could mean no more vouchers.

A walk in clinic was also available, but it seems to have kind of depended on how long you'd been with a particular Psychiatrist as to whether they would see you or whether you had to see one of the Registrars (walk ins were also basically for emergencies not just dropping by for a nice little chat).

If your appointment was for 30 minutes, and you turned up 20 minutes into the start time of your session then generally speaking you'd get the last 10 minutes but no more. If the Psychiatrist themselves were running late then you still got your full session time.

If you decided to stroll in an hour after your appointment time had been and gone, and still demanded to see your Psychiatrist (the girls on the desk had the patience of saints sometimes when trying to explain this to some of the less functional patients) you were given the option of re-booking or waiting for an available registrar.

Miss three sessions in a row and you were removed from the books. It was then up to discretion of the treating Psychiatrist to either reopen your file if you wanted to return, or to request that it remained open.
 
The previous VA I worked at had a really large concentration of urban poverty in its population, so as a result they really increased their resources for walk-in availability in primary care, which to be honest worked out really well in getting those guys the care they needed, since a rigid appointment structure just didn't work for guys with unstable housing, unstable employment, severe substance issues, etc. For better or worse that patient culture spilled into the rest of the clinics. Most of the psychiatry attendings just learned to go with the flow with it. Everyone set followup appointments, but they seemed to be more approximations than exact times or dates for some providers. I remember working as a resident in one clinic where the attending's schedule was 4 patients, all scheduled for 10AM, and no one else on that morning's schedule. His response: "they'll get here when they get here."

It all seemed to work in it's own weird way, but it would probably drive a more OCPD type insane.
 
Last edited:
  • Like
Reactions: 1 user
Bearing in mind this is the observations of a clinic patient. At the CMHC I was originally at with my Psychiatrist, it seemed to operate on three levels - there was the Acute Crisis Assessment Team, the outpatient clinic and then inpatient unit connected to the local hospital.

Acute crisis assessment was typically managed by a social worker and Psych nurse for the initial assessment, they allocated the urgency of the case (eg, must be see within 24 hours versus can be seen within a week) and then a registrar under the supervision of one of the lead/consultant Psychiatrists would do the actual intake. I got accepted into treatment at the clinic under a different scheme so I'm not entirely sure what happens if you are considered an acute crisis case in need of immediate stabilisation (I've mentioned before I was unwell and unstable at the time, but not to the level of being considered a crisis case).

From what I did observe:

There was a medication clinic, presumably for those under community treatment orders, that was run 2 days a week by Psych nurses, but the patients had to have their medication particulars checked and signed off by their treating Psychiatrist first. I'd also see some of the Psych nurses and social workers heading out with packs of medication, so presumably they did home visits as well.

Cab vouchers were/are available for those who are legitimately unwell enough to travel any other way, but that was at the discretion of Medicare itself and abusing the privilege could mean no more vouchers.

A walk in clinic was also available, but it seems to have kind of depended on how long you'd been with a particular Psychiatrist as to whether they would see you or whether you had to see one of the Registrars (walk ins were also basically for emergencies not just dropping by for a nice little chat).

If your appointment was for 30 minutes, and you turned up 20 minutes into the start time of your session then generally speaking you'd get the last 10 minutes but no more. If the Psychiatrist themselves were running late then you still got your full session time.

If you decided to stroll in an hour after your appointment time had been and gone, and still demanded to see your Psychiatrist (the girls on the desk had the patience of saints sometimes when trying to explain this to some of the less functional patients) you were given the option of re-booking or waiting for an available registrar.

Miss three sessions in a row and you were removed from the books. It was then up to discretion of the treating Psychiatrist to either reopen your file if you wanted to return, or to request that it remained open.
This is pretty much what we do in my clinic and many others. There is still immense pressure to make exceptions all the time, and the system is never 100% efficient.

The main difference for me in the VA is that we can never discharge anybody or turn anyone away for any reason due to the current politics and history of the situation, no matter how uninterested they are. Sometimes that's good, sometimes it's bad. On most forums I'd get absolutely blasted for saying this, it's a sensitive topic.
 
  • Like
Reactions: 1 user
I understand the need to work on access to care, but any system that doesn’t have any ability to close a case is a set up for poor care in the other direction. Once there has been sufficient effort to form working relationships, and disagreements about how to obtain goals have been processed, there can come a time when a treatment team has to say that we are at an impasse and we will need to part ways. I’m not saying be rude and tell the patient not to let the door hit them in the keaster, but sometimes it is appropriate to say that our complete evaluation does not agree with your assessment that you need life time disability and since you are unwilling to accept any form of treatment for what we do believe ails you, I’m not sure where to go from here. Or, we understand that Xanax is the only drug that you are willing to accept, but we are uncomfortable giving you that considering your history of addiction problems, unless you will consider alternatives, we are just as determined not to give you Xanax as you are not to consider alternatives.

I get the VA policy given recent history, but I could imagine malingering patients who know you cannot terminate care would be very difficult, if not just extremely frustrating and a waste of time. It isn’t just the VA however; many systems are formalizing / centralizing “change of clinician request procedures”. I’m tired of fighting to keep this case by case and a clinical consideration.
 
  • Like
Reactions: 2 users
I understand the need to work on access to care, but any system that doesn’t have any ability to close a case is a set up for poor care in the other direction. Once there has been sufficient effort to form working relationships, and disagreements about how to obtain goals have been processed, there can come a time when a treatment team has to say that we are at an impasse and we will need to part ways. I’m not saying be rude and tell the patient not to let the door hit them in the keaster, but sometimes it is appropriate to say that our complete evaluation does not agree with your assessment that you need life time disability and since you are unwilling to accept any form of treatment for what we do believe ails you, I’m not sure where to go from here. Or, we understand that Xanax is the only drug that you are willing to accept, but we are uncomfortable giving you that considering your history of addiction problems, unless you will consider alternatives, we are just as determined not to give you Xanax as you are not to consider alternatives.

I get the VA policy given recent history, but I could imagine malingering patients who know you cannot terminate care would be very difficult, if not just extremely frustrating and a waste of time. It isn’t just the VA however; many systems are formalizing / centralizing “change of clinician request procedures”. I’m tired of fighting to keep this case by case and a clinical consideration.

It's frustrating, but at the same time, we're not forcing anyone to not seek care elsewhere. Only the sickest of the sick don't eventually pick up on the fact that we're not going to change after we put our foot down.
 
How does community MH work in your community? I think ACT teams are great, but unfortunately enrollment is so limited.

Here in Philadelphia we have several levels of community involvement. There are case managers which will call the patient and *maybe* go to their house, but won't search around for them. Then intensive case managers who will scout around a bit more and come to the crisis center if you call them. Then of course the ACT team will go to the abandoned house they stay at and give them their Invega on the spot.

Of course private insurances won't pay for any of these, not because they don't work, but I guess because they know they can bide their time until they get put onto medicaid/care...
 
  • Like
Reactions: 1 user
I don't like that either. It's why I didn't like inpatient or CL. I couldn't wake up in the morning with a good sense of what kind of day I'd have. I hated that.

We'll see how this community health gig goes. I'm going to be optimistic. And the bright side is that this organization does more than just community health. That's just where they happened to stick me. If I don't like it, I can switch out after the first of the year. Which I will probably do at least 2-3 days/week just because they have other things going on with a better commute that I kinda want to check out.

I think I want to get more into women's health and primary care integration type stuff. Maybe some psychotherapy. And maybe check out what their physician wellness committee is up to.


Sent from my iPhone using Tapatalk

Upsides I've seen from community work so far -- some of the patients are really awesome and appreciative. Lots of them also don't have the best access to primary care, so you do get to use some of that thinking in your work with them. And yeah, ideally you get to be part of a team without single handedly carrying the burden of your patient load. Honestly, no shows are also somewhat protective because it saves you from being as busy as you would be in a high volume non-community job. As pay and benefits aren't as good as those jobs, I think it's a reasonable trade off.
 
  • Like
Reactions: 1 users
No shows are saving my ass today. First day seeing patients and I had twenty one scheduled. TWENTY ONE. (14-16 was a busy day at my old place and today's my first day). And I must have misheard or misunderstood because I thought I was told yesterday that I had four. So I had a mini freak out this morning and then got to work. I'd say my no show rate today is running at 50%. Thanks all the relevant gods.

And yeah. Everyone has case management, which is great.

At my old gig I had 30 minute follow ups and didn't see a patient for a follow up whom I hadn't personally evaluated. But aside from that one initial freak out, I've been doing okay. I have 15 minutes. There's only so much. I can do. And so far people have been really understanding of my fumbling with their charts.

I do miss my EMR. And my e-prescribing. I had a mini crisis this morning because I couldn't remember my DEA number. I haven't had to remember it in years. But I called an administrative type person and she was thankfully in her office and knew where my DEA was.

I think I'm off to a decent start. Six more scheduled patients and I can go home. I'm exhausted. I stayed up too late last night watching football. But I think I need to buy pants on my way home. I have worn the same pair of pants the last two days because my cool weather work clothes are in a box somewhere.


Sent from my iPhone using Tapatalk
 
  • Like
Reactions: 1 user
That no show rate is a saving grace when we are not given enough time! I can't tell you how many times I've been saved by no shows.

But it's the axe if you are in private practice and you schedule 8 patients for med + therapy visits and only 4 people show.
 
  • Like
Reactions: 1 user
Top