How come we don’t come across more urgent cares in private practice? Too much red tape? Too much overhead? Too few patients willing to pay cash to be methed out in a boutique psych ER?
The first part of what you’re saying is very true.Urgent cares are predicated on the idea that most of what comes in will be stupid stuff you can see in 5-10 minutes that can be addressed with a short term prescription, very minor workup or reassurance, almost 100% of which could have just gone to their PCP anyway for a sick visit if they could or had a PCP.
That applies to almost nothing in psychiatry.
How come we don’t come across more urgent cares in private practice? Too much red tape? Too much overhead? Too few patients willing to pay cash to be methed out in a boutique psych ER?
I meant a psych ER or ER-like practice.I see urgent cases in private practice all the time. Your basic assumptions aren't correct. I mean, I don't know why anyone would pay me a lot of money to see them if it isn't "urgent"...
The first part of what you’re saying is very true.
That said, the same concept of, “could have reached out to your psychiatrist, case manager, NP, counselor” applies to a lot of subthreshold symptomatic patients in psych ER settings too.
That said, the same concept of, “could have reached out to your psychiatrist, case manager, NP, counselor” applies to a lot of subthreshold symptomatic patients in psych ER settings too.
I meant a psych ER or ER-like practice.I see urgent cases in private practice all the time. Your basic assumptions aren't correct. I mean, I don't know why anyone would pay me a lot of money to see them if it isn't "urgent"...
In one of the highest volume ERs of my populous state, the vast majority of what comes through the pipeline are reassurance seeking, respite from interpersonal drama seeking, treatment splitting, substance seeking, socializing seeking cases. Many many complain of showing up for immediate access on the basis of either not accessing their providers on weekends or during snowstorms, not liking their providers in general and being in limbo for months until securing intake elsewhere, and very very often not liking phone/video interactions with their prescriber or therapist. There’s definitely a market for the, “don’t like tele” population out there and wants to be SEEN “whenever I’m in perceived crisis.”Calvin has it right in the sense that the nature of what we treat is not conducive to the goals of "Urgent" treatment, which means something can be done RIGHT NOW in 10-15 minutes that can prevent a patient from needing an ER visit. No one is going to a psych UC clinic when they can call their doc, talk to them for 5 minutes and then be seen in the next few days. Conversely, if someone has a legit concern (SI with plan, I'm dizzy and I keep falling down, this rash keeps getting bigger, etc) they're either going to require a more thorough eval meaning a longer appointment, or require a medical eval which means sending them somewhere else (like an ER).
I'm curious as to what situations you think would warrant a psych UC clinic that couldn't be addressed by a triage RN/quick phone call or a more thorough eval in an ER. I can maybe think of a couple, but there's already a national crisis hotline that people call and get advice regarding "psych crises" for free. So how are you going to convince people to come in and pay for the same services?
In one of the highest volume ERs of my populous state, the vast majority of what comes through the pipeline are reassurance seeking, respite from interpersonal drama seeking, treatment splitting, substance seeking, socializing seeking cases. Many many complain of showing up for immediate access on the basis of either not accessing their providers on weekends or during snowstorms, not liking their providers in general and being in limbo for months until securing intake elsewhere, and very very often not liking phone/video interactions with their prescriber or therapist. There’s definitely a market for the, “don’t like tele” population out there and wants to be SEEN “whenever I’m in perceived crisis.”
Let’s just say it, bull**** walks IN!Yes, but how many are willing/able to pay to be seen? Money talks bull**** walks, right?
I think they are often seeking professional answers in UCs. Some are purely seeking transactions.When people go to UC they aren't seeking a professional opinion typically.
They are seeking a transaction, they want something.
The only something Psych offers is IM/IV ketamine, or benzos that could be perceived as an immediate something / transaction.
Is that the 'cosmetic derm' you dreamed of?
Not unless my SDN colleagues provide their seal of endorsement.So, you thinking you'll open one up?
Let’s just say it, bull**** walks IN!
Now there is an idealist, misguided part of me that wonders if those in-perceived-crisis-and-want-to-be-seen-NOW (as opposed to needs to be seen now) cases wouldn’t be motivated to pay every bit as much as the cosmetic derm population is.
Those boundaries often turn into weekend or late night invitations to the wrong level of care.B.S. will definitely walk in. I don't know about you, but $55 or whatever B.S. Medicaid is paying for a 60 minute new eval is not worth it. Which is why hospitals have the EM doc, resident, midlevel, SW or whoever else that's already there as a fixed labor cost evaluate the "walk in" psych patients.
The patients who can pay to be seen right now likely already have a semi-competent cash psychiatrist who has enforced boundaries as to what to do in an "emergency" in between their appointments.
Not really. Have you actually practiced outpatient psychiatry?Those boundaries often turn into weekend or late night invitations to the wrong level of care.
I have practiced outpatient psychiatry. A whole lot of emergency psychiatry too. Both with indigent and monied populations. Not everyone agrees to increase the frequency of care for the BPD flares you reference. Nor is IOP access so plentiful everywhere. BPD routinely churns the wheels at some psych ERs with 5000+ annual visits. At best I can speculate that there may be geographic nuances in ER psych demographics and education to the public about the appropriate threshold to seek that level of care.Not really. Have you actually practiced outpatient psychiatry?
I see sick sick borderline patients all day and nobody really wants to constantly call their shrink on weekends or randomly show up to ERs at midnight. Maybe it happens at the start of the referral but when you do psychiatry right people get better and learn from their mistakes and gain better impulse control skills. When they don’t learn you end treatment.
If someone calls you constantly you say you have to see them twice a week and you do real TFP or schema therapy. If they can’t afford you you send them to an IOP. The end. I don’t really see where this cash urgent care fits into this.
i think you have some interesting ideas but might want to flush it out more precisely. You want a subscription based service for DBT-style coaching outside of the ER in lieu of ER. Some startup companies are working on these types of things…I have practiced outpatient psychiatry. A whole lot of emergency psychiatry too. Both with indigent and monied populations. Not everyone agrees to increase the frequency of care for the BPD flares you reference. Nor is IOP access so plentiful everywhere. BPD routinely churns the wheels at some psych ERs with 5000+ annual visits. At best I can speculate that there may be geographic nuances in ER psych demographics and education to the public about the appropriate threshold to seek that level of care.
There are lots of psych 'urgent cares' in our state. They are not privately owned, but there clearly is a large number of patients who want to be seen same day at a place other than an ER. One can find reasons to think that they should either be in actual ERs or just go back to their PCPs but for whatever reason it's a very attractive option for patients. Most patients have anxiety. They come in, are assessed, receive psychoeducation, care coordination, and if a follow up is secured may be started on medications recognizing that most psychiatric medications that are reasonable to start in this setting aren't particularly effective for crisis stabilization. I believe one way these settings are helpful is that it provides a low cost environment for brief containment so patients can regress to a less acute mean in a few hours and feel safe to return home and engage in regular outpatient care.
I don't see it being viable from a private practice perspective at all, as we have a nurse, a tech, and ability to get labs etc like most medical urgent cares.
Is it therapeutic to provide that immediate, in-person reassurance to people who don't meet. Crisis criteria? Sounds to me like that would foster unhealthy coping skills.What if you call it a reassurance center? All jest aside, what I probably see the most in psych ERs and psych consults to medical ERs is, “I want instant in-person access to brief therapeutic interventions.” Plenty of these folks abuse the threshold for recruiting crisis services (resulting in them feeling ultimately unheard) or else there are those who feel embarrassed to have CS show up at their door. It’s true that most (on the indigent spectrum of the market especially) don’t care if it’s a physician or SWer seeing them (but don’t psychiatrists hire tons of LCSWs for their PP’s?). I know many who bank on them. The take home is, red tape is the biggest issue. Even reimbursement can probably be mitigated with sufficient marketing and in the right catchment area.