Pilot Walk-in Clinic Improves Access to Mental Health Care

Fran Lowry

December 10, 2018

BONITA SPRINGS, Florida — Changing access to mental health care from an appointment-based model to a walk-in model—where patients receive on-demand treatment without an appointment and gain immediate access to treatment—increases and maintains access to care, new research shows.

When doctors at Massachusetts General Hospital's West End Clinic in Boston changed from an "appointment only" to a "walk-ins welcome" model, they increased patient numbers, retained more of them in treatment, and sped up their access to needed medications.

The West End Clinic serves individuals with substance use disorders and mental health disorders who are connected to a hospital-affiliated provider.

Patients have a wide variety of insurance types, including commercial as well as Medicare and Medicaid, said study investigator Vinod Rao, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston.

The findings were presented here at the American Academy of Addiction Psychiatry (AAAP) 29th Annual Meeting. 

Pilot Project

Dr Vinod Rao

"We have been existing as a clinic for some time and as more and more attention has been focused on the opioid crisis, especially here in New England, we were wondering whether there was more we could be doing to serve our patients," Rao told Medscape Medical News.

"The way people have currently been getting access to our clinic has required multiple steps, and so we recognized that maybe there are things that we can be structuring differently to facilitate access for them," he said.

The traditional model was cumbersome, he added.

"It required people to call the psychiatry access line in the psychiatry department and then be scheduled with an appointment on a Tuesday morning, when they would come in and have an orientation to learn how the clinic was organized," Rao explained. "They would then get to speak briefly to a clinician to make sure they were in the right place. Then they would be scheduled for intake, and then after they completed the intake, they would be put on the waiting list for psychopharmacological management."

Rao and colleague Emine Nalan Ward, MD, Medical Director of Addiction Services at the West End Clinic, began the walk-in clinic as a pilot project in September 2017. 

Instead of going through the original path to initiate treatment, patients could simply show up Monday through Friday between 10 AM and noon, meet a physician or a nurse practitioner for medical assessment, have an intake appointment with a psychologist or social worker, and receive medication if necessary.

"It's first come, first served, so we encouraged people to come early. We would do whatever kind of evaluation was necessary. The goal was to make sure the patients' needs were met. Sometimes patients just needed some additional support. But sometimes, patients would come in to us in crisis," Rao said.

Rao and Ward soon realized that many of their patients had an urgent need for psychiatric medication.

"We were able to start prescribing right away. We've started people on Suboxone [buprenorphine and naloxone], we've started people on antidepressants or anti-anxiety medications, or sleep medications early on to more quickly meet their needs. I think that has been helpful in getting people to engage and stay engaged in the clinic," Rao said.

Faster Access

In the 9 months prior to the pilot walk-in initiative, the clinic took in 4.3 new patients per week. During the pilot program this increased to 8.1 new patients on a weekly basis — an increase of more than 88%.

Patients arriving as walk-ins were younger and more likely to be single than those who entered care in the traditional way. They were also more likely to be diagnosed with bipolar disorder, ADHD, and more severe depression, with concurrent cocaine or opioid addiction.

"These mental health conditions can make it challenging to organize and get engaged into a clinic," noted Rao.

In addition, fewer walk-in patients dropped out of treatment within 3 months. For walk-ins, the drop out rate was 22%, compared with 41% for original care patients (P < .0001).

The walk-in model was also associated with faster access to psychopharmacology than the original model (median 0 days to first prescription vs 30 days). Common prescriptions included anti-depressants, anxiolytics, sleep aids, and anti-craving medications.

Also, patients coming into care as walk-ins were less likely to require emergency room level of care than patients who came in via the old method, Rao said.

More Resource Intensive

However, the walk-in model was more labor intensive, requiring more work from clinic staff.

"Changing the structure of how people get started in the clinic, especially when inviting a walk-in format, tends to require a lot of resources from the clinic. It changes front desk work flow, it changes patient care coordination work flow, and requires a lot of coordination for follow-up," Rao said.

Clinics need to be aware that these changes are profound, he added.

"While it's great that we're getting more patients into treatment, it complicates our ability to provide that treatment in the same ways as we used to, so we have to adapt for that.

"For instance, there may be more patients coming to the clinic with particular diagnoses, and you need to make sure that you have the right services to offer them.  We've noticed that our wait list for individual therapy has grown, and we are trying to manage this and hopefully do a better job. Also, the volume of patients is higher," Rao said. 

The impact on West End Clinic staff was significant, added Ward.

Dr Emine Nalan Ward

"As we increased access, the number of patients and the severity of illness increased, and our staff had to manage patients with higher acuity. That increased the need for more care coordination. The physicians, in particular, had to manage increased numbers of medication prior authorization requests, staff emails, prescription requests, paging, and an increased documentation burden," she noted.

As a result, staff began to experience symptoms of burnout, Ward said.

"The clinicians felt overworked and isolated. It became obvious to us that we had to have more admin support and increase the number of prescribers to manage the increased demand," she said.

To cope with the excess demand for services, the clinic had to temporarily reduce the number of days patients were allowed to drop in.

"Now we are starting to expand again because we've gotten more resources," Rao said.

Promising Model, Unique Challenges

Commenting on the findings for Medscape Medical News, Cornel N. Stanciu, MD, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, said dual diagnosis patients present "unique challenges" when it comes to getting them to engage in treatment.

"Individuals with addictive disorders must be in the right stage of change with sufficient motivation to be able to enter treatment effectively. During the course of addiction, motivation fluctuates and therefore timing is a main determinant in whether someone meaningfully enters treatment and ultimately succeeds," Stanciu said.

An on-demand, walk-in model has the potential to remove one barrier and provide immediate care connecting individuals with services at a time when they are highly motivated for help, he added.

"Currently, with appointment-based initial evaluation, the rates of attendance can be as low as 33% to 52% in some systems. This not only results in financial losses to the system, but also results in failure to provide care to other sufferers who may be highly motivated for help at that particular point in time," he said.

Historically, the local emergency department or a call to a crisis line have been the two options for someone to get immediate help.

"But both of these may result in lack of treatment if severity is not high enough to require inpatient admission or if a referral to an outpatient clinic has too long a wait time," he noted.   

"And if the disease has progressed to where admission as an inpatient is warranted, this can burden an already overwhelmed system, and add to increased healthcare expenditure," Stanciu said.

A walk-in model holds promise, but also requires unique challenges in implementation, as the authors of this study mention, he added.

Ultimately, there are no solid data on the efficacy and cost-effectiveness of walk-in vs appointment-based models for first engagement in care at dual-diagnosis clinics, Stanciu said.

"Prospective studies would be useful to provide this information, as well as allow a true evaluation of retention to care."

Dr Rao, Dr Ward, and Dr Stanciu have disclosed no relevant financial relationships.

American Academy of Addiction Psychiatry (AAAP) 29th Annual Meeting: Abstract 12. Presented December 9, 2018.

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