Elements of the continuum

BEHAVIORAL HEALTH URGENT CARE

As noted previously, an ideal crisis system recognizes that a crisis does not begin with a call to 988 or 911. A crisis is commonly a continuing situation that may evolve over time and last for weeks, not a single, brief emergency event. An ideal crisis system has provision for both services that can respond quickly in the pre-crisis phase to avert decompensation, as well as post-crisis services that continue after the most acute aspects of the crisis have passed. Walk-in behavioral health urgent care services, conceptually equivalent to medical urgent care services, are therefore an important component of an ideal crisis system.

Behavioral health walk-in urgent care can provide easy access to a crisis response that does not initially require intensive or secure intervention. Individuals and families can access these services on their own, in convenient locations in the community or be directed to urgent care centers by the call center or crisis line (when that option is more appropriate than mobile crisis). Following hospitalization or other intensive crisis treatment episodes, behavioral health urgent care can be a valuable safety net in the event there is a breakdown in continuity of care such as a need for an early prescription adjustment or refill.

Behavioral health urgent care provides a valuable cost-effective alternative to ER utilization for behavioral health crises, just as medical urgent care provides similar value for diverting individuals with urgent but non-emergent medical needs. One of the major reasons emergency services are over-utilized for behavioral health is that access to timely care is inadequate, both pre- and post-crisis. Even in an urgent situation, it is not at all uncommon for waits on the order of a month or more to see a therapist and often longer for a psychiatrist. Individuals and families may need to access 911, or simply wait for decompensation, before the system responds. In an ideal crisis system, the moment of the ask is the optimal moment for the response. What may begin as a healthy recognition of the need for help can escalate to a crisis if help appears to be out of reach. Consequently, just as quick care or urgent care centers are becoming increasingly available for medical needs, the same need exists for behavioral health.

For this reason, walk-in urgent care is a certification requirement for CCBHCs. In most communities, the need for behavioral health urgent care requires multiple urgent care options distributed by geography. Each community needs to analyze population need and distribution to determine how best to allocate access to these services.

There are multiple options for developing behavioral health urgent care services:

• Include urgent behavioral health capacity within a general urgent care clinic. This may be achieved through a variety of collaborative care methods, including adequate training and support for the general practice provider, ideally including access to mental health specialty providers either in person or virtually as needed.
• In more dense population areas, dedicated behavioral health urgent care clinics may be created. These are commonly part of larger behavioral health organizations, and certainly part of CCBHCs. Such centers typically operate at a minimum during typical business hours and may have expanded hours, including weekends or evenings, but they are not typically 24/7. They include capacity to engage and triage, prescribe medications and link clients with appropriate follow-up and community resources.
• There is commonly an urgent care walk-in component that is part of a crisis hub or secure crisis access center. This permits the crisis center to provide a safety-net backup for individuals at risk of decompensation due to urgent need for medication refill or adjustment, for example, and provide quick warm handoff for crisis follow-up for individuals who need urgent ambulatory care.

Behavioral health urgent care centers may have variability in their capacity. The more capacity or capability built into these services in the beginning, the better they will provide alternatives to ERs or other intensive interventions. Examples of variable capacity include:

Hours of operation: 12 hours, 16 hours, 24 hours. In a large community, at least one such center should be accessible 24/7.

Medical screening: Availability of on-site or telehealth medical screening reduces the need for diversion to emergency rooms for that purpose.

Laboratory and pharmacy: Availability of on-site or rapidly accessible laboratory testing, as well as access to a pharmacy for provision of medications can facilitate response to a wider array of situations.

Observation space: Having space on-site for observation and intervention over a period of hours can allow for the urgent care center to provide for extended evaluation, stabilize intoxication, observe for signs of withdrawal and observe response to initial interventions.

Measurable Criteria for an Ideal Crisis System

The accountable entity works with the community collaborative and the crisis provider network to design, fund and implement an adequate array of walk-in/urgent care clinics for both adults and children throughout the catchment area.

Geographic access

Urgent care services are located within a 30-minute drive of all residents in urban areas and one hour in rural areas for both adults and children. Services are accessible by public transportation. Ideally, each crisis center provides urgent care capacity directly or through coordination with a nearby community provider. All services welcome the opportunity to work with individuals who are actively using substances.

Availability

Services are available at least 16 hours per day and 24 hours daily at a minimum of one site.

Capacity

Medical screening is available at all sites, either directly or through telehealth. All sites have the capacity for observation of several clients for a period of 2-4 hours.

Medication evaluation

All services provide routine access to medication evaluation and re- evaluation, in person or through telehealth.

Volume and adequacy

The accountable entity monitors ER utilization and urgent care utilization to continuously improve appropriate diversion of behavioral health ER volume to urgent care. The accountable entity monitors call center referral protocols to assure adequate diversion to urgent care and successful follow-through at urgent care.