Urgent behavioral health care providers seek to build a market and regulatory framework that is still in its genesis.
The fledgling segment of the behavioral health space presently lacks national acceptance at the regulatory level. And while a new mode of care will take some time for consumers to adopt, it fills several vital needs in the behavioral health industry.
“People figured out, mostly due to convenience and access to get in, you could deal with a lot of the lower-acuity stuff in urgent care,” Jeff Spight, CEO of MIND 24-7, a Scottsdale, Arizona-based urgent behavioral health care provider, told Behavioral Health Business. “Urgent care has to take care of all this stuff that the emergency room saw as low-hanging [priorities].”
Like primary care, behavioral health struggles with long wait times for outpatient services. The only other option for care for many is an emergency room — a level of care that patients may not want or need.
Further, the COVID-19 pandemic has revealed how poorly prepared many hospital emergency rooms are to handle patients with urgent behavioral health needs.
“All the emergency room really can do is ensure that you’re not going to hurt yourself,” Spight said. “They’re probably not going to get you treatment, and they’re probably not going to figure out how to help you get to where you need to go next.”
About 32% of all health care settings that offer mental health services offer emergency care. Certified mental health clinics (CMHCs), a specific type of facility defined by the Centers for Medicare & Medicaid Services (CMS), make up most of the facilities that offer emergency mental health care. But the number of CMHCs in the U.S. has been shrinking long before the pandemic — with many more having closed since then.
Urgent behavioral health care is different in key ways from physical health care. Often, behavioral health needs requiring immediate attention vary widely in acuity. Patients may walk in needing medications refilled, having mild panic attacks or severe intoxication or in psychosis.
As a result, urgent care providers must prepare to deal with various issues. MIND 24-7 offers 23-hour observation, intensive outpatient and partial hospitalization programs and express care. Its locations are staffed 24/7 by multi-disciplinary teams, including psychiatric nurses, therapists, social workers, behavioral technicians and case managers.
MIND 24-7 operates four locations in Arizona — three in the Phoenix area and one in Mesa. Spight said the company is seeking to expand into Nevada.
But it has run into regulatory barriers, which means MIND 24-7 will need to partner with a Nevada-based hospital system, Spight said. This highlights the limitations of what the collective behavioral health system will allow regarding service innovation despite needs.
How urgent behavioral health care differs
Most regulatory bodies categorize urgent behavioral health as an outpatient offering.
However, the services must be prepared to handle some higher-acuity levels regardless of classification. And despite the opaque national regulatory landscape, the objectives of urgent behavioral health are the same.
“When patients come in, they’re in a self-defined crisis; they’re not capable of diagnosing the acuity of that crisis,” Colin LeClair, CEO of Phoenix-based Connections Health Solutions, told BHB. “The goal is always to move patients to the most appropriate and lowest-cost setting possible and help them avoid hospitalization.”
Connections Health Solutions’ locations offer a 23-hour observation unit, crisis stabilization (or a sub-acute inpatient unit), outpatient mental health services, and discharge planning and services called “Transitions.” It operates two locations in Arizona — one in Phoenix and another in Tucson.
The company has plans to open locations in Kirkland, Washington, and in Woodbridge, Virginia, via partnerships with local governments. Both centers are slated to open in the second half of 2024. Its centers are also open 24/7.
However, urgent behavioral health is different from emergency services.
Patients who would present at an urgent behavioral health center that are a danger to themselves or others, severely agitated, or otherwise meet the criteria for inpatient admission.
“Urgent care is for everyone else,” LeClair said, adding a “small portion” of those that come to Connections Health Solutions are admitted to the hospital.
Expanding the care continuum
On April 19, Baltimore-based behavioral health and social services provider Sheppard Pratt celebrated a major renovation at its Towson, Maryland, hospital.
The renovation redesigned the main lobby entrance area to increase the capacity and efficiency of its admissions and urgent behavioral health center — which the organization calls psychiatric urgent care. Sheppard Pratt established the psychiatric urgent care center at the Towson campus in 2011 and opened another at its Elkridge, Maryland, location in 2021.
“What we want to do is continue to do a better job of providing the whole continuum of care to our patients so that if a patient needs a level-of-care assessment, they can stop, they can have a one-stop shop, rather than going back to an emergency room where they can be waiting for several hours to several days at times, unfortunately,” Dr. Deepak Prabhakar, chief of medical staff and outpatient services medical director, told BHB.
Such services are “not too common” in the U.S., Prabhakar told BHB. Unless a health system is heavily invested in behavioral health — which is not likely — this type of service is often unavailable.
For Sheppard Pratt, the physical connection to its psychiatric hospitals allows patients to easily be escalated to higher levels of care if they need them. Only about a third of patients do, Prabhakar said.
Regulatory, payer frameworks are still developing
Urgent behavioral health is capital intensive, sources tell BHB. They require several and diverse professions to be in centers 24/7. Further, they have to bear the cost of operating facilities that demand specialized amenities.
On top of that, the still-developing regulatory environment also translates into a somewhat muddled payer reimbursement question. While many of the urgent behavioral health services offered are tied to common billing codes, payers often don’t reimburse for the whole of the services provided, missing the added value of having the services consolidated and centrally coordinated.
“The reason you want to do this a bit different from a regular outpatient clinic is that a lot of these patients do need a higher level of services,” Prabhakar said. “This gives you that platform to bring those things to these patients a bit more systematically rather than having to wait for long durations of time in an emergency room or just going without care in many cases.”
MIND 24-7 and Connections Health Solutions can operate in Arizona, partly because of the state’s unique approach to allocating behavioral health-related funds. Arizona has three regional behavioral health authorities (RBHAs) that control the distribution of all state and federal dollars related to behavioral health. The companies can receive funding for crisis service from these authorities regardless of a patient’s insurance status.
“That covers most of our services for the uninsured population, which is a really important gap that would otherwise be there,” LeClair said. “For the insured population, it’s a professional capitation for all crisis services for anybody in our catchment area.”
Connections Health Solutions also has contracts with all of the region’s Medicaid managed care organizations (MCOs). The urgent care and Transitions services operate on a fee-for-service basis.
Weaving together revenue sources has been monikered the “braided funding mechanism” at Connections Health Solutions, LeClair said.
These types of arrangements are universal across states. Washington does have well-funded local authorities at the county level over crisis services. The allotment for crisis services is much smaller in Virginia, LeClair said, and is more focused on the uninsured.
“We’re putting this puzzle together by finding ways to cover everything,” LeClair said. “The goal always is to ensure that we get funding that is sustainable.”
Spight says urgent behavioral health services primarily exist because local municipalities have floated them on tax dollars “almost like a fire station.”
But the result of that tends to be limited capacity and services that are withheld from much of the community. Often, the services are limited based on condition type or payment source. To be fully realized, urgent behavioral health centers need to be able to take most patients.
“It also has a fundamental problem and that, once you created that, everybody that might send you somebody is forced to do a bunch of extra math,” Spight said.
Spight and LeClair said their organizations hope to partner with local law enforcement agencies interacting with those with behavioral health needs. MIND 24-7 allows law enforcement officers to drop off people at their centers and will handle their care from there, freeing the police from having to stay with the patient while waiting for care in an E.R.
About 65% of Connection Health Solutions patients are brought to their existing clinics by law enforcement officials.
“So to be ready for a patient that is that acute and that law enforcement would prefer not to drop off in a jail, the need for psychiatric care is pretty different,” LeClair said. “To be able to take that patient from law enforcement in less than five minutes from them knocking on the back door is a big, big distinction from everything else out there right now.”