Carolina Outreach Provides an Urgent Care Alternative for Psychiatric Crisis

September 13, 2017 | By Rose Hoban

Where do people go when they sprain an ankle? Or when they have a mysterious rash or a sore throat? Increasingly, when people can’t get into their doctors’ offices in a timely way, they walk into urgent care centers. These places aren’t emergency rooms, but a patient can get reassurance that the rash or sore throat is nothing too serious. Perhaps they can get a prescription, or get that ankle wrapped.

A new service in Durham seeks to fill that same space in the mental health system, an urgent care center where patients can get a little bit of help to keep a worsening mental health problem from blossoming into a full-blown emergency.

It’s the only service of the kind in the state.

Carolina Outreach, located on 15/501 across from a gas station and car wash, is intended to be an alternative to the emergency room, where mental health or substance abuse patients often end up sitting for hours before being seen.

“We’re hoping that if we can be preventing a crisis or intervene in the middle of a crisis that’s escalating,” said clinic director Marissa Holsten.

Holsten said there’s a broad spectrum of folks who’ve walked in their doors since they opened on July 31.

“We’ve got the people who come in and say, ‘I ran out of my medication today, and I’m not going to be able to get it until I see my doctor next week,’” she said. “For whatever reason, that’s a crisis for them and so we can bridge that prescription.”

Mental health crisis can also look like someone who finally realized that they need help with their substance abuse problem or their mental health issues. Sometimes people arrive with thoughts of hurting themselves.

“That doesn’t even mean they necessarily have a plan to hurt themselves which means they don’t need to hospitalized,” Holsten said. “We can give them what they need and hopefully the tools or the medication they need to keep them stable from feeling like they have to go into the hospital.”

Patients have started arriving as the word spreads. In the first six weeks, they’ve seen 101 clients, including 14 children. All of those people reported being “satisfied” or “very satisfied” with the service. Forty-one of those patients said they would have gone to an emergency department if Carolina Outreach were not there.

Reducing the overflow

Alliance Behavioral Healthcare, the state-funded mental health managed care organization that provides services in Durham, Wake, Johnston and Cumberland counties, contracted with Carolina Outreach to provide urgent care services for its Medicaid patients and folks who are uninsured in those four counties.

“We chose Carolina Outreach because they are a larger provider and mainly because they were already operating a walk-in clinic,” said Margaret Brunson, Alliance’s director of hospital relations.

Eventually, the service should ramp up to see about 600 people per month, Brunson said, which should help reduce the load at local emergency departments.

Increasingly, EDs across North Carolina have been clogged with mental health patients who have nowhere else to go. Recently, for example, WakeMed’s emergency department was so backed up that it closed to patients with emergent medical problems such as heart attacks and broken bones.

Often, people who show up to an emergency room in psychic distress don’t need a psychiatric hospital stay, they just need a little help to get back on track. But many of those folks delay, with symptoms worsening, knowing they are likely to face a long wait in a local emergency department.

They’re right about the waiting. As of the end of June, the average wait time for admission to a state-run psychiatric hospital was almost six days.

In Durham, it was longer. Alliance sends 90 percent of its psychiatric hospital admissions to Central Regional Hospital in Butner. In June alone, that was 184 patients, who waited in an ED for a bed at Central Regional for more than seven days on average.

Waits in the emergency departments themselves are pretty long too. Community outreach director Mark Sullivan recounted a story about a mother who waited with her child for about 10 hours in a nearby emergency department,before staff there sent her to Carolina Outreach.

The woman actually had commercial insurance, which Carolina Outreach can’t yet accept.

“And she said, ‘I don’t care, we’ll pay out-of-pocket,’” Sullivan said. “And our out-of-pocket cost is about $440.”

He said the response from local providers has been “overwhelmingly positive.”

“We’ve heard a lot of relief, from people especially in the hospitals that are just completely swamped with psychiatric patients to have another resource to divert those patients,” he said. “It gives them a little glimmer of hope, I think. It’s a win, win, win. Everybody wins.”

Safe space

Prior to opening the urgent care center, Holsten explained that if patients walked into their other clinical services experiencing acute mental health symptoms, they’d have to go through an intake process and often get an appointment for several days or maybe a week later.

“You could see how we were losing people,” she said.

But the urgent care model has empowered clinicians to jump in.

“If someone is really agitated, we’re not going to start into ‘Why are you here, etc.’” Holsten explained. Instead, the emphasis might be on sitting clients down, doing some crisis counseling, “until we’ve got you at least down to a level where you can be engaged and coherent and let’s talk about what you need.”

“Maybe they do need four or five hours to just calm down and have a safe place and feel supported,” she said.

Another emphasis is getting people connected with other services and providers in order to get them settled, maybe it’s a referral to a food pantry or shelter, maybe it’s medication, maybe it’s getting them to a detox facility.

Carolina Outreach has been around since 2003 when two social workers started it as a counseling and therapy center. The organization has grown to 10 locations in the Triangle and beyond, surviving the changes in North Carolina’s mental health system with a decent reputation. So, in September 2016, Alliance, which has contracted with Carolina Outreach for other services, approached the organization to create the urgent care center as a one-year long pilot. The planning process itself took close to a year.

Brunson said it took time because Alliance felt they were doing something new in North Carolina.

“We also wanted to also be innovative about how we devised this model, so we took our time and fleshed out the workflows and we fleshed out the elements of this service and what we actually wanted to see happen as opposed to starting from a template and then working backwards,” she said. “We’re really excited to see what happens, what the outcomes are.”

Sullivan said he breathed a sigh of relief when Alliance made the decision to continue despite cuts in the state mental health budget.

“Unfortunately, the General Assembly has pulled the rug out from under the managed care organizations by undermining the whole rationale for how they were set up,” he said. Alliance cancelled other projects in the planning phase, such as a crisis center in Wake County and a walk-in center in Johnston County.

Alliance passed on some cuts to Carolina Outreach, but Sullivan said if no more come, they’ll be alright, especially if they can start billing commercial insurance.

“I think we can help the other places across the state that are trying to figure out how to fill this gap,” Holsten said.