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Mental health care without an appointment? Hospitals are pushed to improve access

The Patriot Ledger - 2/2/2020

WEYMOUTH – In the decade since she was diagnosed with post-traumatic stress disorder, Stella Welch has already been through three or four therapists. She had to wait eight months to see her latest clinician and at times had gone to hospital emergency rooms to get help. "It makes me feel bad, and I feel like the type of people with my income, we're only getting fresh out of college, no-experience therapists ... when most of us need a lot of experienced therapists and intensive therapy," the 39-year-old Braintree woman said.Experiences like Welch's are increasingly seen as the result of a lack of access to mental and behavioral health care in Massachusetts that is affecting patients who tend to spend more time in hospitals and are readmitted more often, and straining the state's health care system.

Gov. Charlie Baker has acknowledged the problem by proposing legislation last fall that would require certain health care providers to increase their combined spending on behavioral health and primary care by 30 percent over the next three years without increasing overall spending."The idea here, frankly, is to force everybody to just get out of doing what they've always done," Baker said this past week while testifying before the Legislature's Joint Committee on Health Care Financing.But some health care providers say they're already working on their own to improve access to mental health care. South Shore Hospital, for example, recently launched a new clinic for those struggling with substance use disorder.The Bridge Clinic, on the lower level of the Weymouth hospital, is a small, unassuming space with a small but growing staff that provides immediate support to anyone who walks through its doors, even if they don't have an appointment."We are addressing access to addiction treatment with the program in a dramatic way," said Dr. Todd Kerensky, director of South Shore Health's addiction medicine division. Patients don't need a referral to the newly opened clinic, which is closely modeled after clinics at Massachusetts General Hospital and Boston Medical Center, nor do they need to have been registered with South Shore Health's system. They can receive therapy and medication-assisted treatment for up to six weeks, at which point the clinic will refer them to long-term care with community partners. The clinic aims to address two problems identified by the Baker administration: long waits for appointments, and programs that accept only a limited number of insurance plans. A spokesperson for South Shore Health said there are no barriers to care at the clinic and that it accepts all insurance. It will refer patients to financial counseling to obtain insurance if they don't have any. "Community services have largely evaporated and have been really underfinanced, and now we find people on the street and people with behavioral health problems in emergency departments that don't really know what to do," said Alan Sager, a professor of health law and policy at Boston University. "The behavioral health problem is enormous, and the related substance use problem is enormous, and I don't think we're coping really well."

The state's Center for Health Information and Analysis released a report last October that found Massachusetts patients with behavioral health conditions stayed, on average, 1.3 days longer in the hospital than other patients. They also had readmission rates nearly double those without a behavioral health condition. This lack of mental health care services also contributes to the overall cost of health care, officials say. A 2017 report compiled by the state's Health Policy Commission concluded that admittance of behavioral health patients at emergency departments contributed to "significant cost and care delivery inefficiencies" due to an inadequate supply of outpatient and inpatient behavioral health services.These costs are felt beyond the walls of the emergency department, particularly in the trucks that are called to carry these patients to the hospital. South Shore Health is reworking the mobile aspects of its system, emergency medical services. Called Mobile Integrated Health, it is a new way of providing health care in the state."Around 30 percent of people calling an ambulance have some sort of behavioral health concern," said Antony Sheehan, CEO of Aspire Health Alliance, which is partnering with South Shore Mental Health on the initiative. "We need to redesign; we can't have a situation where services aren't convenient for people to use, where medical care is at some distance and disjointed from behavioral care." In response, Aspire Health, which specializes in behavioral health services, has been training paramedics at the hospital to better treat and refer patients experiencing behavioral health problems. The three areas of focus are: chronic health issues, such as chronic obstructive pulmonary disease or diabetes; behavioral health, such as substance use disorder; and access to care, such as providing transportation to clinics. The goal isn't to parallel the treatments provided in hospitals but to dovetail with them, catching patients who might fall through the cracks and effectively treating them outside the acute setting of the emergency department, said Dr. William Tollefsen, the medical director of emergency services at South Shore Health. "If you're able to effectively treat patients ... and allow people to be cared for in their home or the community, in effect you increase access for care by increasing the capacity in the system, which kind of aligns with Gov. Baker's bill," said Tollefsen. EMS officials would much prefer having the appropriate patients taken care of in a less acute setting -- be it an outpatient center or a therapist's office for long-term treatment -- than in the emergency department."We often are tied with the regulatory process where we have to transport patients to the hospital when oftentimes we know that's not the right thing," said Eugene Duffy, director of emergency services at South Shore Health. Some paramedics have already identified patients who are vulnerable and may benefit from this new approach, said Duffy. To prepare for their changing roles, they have completed 300 hours of rotations throughout specialty clinics to get a better grasp of long-term management of certain conditions.Kerensky said the initiatives are part of a move toward making health care professionals more comfortable with and capable of having a conversation about substance use or behavioral health issues. "To some extent, treatments in general ... are stigmatized by patients, families, communities and criminal justice," said Kerensky, who was wearing a purple lanyard that read "No Stigma" in bold letters. "I think it's important for the health system and others, especially the government, to help address that."

Material from State House News Service was included in this report.

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