In the fall of 2017, Danny, a twenty-nine-year-old from Durham, stopped by the office of Carolina Behavioral Health Urgent Care in the middle of an acute mental health crisis.
Danny, whose real name the INDY is not sharing for medical privacy reasons, was homeless and suffering from a major depressive disorder with psychotic features. When Danny arrived at Behavioral Health Urgent Care, or BHUC, he was paranoid—so much so that he was not able to ride the bus or stay in a local shelter; instead, he was living in the woods. For Danny to manage his condition, he needed to be looped into mental health services as soon as possible—medication, therapy, and outpatient care.
Danny's success with long-term treatment had not been great. Over the years, he'd bounced around various mental health agencies, but, likely due in part to a combination of his homelessness and his mental health condition, he was never able to consistently stick with a care regimen.
This time, though, was different. Danny felt his symptoms worsening and getting in the way of his ability to function. He believed he needed to be back on his meds, but he didn't have insurance.
When Danny walked through the doors of BHUC, he had no idea that the program supporting him was new, set up to help people just like him. It's the only service of its kind in North Carolina, in fact, located in an unassuming building off Durham-Chapel Hill Boulevard.
The yearlong pilot program, which launched in July, was created to fill a gap in the local mental health care system. It's best thought of as the psychiatric version of an urgent care clinic—a destination for patients who may need their medications refilled or want to be seen by a clinician for anxiety or depression, but don't necessarily need to go to the hospital or a higher-level crisis facility.
In the past, a patient like Danny may have ended up in a hospital's emergency department—a destination that is becoming increasingly common for patients in need of mental health care in North Carolina. Compared with other states, North Carolina sees nearly twice the rate of patients with psychiatric needs who opt for the emergency room each year, according to The Charlotte Observer. The system is costly for hospitals, which have to absorb much of the cost for people who are uninsured or covered by Medicaid, and ineffective for patients, who can end up waiting for hours before being seen—or days before being admitted to a state-run psychiatric hospital.
Those problems will likely be exacerbated as mental health funding declines in North Carolina.
This year's budget made cuts to publicly funded mental health organizations, also known as local management entities or managed care organizations, or LME-MCOs, which cover the costs for mental health services for people on Medicaid or without insurance. In North Carolina, there are seven LME-MCOs. Alliance Behavioral Healthcare, which serves Cumberland, Durham, Johnston, and Wake counties, was hit with a $19 million cut for fiscal year 2019. (Alliance received about $495 million last year, most of which came from Medicaid.) The total funding for the seven LME-MCOs was reduced by $90 million.
"Unfortunately, North Carolina has been cutting mental health care services through the money of the LME-MCO system consistently these past few years," says Nicholle Karim, the interim executive director for the National Alliance on Mental Illness-North Carolina. "One in five people are affected by mental illness in a given year. That's about twenty percent of North Carolinians who are dealing with a mental health diagnosis. When mental health care is not funded adequately or there's not an array of services available to folks, then we see people lose their jobs or people end up in the emergency room because they don't have access to the care that they need. Or people may end up in jail, or prison, experience homelessness, or die by suicide."
With services already strained, BHUC is trying to ease the burden on local emergency rooms. Although the ER is often the first—and only—stop for patients seeking psychiatric care, it's not always the best choice, BHUC clinic director Marissa Holsten explains.
"A lot of times it's just not appropriate," she says. "Everyone goes for a lot of different reasons. They estimated the wait to be about six hours. Anecdotally, it's never that quick. A lot of times, people can spend the whole night in the emergency department waiting. And then in the morning, someone is like, 'Hey, you might be better served by Behavioral Health Urgent Care.' We're hoping that we would fill this gap in the crisis continuum."
The process for a patient like Danny, walking through BHUC's doors for the first time, is relatively quick. Clinicians see clients ages four and up who live in Alliance's coverage area and who either have Medicaid or are uninsured and are eligible for state mental health funds because they meet or fall below an income threshold ($71,550 for a family of four). Services for eligible patients are free.
BHUC provides safety assessments, crisis counseling, medication, and connections to further mental health care. Patients come in for a range of reasons, Holsten says.
"We see people who are like, 'I'm in crisis, I might feel suicidal, and I need support—crisis counseling and appropriate referrals because I am going to need more than what you can provide here,'" she says. "And we also see people who are like, 'I'm about to run out of my medication and I can't see my psychiatrist for a week. I'm not in crisis yet, but if I stop taking my medication there's a high likelihood I can go into crisis.'"
When Danny stopped by BHUC, he fell into the category of patients who needed help with medication. He did not have Medicaid, but the program was able to connect him with state funding for services while he waited to get his Medicaid activated. Now he has a therapist, a caseworker, and a community support team that will bring him to BHUC for his medication appointments—an injection once a month. His community support team, meanwhile, sees him about once or twice a week. (During a particularly cold snap, BHUC got the paramedics to deliver him a sleeping bag and a toiletry kit).
It's possible those services have helped prevent Danny, who had previously been in and out of jail, from cycling back into the criminal justice pipeline. Since his first visit with BHUC in the fall, he has become a regular client, and he's currently waiting on Medicaid approval. Occasionally, he'll just pop in to BHUC say hello.
One of the reasons this model may be successful for patients like Danny is because it brings providers directly to them, an approach common in urgent care centers.
"The way the model is set up, the urgent care model where an individual comes into a clinic, stays in the room, and then the providers come to that individual, that's pretty unique in the behavioral health community," says Margaret Brunson, Alliance's director of hospital relations.
On a Thursday afternoon at BHUC, a receptionist calmly answers patients' questions while a handful of people wait to be seen. Holsten files past patients in the waiting room and gives a brief tour of the space. There are eight clinic rooms in total, including a play area for patients' kids, decked out with books and toys. The rooms are painted white, decorated with potted plants and colorful paintings of trees.
- photo by Caitlin Penna
- Marissa Holsten
The goal is to make the patients comfortable, Holsten says. "We want to bring our services to them."
The program came about after Alliance reached out to a group of therapists and social workers at the mental health organization Carolina Outreach and asked if they'd be interested in teaming up on a pilot project. Carolina Outreach concurred. The program is funded by Alliance, which covers the costs of uninsured patients who aren't on Medicaid.
Patients are often referred from their primary care providers, hospitals, mental health courts, and schools. BHUC is also working with crisis intervention officers at the Durham Police Department to help set up a guide for officers about when it would be appropriate to send patients to the clinic instead of an emergency department or crisis facility.
So far, gathering clients has been a bit of a slow burn. The question for service providers and other state-funded care organizations that cover counties outside of Alliance's purview is whether the program is working well enough to continue or be replicated elsewhere. It's as yet unclear if BHUC has achieved its goal of reducing emergency department admissions. Alliance is still in the process of figuring that out, Brunson says.
"We know anecdotally that people are choosing this facility over the emergency department at times," she says, "but we don't have any clear data at this point, not yet, to see how much we're diverting people from the ED and if we're impacting ED admissions. And I think that's something that will probably come over time as well."
Holsten says the program's numbers aren't where she wants them to be—the clinic typically sees about six to nine clients a day, though it has the staffing to serve twelve. (On slow days, when the weather is bad, it can see as few as two or three clients.)
Even without the clinic operating at full capacity, Brunson says keeping BHUC's doors open after the pilot program expires at the end of June is a priority. Alliance plans on supporting the program for the 2019 fiscal year, although it does not know exactly how much money it will be able to set aside for patients without insurance. After the year is up, it will reevaluate its support for the program on an annual basis.
Wake County wants to bring a similar program to its residents. Commissioners plan to set aside $750,000 in this year's budget to create their own version of BHUC.
"We have seen what our neighbor is doing and observed how effective it has been, and we want to try to improve our outcomes in Wake County," says Commissioner Matt Calabria. "This is a tremendously exciting program because there is a huge unmet need in the community, and this is an opportunity to be very proactive about it."
He continues: "A lot of this stems from the state not doing its job. We are constantly battling a state that underfunds behavioral health care."
So far, BHUC's clients seem satisfied with the care they've gotten. Since launching in July, BHUC has served about seven hundred patients; 98 percent of them, according to a survey the clinic conducted, said they were extremely satisfied with the program's services. About half said they would or may have gone to an emergency room if they hadn't gone to BHUC. Ninety-five percent said their needs were met after their visit—a success rate Holsten chalks up to the strength of "the clinicians and how they engage the client."
Clients hail from beyond Durham, too. As the word slowly trickles out, BHUC is seeing patients from across the four counties Alliance serves—some even driving more than an hour for a visit. But the long haul is worth it, especially for clients who need BHUC's help with medications. Sometimes, a patient may run out of medication before his or her next appointment with a doctor, and BHUC will provide "medication bridges"—enough to get the patient through a potential crisis before the next appointment with a provider, which, in a strained mental health system, happens more often than you might expect.
"We have people who go in and are seen by a psychiatrist somewhere else, get started on a med, go to fill it, and can't afford it," says Holsten. "But for some reason, and I think it's the volume, they cannot get back in to get that addressed or changed in a timely manner. So they come to us and say, 'I am trying to get this medication filled, but I can't afford it,' so we can offer different options. A lot of times, thankfully, there are different types of medication that have a similar effect that could be cheaper, and sometimes it's just linking them to the right pharmacy and helping them do some of that legwork or calling around."