Health systems are grappling with how to improve behavioral health access while ensuring patients are connected to the right level of care but capacity does not equate to continuity, Melissa Brule, director of behavioral health and specialty services at Elliot Health System in Manchester, N.H., told Becker’s “Behavioral Health Podcast.”
By implementing a centralized referral system, standardized assessments and behavioral health navigator roles, Elliot Health reduced behavioral health intake wait times from more than 50 days to less than seven while improving continuity of care for patients.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: Your team has spent the last year redesigning outpatient access and navigation pathways. What was the original problem or gap you were trying to solve, and what made it urgent to address?
Melissa Brule: In 2023, it was raised in our ambulatory operating board that access to behavioral health was a top priority. The primary care nursing triage phone time continued to increase because of the lack of ability for patients to find support.
At that time, the third-next available appointment for an intake appointment with behavioral health was more than 50 days. Primary care was reporting that if patients were not able to be served in Elliot’s outpatient department, they continued to cycle through their primary care practices due to acuity or other social determinants of health.
Conversely, the behavioral health team continued to be concerned about new patients presenting in the practice with high acuity or social needs that could not be supported in our own internal practice. The patients waited almost two months to be seen only to be told, “This isn’t actually the right place for you,” without a pathway to find care elsewhere.
We knew there had to be a better way to serve patients.
Q: What changed operationally to make faster assessments possible, and what impact have you seen so far?
MB: We designed what we called a “no wrong door” entry system. We said that if patients were asking for help, we wanted behavioral health to be the owners, since they were the subject-matter experts, to assess where the correct landing spot should be for patients in the community.
We created a single referral system. Primary care providers no longer needed to assume or question whether they were choosing the right diagnosis or programs for the patient to enter. All behavioral health referrals dropped into the same scheduling work queue for outreach.
We essentially removed all barriers for patients outside of imminent risk of harm to themselves or others. Patients with any psychiatric concern can now be scheduled into our intake system.
We trained all front desk receptionists to schedule new patient appointments. There was no longer a need for a singular intake receptionist to be calling and screening patients. Since there was no exclusion criteria, if patients wanted to be booked, we booked them into the schedule.
We also stopped asking patients, “Do you have a referral?” If a patient is asking for behavioral health support, we’ve never had a primary care provider say, “No, you don’t need behavioral health support at this time.”
We increased our capacity for licensed social workers to perform evaluations by contracting with a telehealth vendor. Currently, we have two full-time intake clinicians booked almost 40 hours a week. In total, almost 80 hours of intake assessments are completed every week.
These clinicians do not provide longitudinal care in our practice. They assess patient needs and determine what level and type of intervention would most likely help them succeed in treatment.
Our wait time for an average assessment is now less than seven days. In the last 10 months, we went from almost 50 days of waiting to an assessment that gets patients to the right level of care in less than seven days.
Q: How did Elliot Health System design a navigation pathway that better aligns a patient’s clinical presentation with the services most likely to lead to a successful outcome?
MB: By creating a wide-open intake door, we needed some type of standardized clinical tool that intake clinicians could use. We knew this would create continuity across the system and support patient outcomes.
In New Hampshire, the Department of Health and Human Services requires all community mental health centers to use a screening tool called the Child and Adolescent Needs and Strengths Assessment and the Adult Needs and Strengths Assessment.
We decided to align our services by using that same tool to provide better continuity within the state. We also felt we would be speaking the same language as community mental health centers if patients needed to transition to higher levels of care.
Patients who require additional support to get into community mental health centers are assigned a case manager. These case managers assist patients in connecting with care, provide more intense touchpoints and strongly encourage releases of information between organizations to create continuity during care transitions.
We also created a behavioral health navigator position modeled after navigators in other specialty medicine areas to assist with providing personalized care recommendations in the community and support patients in getting connected. They provide concierge-like services and multiple touchpoints to help patients get what they need.
We know access to care in the community is available, but there are still barriers. It almost feels like a maze trying to navigate through these systems, even for the most savvy patients.
Q: What did you learn about patient behavior, community needs or barriers to care during this project?
MB: I think the biggest thing — and I say this almost every time I talk about this project — is that capacity does not create continuity for patients.
Creating more access for patients was what we initially thought was the answer, and we actually had to revisit this project and realize that just adding more capacity was not going to solve the problem at hand.
Behavioral health is complicated and plentiful with internal and external barriers. Navigators and case managers are successful in many other areas of chronic disease management, and behavioral health should be thought about as one of those.
Q: What advice would you give other organizations trying to build a more seamless and patient-centered outpatient behavioral health experience?
MB: Creating a system that uses the subject matter experts on hand to evaluate psychiatric needs satisfies the referring provider, the patient and the behavioral health provider internally in the system.
There’s never going to be a better outcome than having somebody who knows psychiatric conditions assessing psychiatric conditions.
I also think it is really important for leaders to understand what community resources are available. We realized during this project that there were far more community resources than we initially understood, especially because of the explosion of telehealth.
The maze of connecting patients to care too often is what lands patients back in the primary care office or the emergency room. Organizations do not always have to shoulder the burden of expanding internal capacity at all times.
The redesign from longitudinal care to evaluate-and-navigate care can be bumpy, but it drives better patient outcomes and provider satisfaction. The ownership of the patient from a health system level with navigation and case management can also be a relatively low-budget investment compared to recruiting specialized providers like psychiatrists and therapists.
At the Becker's Fall Behavioral Health Summit, taking place November 4–5 in Chicago, behavioral health leaders and executives will explore strategies for expanding access to care, integrating services, addressing workforce challenges and leveraging innovation to improve outcomes across the behavioral health continuum. Apply for complimentary registration now.
