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11/25/2013
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Open Access
Pinehurst-NC Council ConferenceBen Millsap
Jamie GarrettCaroline Fisher
Monarch History and Services
• Large Not for Profit—providing IDD, MH and SA services
• Existed for well over 50 years• Continuum of MH Services
• Currently 17 OP sites
Open Access
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Open Access
• What is Open Access?– Open access for Monarch means we
generally do not schedule first appts.– Other appointments are scheduled like any
other clinic based service– Means people get the help they want and
need when they want and need it
Open Access
• Why should you consider open access– Best Practice and nationally recognized – Without timely access people get lost– No shows for first appointments are virtually Zero!– Better outcomes for the people you support– Better engagement (less no shows) for your programs – MCOs want and need access!!!– Open Access can and should be part of a crisis
continuum
Open Access—Our Model
• Expectations in our programs:
– A CCA from a licensed clinician
– CCA will indicate medical necessity and start the process for referrals as appropriate.
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Open Access—Our Model
• Expectations cont…– A treatment plan will be completed– Same Day Psychiatric Eval– If medically appropriate a script will be
provided– Next appointment(s) scheduled– Door to Door 3 hours or less
Open Access—Our Model
• How it works:
• On site resources may include blocked time for licensed clinicians and MD’s
• 3 Open Access hubs (Guilford, Wake, Mecklenburg)
Open Access—Our Model
• How it works cont…
– HUBs will consist of:• 2-3 therapists• 1 RN• 1 Psychiatrist• 1 Admin staff
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Open Access—Our Model
• How it works cont…– Team members are selected purposefully
• We use LCSWs—can see all insurance/use telemed
• Psychiatrist provides psych eval/scripts– RN triages and supports the physician to be efficient – Admin Staff—Runs the show!
• Connects with and rallies other resources
Open Access—Our Model
• Informed Consent– Critical to be open and transparent – Focus on the positive…what they are getting– Keep the MCO informed
Open Access—Our Model
• Open Access is often feast or famine.
• How to ensure we have enough staff to see people but not be overstaffed to the point of hurting the bottom line???
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Telemedicine!
Open Access—Our Model
• Telemedicine– Telemed when using the appropriate
equipment is safe, effective and HIPAA compliant.
– Allows for efficient use of resources – Bus line example…
Open Access—Our Model
• Telemedicine cont…– Telemed allows us the capability to use a MD,
NP or LCSW who is not located at a speciifcfacility to provide a Psych Eval or CCA
– Hire LCSWs for open access—provides maximum flexibility
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Open Access—Our Model
• Telemedicine cont…– 1-2 telemed set ups (use small offices) per
OP location– Dedicated fiber and circuits= quality product– Functions like closed circuit TV. Instant, clear
connection at the touch of a button.
Open Access—Our Model
• Tiered Support– 1st Tier is any clinicians at the location – 2nd Tier are our open access staff at the
location– 3rd Tier—Admin staff contact open access
staff at other locations (open access staff get credentialed everywhere we provide OP)
– 4th Tier local management staff provide services
Open Access—How to get there
• Define your vision.
• Determine a starting point.
• Commit resources
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Open Access—How to get there
• To know what number of FTEs or hours of the week Open Access makes sense you need to know a couple of things:– What is your volume of assessments now– How are CCAs considered in your productivity
requirements
Open Access—How to get there
• Determining the number of clinicians– We use a point system
• 90837 Psychotherapy, 53+ minutes= 1.0 pts• 90834 Psychotherapy, 38-52 minutes= .68 pts• 90791 Psychiatric diagnostic eval = 1.26 pts
– Our expectation is for our clinicians to reach 27 pts. per week
Open Access—How to get there
Determining number of clinicians cont…– Social work math!!!
– At 1.26 pts. per CCA it would take 22 CCAs in a week to meet our expectation.
– If you look at your current output and your program is completing 10 CCAs per week then start with a ½ time staff member dedicated to open access
– If you are already hitting 40+ CCAs in a week then you are looking at 2 FTEs focused on walk in.
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Open Access--How to get there
• Start with limited days/times for Open Access• Make sure to communicate those days/times and limits
to the MCO as well as to any potential referral sources• Monitor your wait times—Long wait times frustrate
people supported, your staff and the MCO who will field complaints
• Develop Telemed capabilities
Open Access—How to get there
• Building Telemed capabilities– Look for grants. We’ve been able to use
grants to purchase quality equipment– Invest in connectivity– Consider possibilities of contracting with a
psychiatric provider
Open Access—Lessons Learned
• Be aware of the possibilities for numbers to jump when word gets out about “walk in”– We expected to see 35 people per day in
Guilford. We talked up open access and saw 78 people day one. We now see in excess of 135 people a day with an average of 17-21 new walk ins per day.
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Open Access—Lessons Learned
• Good informed consent makes a world of difference!
• Look at your processes, anything you can do to streamline, reduce repeated steps, etc. the better it works.
• Develop good processes about what happens when someone cannot be seen and triaging individuals
Open Access—Lessons Learned
• Put the right staff in these positions. Staff need to be efficient and good at paperwork. Concurrent documentation is a must—people are waiting
• Staff in these positions need to be comfortable with a wide range of populations.
Open Access—Lessons Learned
• Stick with it. • Change can be tough
• Plan� Do� Study� Act• Open Access doesn’t mean walk in any
time you want for established folks!
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Open Access—Next Steps
• The HUBs work but there was a ton of work done to contact the HUBs, determine their availability, send info to them, etc.
• We developed a program to help us obtain efficiencies within Open Access called OASIS.
OASIS
• Tool to assist with coordination of care between Open Access Clinics
• Think “Airplane Terminal” Arrival/Departure Screen
• Real-Time Capabilities• Eyes On the Ground
OASIS-Local Queue
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OASIS-Local Queue
OASIS-Local Screening
Remote Queue
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Oasis-Remote
Oasis-History
Outcomes/Data
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139217 187
270
492
696761
832
553
1170
1274
1706
0
200
400
600
800
1000
1200
1400
1600
1800
October November December January February March April May June July August September
Total Walk-Ins
October November December January February March
April May June July August September
66
5653
79
54
6664
74
67 65
8681
0
10
20
30
40
50
60
70
80
90
October November December January February March April May June July August September
Average Wait Times in Minutes
Agency
MB RM EM SM RP US JS TW
PBH/Mec
k Total
% of
encounters 38% 93% 0% 83% 42% 83% 76% 23%
Guilford
Total
% of
encounters 62% 0% 0% 2% 1% 1% 3% 1%
Eastpoint
e Total
% of
encounters 0% 1% 0% 11% 57% 10% 16% 76%
Wake
Total
% of
encounters 0% 5% 100% 3% 0% 3% 2% 0%
Wilson/N
ash Total
% of
encounters 0% 0% 0% 1% 0% 3% 2% 0%
Total
% of
encounters 10% 7% 2% 4% 6% 5% 8% 5%
Grand
Total
% out of
home area 38% 7% 0% 17% 43% 17% 24% 24%
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If Monarch did not have a walk in open access center, I would have received my
services from:
Gone to
an urgent
care
center
Gone to
another
agency to get
services
today
Gone to
my
primary
care
physician
Gone to the
hospital
emergency
department
Not gotten
services
anywhere
Waited
weeks/mo
nths to get
services
from
another
company
July 5% 13% 9% 27% 25% 21%
August 5% 6% 11% 27% 33% 18%
September 3% 14% 12% 26% 30% 15%
October 4% 14% 10% 25% 31% 16%
I would recommend Monarch to a friend or family member.
Agree Disagree
July 99% 1%
August 100% 0%
September 91% 9%
October 99% 1%
I received services in a reasonable amount of time from the time I walked in
today.
Agree Disagree
July 97% 3%
August 97% 3%
September 80% 20%
October 85% 15%
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I was treated with courtesy and respect today.
Agree Disagree
July 90% 10%
August 90% 10%
September 100% 0%
October 100% 0%
I was educated about any medication ordered for me.
Agree Disagree
July 95% 5%
August 95% 5%
September 95% 5%
October 98% 2%
I was educated about any follow up treatment ordered for me.
Agree Disagree
July 96% 4%
August 96% 4%
September 97% 3%
October 100% 0%
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I am in charge of my plan and it clearly reflects what I need and want to achieve.
Agree Disagree
July 97% 2%
August 97% 3%
September 97% 3%
October 97% 3%
Related Data • Tracking walk-ins by day of week; week in
month; and month• State engagement – 2 visits in 14 days; 2
additional in 30 days• Tele-Med - # completed and office vs. tele-
med. • Satisfaction with tele-med.
• Medical screenings
Questions
