Phase-Based Care in
Community Mental Health

A Novel Approach to Treating Depression

Mind Springs Health (MSH) is honored to receive the prestigious Sherman Award for our innovation of “Phase-based Care” (PBC) and specifically, the Rapid Recovery Clinic for Depression.

Community Mental Health Centers  (CMHCs) in the U.S.  face demands for service far exceeding capabilities.  Following the implementation of the Affordable Care Act, CMHCs experienced 25% greater demand for services from newly insured consumers.  If you or a loved one have attempted  to access psychiatric care, you might be aware that wait times to engage in in treatment can range from 7 to 12 weeks.  These delays have profound impacts on the lives of patients and families, and potentially contribute to the escalating rates of suicide.  A tsunami of patients seeking mental health services overwhelms our hospital emergency rooms. Furthermore, once treatment of depression finally starts, symptom resolution in community-based care is only 16% and 33% by weeks 6 and 12, respectively.

Our mental health system is broken and communities all across the country are demanding “better’ service to meet societies needs.   Yet, solutions to achieve better service and fix the system are elusive.

Mind Springs Health accepted the challenge.

We had to figure out how to engage acutely ill consumers  in care without delay and to provide high intensity treatment at the time of need. We had to be ever mindful of patient and staff satisfaction, as well as the likelihood of reduced financial resources due to federal and state budget adjustments. Phase-based care, a strategy that preferentially directs existing resources towards the patients at the time of their greatest need, is our proposed solution.

After 2 years and 300 patients, EngagingPatients.org and Taylor Healthcare recognized the significance of this innovation through the Sherman Award for Excellence in Patient Care presented at the national meeting of the Institute for Healthcare Improvement.

Patients engage in comprehensive  treatment within 4 days, instead of 2 to 3 months.  At weeks 6 and 12 depression resolution rates are 63% and 78%, far superior to the national norms of 16% and 33%.  The average psychiatry and therapy time provided for depression symptoms to resolve (or week 12, whichever comes first) is 1.5 and 2.5 hours respectively.  While some patients received 8 hours of therapy to achieve recovery, others opted for medication management, alone.  Staff and consumer satisfaction is high and productivity is enhanced, with no additional staff required.

As simple as the concept of providing care to patients when they need it appears, there were formidable challenges to be addressed.

In traditional CMHC settings, psychiatrists, therapists, and others work independently without a coordinated patient care plan.  Patients are scheduled for routine visits for years on end based on habit and culture rather than need, thus saturating the schedules of mental health providers.  As a result, patients presenting in acute, highly symptomatic states (or phases) experience long delays to access care and do not receive timely, intensity-appropriate treatment that would result in rapid improvement.

We developed mathematical algorithms to guide the re-allocation of psychiatry, therapy, case management and peer-support resources into a single patient-focused care plan to provide rapid and intense treatment during the “acute phase” and  modify treatment intensity according to the patient’s progress (or lack of progress).

We integrated three simple, scientific principles into one unified approach

  1. Medication, psychotherapy, and social support / life support skills all contribute to the resolution of depression when offered in a systematic, coordinated manner guided by patient preference.  A treatment team that meets weekly to review  progress allows coordination of all team members into a single patient-focused care plan.
  2. Every “touch” (patient contact) provides meaningful therapeutic benefits regardless of the credentialing letters behind staffs’ names. Patients have scheduled appointments with psychiatrists or therapists, or can opt to walk-in to join the weekly clinic.
  3. Measuring care has a profound impact on outcomes. Measured-care, while widely accepted in physical medicine (blood pressure, blood sugar, weights), is a relatively new concept to CMHCs.

To implement these principles, we had to address the culture of traditional CMHCs.   Stable patients had to be seen less intensely in order to reduce the bottleneck for new patients seeking care.  In most CMHC settings, the “one in – one out” philosophy assumes that when a new patient enters treatment, a stable patient  must be discharged to maintain caseload equilibrium and not over-burden staff.  This is a false assumption!  Far more resources are needed for a new, acutely ill patient compared to those who have reached stability.  In fact, according to our algorithm, in order to see one additional acutely ill patient per week, 48 stable patients receiving routine “check-in” care must be seen differently or discharged!

Guided by our algorithms and our beliefs in the value of a fully integrated treatment team, the use of measurements, and value of each “touch”, we have successfully improved the care for our patients who are engaged in PBC without requiring additional resources.

Phase-based Care programs are currently active in Grand Junction, Glenwood Springs and Steamboat Springs.  Mind Springs Health has additional clinics in various stages of development as we spread this approach throughout our 10 counties. All offices are expected to offer Phase-based Care by the end of 2019. The recognition and honor bestowed by receiving the Sherman Award has motivated us to explore how to share this approach other CMHCs across the U.S.   Finally, current Medicaid funding does not provide financial incentives if patients get better quicker.  In fact, there is no difference in funding if patients get better or not!  PBC could provide an infrastructure for a ‘pay-for-performance’ strategy in which CMHCs would receive funding for achieving rapid recovery rates based on the principles of PBC.