The Access Initiative: Improving Appropriateness of Patient Fit for Resident Case Assignment.

Abstract

The Virginia Commonwealth University Health System (VCUHS) is an inner-city hospital complex that serves as a “safety net hospital” for a challenging mix of patients and clinical needs. Our health system has traditionally provided care to a large percentage of Medicaid and indigent patients. Virginia Coordinated Care (VCC) is the specially funded program at VCUHS that aids the provision of indigent care. The VCC population represents a high percentage of cases in our residents’ general psychiatry training clinics, as well as in their individual psychotherapy caseloads. Consistent with research on challenges to treatment engagement, our clinic has faced treatment, residency education, and financial challenges resulting in part from our setting [1] and population characteristics [2, 3]. The Residency Education Program at VCUHS includes several distinct components in its outpatient training. Year-long general psychiatric clinics offer trainees a critical continuity experience, working in teams and following approximately 100 patients. Subspecialty clinics, such as geriatrics, schizophrenia, mood disorders, and neuropsychiatry, offer residents the opportunity to conduct detailed assessments and advanced treatment under the aegis of expert faculty. Additionally, a comprehensive psychotherapy training program introduces second year postgraduates (PGY-2 s) to supportive therapy and medication management of the residents’ own cases. These expand and continue into the third year (PGY-3), augmented by assigned cases in psychodynamic therapy, CBT, and group therapy. Residents remaining through PGY-4 continue most of these modalities, and in addition receive training in family and couples therapy. Referrals for our resident training clinics and other outpatient psychiatric services come from primary care providers, community mental health centers, and patient requests. Due to high demand and limited community resources for mental health services, wait times have historically been as long as six months in our clinic. Prior to piloting the Access program, our outpatient services (including our resident training clinics) lacked a coordinated intake system. The centralized scheduling service historically conducted an initial phone screen and placed patients in first-available general psychiatry intake clinics. We had long struggled with several limitations of this scheduling arrangement, often due to “poor fits” for our training clinics. At the time of developing the Access program described herein, impacts of patient “fit” on providing care included those seeking forensic or disability assessments, pursuing court-ordered treatment, wanting primary substance abuse treatment, or seeking refills for untreated prescription medication dependencies. This created a frustrating scenario for many patients who waited an inordinate amount of time to be seen, only to eventually be redirected to more appropriate services elsewhere. Our providers, including psychiatric residents, also felt the reverse complication—the perceived pressure to accommodate patients whose needs or goals were not well-suited to our clinical services and training goals. Residents struggled with many patients who lacked the capacity and/or commitment for treatment, and with those not sufficiently motivated or oriented to psychotherapy and psychopharmacology to be consistent in their attendance. In addition to the issues of patient “fit,” our clinic has struggled with high no-show rates, similar to that often seen in clinics of our setting and population [2]. Our baseline no* William T. Nay wnay@vcu.edu