Applying an open-access model to a psychiatric practice.

Introduction It is generally agreed that access to timely medical care is a key to providing quality service. Many practitioners and organizations, including Kaiser Permanente (KP), struggle to achieve this. Psychiatric care is no exception. Employers who provide insurance for their employees have emphasized initial access and much energy is aimed at getting that first appointment for the prospective psychiatric patient; however, there has been comparatively little attention to follow-up visits. Increasing the number of intake appointments per week, using unbooked return appointments for new patients, and appropriating time allocated for activities other than direct patient care (eg, paperwork time, meetings) have improved a member’s chances of seeing a psychiatrist for the first time more quickly. The second and subsequent visits are harder to secure. After 23 years practicing outpatient adult psychiatry at KP, first in Los Angeles County and now in Orange County, I have seen the continuing high demand for, and emphasis on, initial appointments resign doctors and their patients to some very long waits between visits. Most episodes of care that involve psychiatrists as treaters—not simply evaluators—require return visits, care beyond the skills of psychotherapists or referring physicians. Although many KP psychiatrists have wrestled with this dilemma, longer intervals between visits have become increasingly common. A recent random search for “next available” return appointments in KP Orange County showed that waits of three to four months were common; access reports from other psychiatry departments at KP in Southern California have shown this as well. Increasing the number of psychiatrists, requiring more mental health care from primary care physicians (PCPs), and reliance on community support services have been some of the remedies that have been proposed to decrease the pressure for better access. Typical guidelines for monitoring antidepressant therapy call for re-evaluation within four to six weeks. Phone calls are one way to follow-up, but phone calls do not constitute thorough assessments. A patient beginning treatment for a psychotic or manic disorder cannot usually be evaluated from a distance. On the basis of these guidelines, patient care suffers. In our system, initial appointments are one hour. Most returns are 30 minutes, but each psychiatrist must have six 20-minute return appointments per week. Time itself has had a prominent role in psychodynamically informed psychotherapy, but our current practice is primarily pharmacotherapy.