Walk-in clinics tackle urgent mental health needs

Psychiatrist Eric Alcera, MD, at the Hackensack Meridian Urgent Care With Behavioral Health in Neptune, New Jersey. Staff at the clinic treat such conditions as anxiety and depression seven days a week.

Photo courtesy Hackensack Meridian

Faith Beaty could feel depression seeping back in. She missed - and worried about - her daughter, a 14-year-old receiving treatment for mental health and behavioral issues in a residential facility outside Rochester, New York.

"It really gets to you when you can only see your child on the weekend and the rest of the time they're in somebody else's care," she says.

Other concerns weighed on her as well: caring for her aging mom, missing her deceased father, and dealing with a precarious housing situation.

"It was a lot. It was overwhelming," says Beaty, 45, who works as a mediator for a youth nonprofit. And she was going it alone, having stopped therapy when her provider moved to a practice that didn't accept her insurance.

So Beaty went to Rochester Regional Health Behavioral Health Access and Crisis Center - a walk-in mental health clinic open seven days a week, 12 hours a day.

"The [clinic counselor] was very supportive. He met my eyes with real compassion, and he was very calming. That meant so much to me," she says. She also received a referral to a community-based therapist who could start seeing her in two weeks.

In an alternate scenario, someone like Beaty might have gone to the emergency department (ED), waiting long hours among patients with contagious diseases or gunshot wounds, in a noisy, stressful, and potentially chaotic environment.

In the United States, approximately 8% of all ED patients come seeking mental health care. And while their needs are often not true psychiatric emergencies, they frequently have no place else to go for care.

That reality has spawned an innovative model: urgent care clinics whose providers treat a wide range of mental health problems, though they often exclude such severe concerns as acute aggression or an immediate risk of suicide.

Some mental health urgent care clinics - also called behavioral health urgent care clinics (BHUCCs) - opened prior to COVID-19, but pandemic-related needs sparked a significant uptick in their numbers. "Around 30 opened in 2019-2020 alone, and they've been continuing to grow at a steady pace since," says Katherine Du, a University of Pittsburgh School of Medicine student who conducted a nationwide survey of 77 such clinics.

"People sometimes wait three to four months for an [outpatient mental health] appointment. There should not be such a need for these clinics. They are a clear sign that our system is broken. Given the need, I can only expect the trend to continue."

Robert Trestman, MD
American Psychiatric Association

BHUCC models can vary widely. Some are open 24-7; others, much less. Some are run by hospitals; others, by private companies or municipalities. Some see only children or only adults, while others treat both groups.

But all aim to help address the country's mental health crisis.

In 2021 nearly 6 million U.S. adults went to the ED for mental health care - up 1 million from 2017. Among people ages 6 to 24, the proportion of ED visits for mental health issues has nearly doubled in recent years.

Finding treatment can be tough. Roughly half the U.S. population - some 169 million people - live in mental health professional shortage areas, according to the Department of Health and Human Services. "People sometimes wait three to four months for an appointment," says Robert Trestman, MD, chair of the American Psychiatric Association's Council on Healthcare Systems and Financing.

"There should not be such a need for these clinics. They are a clear sign that our system is broken," says Trestman. "Given the need, I can only expect the trend to continue."

Meeting urgent needs

In the United States the median wait for a mental health appointment is 67 days. At a BHUCC, the wait can be less than an hour.

The visit usually begins with some brief paperwork, such as a symptom checklist. Next comes a thorough interview with a care provider, perhaps a social worker, nurse, psychologist, or psychiatrist.

"We discuss symptoms, psychiatric history, some family history, and current treatment if any," explains Joseph Majauskus, MBA, who runs the Rochester BHUCC. "With consent, we may also contact people close to the patient to get a fuller sense of what they've been going through."

Often, patients come seeking help for depression or anxiety, but issues run the gamut, says Carlos Guerra, MD, a psychiatrist at the Memorial Hermann Mental Health Crisis Clinics in Houston. "I've seen everything from a first-time psychotic break to an immigrant who needed medications because hers got left behind in Nicaragua."

With young patients, self-harming behaviors and suicidal thoughts often drive visits, says Vera Feuer, MD, the psychiatrist who spearheaded creation of the Pediatric Behavioral Health Urgent Care Center at Northwell Health on Long Island. Sometimes a youngster's passing remark in school can trigger a required mental health assessment.

"Imagine you get a call at work that your child wrote in an essay that they don't want to live, and you're told they can't return until they're assessed as safe. [Before we opened], if you wanted to get that assessment quickly, you could only go to the emergency department," says Feuer.

"I've seen everything from a first-time psychotic break to an immigrant who needed medications because hers got left behind in Nicaragua."

Carlos Guerra, MD
Memorial Hermann Mental Health Crisis Clinics, Houston

Of course, some patients need ED care, but that's fairly rare, says Majauskus. "It's less than 10% for us," and his clinic can arrange for appropriate transport should the need arise. In some regions, patients can be seen in psychiatric EDs, places that are equipped to use sedation or restraints - but in a much calmer atmosphere than that of a regular ED.

Atmosphere matters for people experiencing mental health issues, and the relative calm of a BHUCC can mean a lot to them, notes Feuer. Northwell, for example, offers spaces that feel much like a pediatrician's office, replete with toys, books, and comfy couches.

Clinics take other steps to address the particular needs of mental health patients. At Rochester, patients receive support from peer counselors who have had mental health issues themselves. At Hackensack Meridian's BHUCC in Neptune, New Jersey, doctors check for physical conditions to see whether those may be causing mental health symptoms, says psychiatrist Eric Alcera, MD.

Whatever the clinic's intended approach, Trestman believes the devil lies in the details of implementation.

"There are many questions," he says. "A key one is how patients will manage in the long run. Will they receive follow-up care?"

What happens when the visit ends?

Mental health urgent care clinics are not meant to provide long-term treatment. "The problem is that psychiatric issues are rarely one and done," says Trestman. "So well-designed clinics have partnerships with a health system, a teaching hospital, or other source of ongoing outpatient care."

In Rochester, clinic staff provide referrals to various levels of outside care, from peer counselors to intensive treatment for severe mental illnesses. They also help connect patients with much-needed social services, like housing and transportation assistance.

Provider referrals can be invaluable for patients who struggle to navigate the health care system, says Feuer. Importantly, they can speed up access to care too.

"Public agencies often honor a referral from us like they do ones from the ED, as representing a greater need for care," Feuer says. "Also, private practices are more likely to accept our patients because we provide a preliminary diagnosis and treatment plan, which makes the process easier for them."

If patients already have a provider, Northwell staff share visit findings and recommendations to smooth continuity of care. They'll also communicate with a patient's school or pediatrician when appropriate.

Sometimes BHUCCs go even further than making connections, providing "bridge" services when patients can't access an outside provider quickly enough.

"If our psychiatrist starts the patient on a medication, we have them come back [so we can] monitor for a need to adjust the dose and for side effects, until they can get to their permanent provider. The bridge appointment happens within days or weeks, not the months it might otherwise take," says Alcera.

At Northwell, some 30% of patients need to begin ongoing care right away, says Feuer. So her clinics - there are three community-based ones in addition to the hospital site - can offer patients several follow-up visits, either virtually or in person.

Clinic leaders say such extra supports can have powerful impacts. Majauskus points to one recent example.

"We had a patient who was going to the ED a lot," he says. "Our staff consulted with others who'd been involved with her care and created a coordinated plan. That led to tremendous success. In 2023 she'd been hospitalized around six times. In 2024 she's had zero hospitalizations so far."

Obstacles to overcome

Much work lies ahead for mental health urgent care clinics, says Trestman.

For one, clinics need to ensure effective and equitable payment models. So far, more than 90% accept Medicaid and most offer a sliding scale - or even no-cost services - for uninsured patients, according to Du's survey.

At Northwell, patients without insurance can receive help signing up for it. "Unfortunately, that's not a complete answer because many insurers don't reimburse well for mental health care," says Feuer.

Providing reduced-cost services can strain clinic coffers, Guerra notes. "Here, we are happy if we just break even. But we are saving the system money because our patients are not tying up expensive ED beds."

Of course, affordable care only goes so far if patients can't easily access clinic sites. "My sense is that these are similar to walk-in medical clinics, in that they are mostly situated in more affluent communities, unless they're created by places like teaching hospitals," says Trestman.

Clinics also need to make sure they have enough providers to staff clinics, a concern that may rise as the psychiatrist shortage grows. By 2030 the number of U.S. psychiatrists is expected to drop 20%, notes Trestman. The decline is driven by such factors as burnout, retirement, and a shortage of medical residency training slots.

"So far, our recruitment has been good because we're at a large system," says Feuer. "But it is hard to find providers who are more diverse linguistically, ethnically, and culturally. That's a major struggle for us."

Observers like Trestman make another crucial point: If the field is going to advance, it needs to research which approaches work best.

"There's really no playbook for how to do this work," says Alcera. "As more clinics are being created, we can collaborate to identify best practices. Once we have more data, we can refine efforts."

He adds what he considers a significant caveat. "Because we have a crisis, we can't afford to wait for the data and for perfection. Let's build clinics so we are reaching as many people as possible and fine-tune as we go."

Beaty certainly appreciates that she had access to such a clinic. "I'm so grateful, especially for one thing the counselor said to me. He said, 'You are not alone. You can come back if you can't wait until your [new provider] appointment.' That really set my mind at ease."