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moominmuppetI'm planning on sending this to my GP, the Ombuds dept, and the head of psychiatry, at least. Any other suggestions? I know the bit in the middle about my experience is pretty long, and that's mostly for my GP's benefit, since I'd like her clearly informed on all this (I don't know exactly what the nurse relayed to her).
To Whom It May Concern,
I wish to explain a specific appointment scheduling issue that happened for me as a patient, why I see this as symptomatic of a serious larger issue, and what suggestions I would make for handling this differently in the future.
In very brief, I strongly believe the Clinic needs to invest in additional Adult Psych Triage Nurses, and provide Same-Week appointment scheduling with them, at least. The two major benefits to this are avoid unnecessary expenditures for inpatient hospitalization, and preventing patients from "slipping through the cracks" in potentially disastrous ways.
My Specific Example
I am a Clinic employee with Antares insurance. I have had a diagnosis of Bipolar II for approximately 17 years now. I am fortunate that my case is only of moderate severity, and for personal reasons I have not been on mood stabilizers for about a decade now. I am also under treatment for fibromyalgia, and in order to address my fatigue issues more effectively we needed to modify my meds in a manner we knew might cause more difficulty for me with the bipolar. In working with my GP on this and asking at that appointment for a mood stabilizer, she requested that I see my psychiatrist instead, since she was less familiar with some of the questions at hand. Given some of the complexities of my case, I don't blame her for that. The last time I'd see my psychiatrist was a few years ago, but I thought she was still in town, so I was trying to find where she'd moved to schedule an appointment. I did not expect that I would need a new psychiatrist, or I would've started the search much sooner. As a result, the following happened:
My new meds worked well for about a month (they're still making a massive difference in my quality of life and ability to remain employed), during which I discovered that my psychiatrist might no longer be in practice. I was getting mixed and very confusing messages on this; she showed on the Clinic's Physician listings without mention that she's now inpatient-only, and when I called the number on her listing (http://my.clevelandclinic.org/staff_directory/staff_display.aspx?doctorid=15029), the Appointment line was utterly baffled and couldn't find her in their system anywhere. It took a number of calls to even get that much sorted, and learn she's working inpatient now and unavailable to me.
Friday around noon a concatenation of circumstances led to what I recognized as a hypomanic episode with mixed state aspects that was getting beyond my ability to control. I'm a rapid-cycler, so this happened fast. When I got to work, I had to warn my boss about my state, I was feeling so likely to get adversarial during the staff meeting. I immediately set about trying to get myself the care I needed, hoping to get an appointment scheduled before the weekend hit and the schedulers all closed.
I called my GP to see if she would prescribe a month of one of the mood stabilizers until I could get in to see someone and get that all sorted out. Per her nurse, this was a definite "no".
I called the Appointment Center to schedule one of our vaunted Same Day appointments. I could've coped with any appointment that would've gotten me in to see someone within a week or so. I learned that this is not possible in Psychiatry. In fact, the soonest it was likely I would see anyone was 4-5 weeks. The best I could do was get on a list and wait for the one(!) psychiatric intake nurse for adults to call me back and determine whether I would get the appointment I needed, and I was told it was unlikely I'd even hear from the intake nurse for a few weeks!
In attempting to work around this and avoid either ending up broke/unemployed (the possible risks of a manic episode for me), I keep calling around to every option I could think of. Over and over again, in explaining my situation (need urgent care for med adjustment, not severe enough to warrant inpatient care), I stumped the people I spoke with. To their and the Clinic's credit, almost every person I spoke with did their best to find assistance and resources for me. I was various referred to CONCERN, Nurse Oncall, back to my GP, and to the ED.
CONCERN handles only counseling issues, which are totally different than med issues. Nurse Oncall was unable to assist. My GP's nurse, on second call, reconfirmed that they would not assist me and referred me to the ED.
At this point I was so stressed that I was rapidly losing control, panicking about the idea of having no way to handle this for such an extended period of time, bursting into tears at the office and unable to work. This set off my various stress-mediated autoimmune problems (comorbid with the fibromyalgia), and by late that night I actually had blood in my urine from an interstitial cystitis flare set off BY TRYING TO GET CARE. I had to ask my partner to leave work and come get me. I had to take another half-day of my shrinking FMLA time. I had to abandon my coworkers in the middle of a downtime. Missing work is the single biggest issue we've been trying to PREVENT by being more aggressive with the fibromyalgia.
We headed for the ED, but on the way I thought I recalled that Antares requires a call-ahead about any psych-related ED visits, so I dug out my insurance card and gave them a call. Because it was after-hours by then (I'd been working steadily on this issue since 3pm that day) I was put through to the Behavioral Intake line at Lutheran. This turned out to be a godsend; although they were just as stumped as to any way to get me urgent care within current procedures, the nurse, Colleen Mayo, was able to divert me from what would've been a useless ED visit -- apparently they wouldn't have been able to prescribe me anything without admitting me. She also worked for an extended period of time researching any way to get me what I needed without us having to make a monumental waste of clinic resources and admit me to the hospital. Eventually she was able to reach a sympathetic psychiatrist, Dr. Ranjan, who was willing to add me to his schedule for the upcoming week (first thing Monday, in fact).
I have since had the appointment, have the med script for Trileptal that I needed, and have scheduled followup appointments. I'm still coping with a pretty problematic mixed state hypomania, but now that the stress has been alleviated, I feel perfectly competent to do so for the period of time it takes for the new med to start to have an effect.
I am a Clinic employee with extra insight into how to navigate the Clinic systems and protocols, I am highly educated about health care, I have long experience functioning as my own health advocate, I have excellent health insurance, I'm not embarrassed about having a psych condition, and I was manic enough to keep fighting for the care I needed. I really hope you already see what I'm getting at here.
The General Issue:
If this happened to me, under those relatively ideal circumstances, I can't imagine what other patients in similar situations must be dealing with.
Psych patients are some of the most difficult to get in for care in the first place. Depression, one of the most common diagnoses, makes it all that much harder to even reach out that one time, let along aggressively pursue anything. Patients voluntarily seeking care during a mania, like I was, are vanishingly rare. Many patients with other diagnoses are struggling with mental states that makes accessing and navigating channels to get care especially difficult.
We are also, as everyone knows, chronic illness patients and notoriously "non-compliant" (this is not a term I entirely accept, but that's a separate debate). People who have psych diagnoses but are not under current medical care for their condition are rampant in our society. Some are without care because of lack of access (cost, insurance, etc), but plenty are in a similar boat to mine -- in the middling range where situational factors make a big difference in how well we can handle our condition, and we may make the choice to handle it non-medically when we can. I'm not interested in debating the wisdom of that at the moment, this is simply a statement of fact. We exist. Likely in large numbers.
When we can identify that we are heading into territory that needs medication, and have enough clarity about that to call in and pursue care, the last thing the Clinic should want to do is turn these people away, or postpone care so long that a minor issue becomes major or potentially life-threatening. It's not humane, and it's not good management. It's also hideously wasteful and expensive.
Potential Solutions
If I missed the path I should've chosen to get the care I needed, then this path needs to be more clearly marked, and the Appointment Center, Nurse Oncall, and other departments need to be notified of the proper process as well.
If that path does not exist, we need to hire more adult psych triage nurses, and be able to guarantee an appointment with one within three business days (if someone isn't capable of waiting that long it's likely they do need to be inpatient). The current backlog is absolutely unacceptable and likely endangering lives.
I am deeply concerned about this issue, and would appreciate detailed feedback. Thank you for your time.
Sarah Young
To Whom It May Concern,
I wish to explain a specific appointment scheduling issue that happened for me as a patient, why I see this as symptomatic of a serious larger issue, and what suggestions I would make for handling this differently in the future.
In very brief, I strongly believe the Clinic needs to invest in additional Adult Psych Triage Nurses, and provide Same-Week appointment scheduling with them, at least. The two major benefits to this are avoid unnecessary expenditures for inpatient hospitalization, and preventing patients from "slipping through the cracks" in potentially disastrous ways.
My Specific Example
I am a Clinic employee with Antares insurance. I have had a diagnosis of Bipolar II for approximately 17 years now. I am fortunate that my case is only of moderate severity, and for personal reasons I have not been on mood stabilizers for about a decade now. I am also under treatment for fibromyalgia, and in order to address my fatigue issues more effectively we needed to modify my meds in a manner we knew might cause more difficulty for me with the bipolar. In working with my GP on this and asking at that appointment for a mood stabilizer, she requested that I see my psychiatrist instead, since she was less familiar with some of the questions at hand. Given some of the complexities of my case, I don't blame her for that. The last time I'd see my psychiatrist was a few years ago, but I thought she was still in town, so I was trying to find where she'd moved to schedule an appointment. I did not expect that I would need a new psychiatrist, or I would've started the search much sooner. As a result, the following happened:
My new meds worked well for about a month (they're still making a massive difference in my quality of life and ability to remain employed), during which I discovered that my psychiatrist might no longer be in practice. I was getting mixed and very confusing messages on this; she showed on the Clinic's Physician listings without mention that she's now inpatient-only, and when I called the number on her listing (http://my.clevelandclinic.org/staff_directory/staff_display.aspx?doctorid=15029), the Appointment line was utterly baffled and couldn't find her in their system anywhere. It took a number of calls to even get that much sorted, and learn she's working inpatient now and unavailable to me.
Friday around noon a concatenation of circumstances led to what I recognized as a hypomanic episode with mixed state aspects that was getting beyond my ability to control. I'm a rapid-cycler, so this happened fast. When I got to work, I had to warn my boss about my state, I was feeling so likely to get adversarial during the staff meeting. I immediately set about trying to get myself the care I needed, hoping to get an appointment scheduled before the weekend hit and the schedulers all closed.
I called my GP to see if she would prescribe a month of one of the mood stabilizers until I could get in to see someone and get that all sorted out. Per her nurse, this was a definite "no".
I called the Appointment Center to schedule one of our vaunted Same Day appointments. I could've coped with any appointment that would've gotten me in to see someone within a week or so. I learned that this is not possible in Psychiatry. In fact, the soonest it was likely I would see anyone was 4-5 weeks. The best I could do was get on a list and wait for the one(!) psychiatric intake nurse for adults to call me back and determine whether I would get the appointment I needed, and I was told it was unlikely I'd even hear from the intake nurse for a few weeks!
In attempting to work around this and avoid either ending up broke/unemployed (the possible risks of a manic episode for me), I keep calling around to every option I could think of. Over and over again, in explaining my situation (need urgent care for med adjustment, not severe enough to warrant inpatient care), I stumped the people I spoke with. To their and the Clinic's credit, almost every person I spoke with did their best to find assistance and resources for me. I was various referred to CONCERN, Nurse Oncall, back to my GP, and to the ED.
CONCERN handles only counseling issues, which are totally different than med issues. Nurse Oncall was unable to assist. My GP's nurse, on second call, reconfirmed that they would not assist me and referred me to the ED.
At this point I was so stressed that I was rapidly losing control, panicking about the idea of having no way to handle this for such an extended period of time, bursting into tears at the office and unable to work. This set off my various stress-mediated autoimmune problems (comorbid with the fibromyalgia), and by late that night I actually had blood in my urine from an interstitial cystitis flare set off BY TRYING TO GET CARE. I had to ask my partner to leave work and come get me. I had to take another half-day of my shrinking FMLA time. I had to abandon my coworkers in the middle of a downtime. Missing work is the single biggest issue we've been trying to PREVENT by being more aggressive with the fibromyalgia.
We headed for the ED, but on the way I thought I recalled that Antares requires a call-ahead about any psych-related ED visits, so I dug out my insurance card and gave them a call. Because it was after-hours by then (I'd been working steadily on this issue since 3pm that day) I was put through to the Behavioral Intake line at Lutheran. This turned out to be a godsend; although they were just as stumped as to any way to get me urgent care within current procedures, the nurse, Colleen Mayo, was able to divert me from what would've been a useless ED visit -- apparently they wouldn't have been able to prescribe me anything without admitting me. She also worked for an extended period of time researching any way to get me what I needed without us having to make a monumental waste of clinic resources and admit me to the hospital. Eventually she was able to reach a sympathetic psychiatrist, Dr. Ranjan, who was willing to add me to his schedule for the upcoming week (first thing Monday, in fact).
I have since had the appointment, have the med script for Trileptal that I needed, and have scheduled followup appointments. I'm still coping with a pretty problematic mixed state hypomania, but now that the stress has been alleviated, I feel perfectly competent to do so for the period of time it takes for the new med to start to have an effect.
I am a Clinic employee with extra insight into how to navigate the Clinic systems and protocols, I am highly educated about health care, I have long experience functioning as my own health advocate, I have excellent health insurance, I'm not embarrassed about having a psych condition, and I was manic enough to keep fighting for the care I needed. I really hope you already see what I'm getting at here.
The General Issue:
If this happened to me, under those relatively ideal circumstances, I can't imagine what other patients in similar situations must be dealing with.
Psych patients are some of the most difficult to get in for care in the first place. Depression, one of the most common diagnoses, makes it all that much harder to even reach out that one time, let along aggressively pursue anything. Patients voluntarily seeking care during a mania, like I was, are vanishingly rare. Many patients with other diagnoses are struggling with mental states that makes accessing and navigating channels to get care especially difficult.
We are also, as everyone knows, chronic illness patients and notoriously "non-compliant" (this is not a term I entirely accept, but that's a separate debate). People who have psych diagnoses but are not under current medical care for their condition are rampant in our society. Some are without care because of lack of access (cost, insurance, etc), but plenty are in a similar boat to mine -- in the middling range where situational factors make a big difference in how well we can handle our condition, and we may make the choice to handle it non-medically when we can. I'm not interested in debating the wisdom of that at the moment, this is simply a statement of fact. We exist. Likely in large numbers.
When we can identify that we are heading into territory that needs medication, and have enough clarity about that to call in and pursue care, the last thing the Clinic should want to do is turn these people away, or postpone care so long that a minor issue becomes major or potentially life-threatening. It's not humane, and it's not good management. It's also hideously wasteful and expensive.
Potential Solutions
If I missed the path I should've chosen to get the care I needed, then this path needs to be more clearly marked, and the Appointment Center, Nurse Oncall, and other departments need to be notified of the proper process as well.
If that path does not exist, we need to hire more adult psych triage nurses, and be able to guarantee an appointment with one within three business days (if someone isn't capable of waiting that long it's likely they do need to be inpatient). The current backlog is absolutely unacceptable and likely endangering lives.
I am deeply concerned about this issue, and would appreciate detailed feedback. Thank you for your time.
Sarah Young
