Therapy Safety Net Outcome Evaluation

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TherapySafetyNetFour-year outcome evaluation

of a free referral service for

uninsured New Yorkers

Geoffrey Steinberg, Psy.D., Executive Director

September 2011

© 2011 TherapySafetyNet

www.TherapySafetyNet.org

Facebook.com/TherapySafetyNet



TherapySafetyNet: Four-Year Outcome Evaluation 1

TherapySafetyNet:

Four-Year Outcome Evaluation

of a Free Referral Service for Uninsured New Yorkers

Geoffrey Steinberg, Psy.D., Executive DirectorSeptember 2011

Introduction

An estimated 2.5 million New Yorkers do not have employer-sponsored healthinsurance (New York State Department of Health, 2009), yet do not qualify forpublicly funded programs such as Medicare or Medicaid. Approximately 1.2million of these uninsured people live in New York City. The uninsured includetemporary workers, part-time workers, unemployed or self-employed individuals,and workers whose employers choose not to provide health insurance coverage.

TherapySafetyNet is a free referral service that aims to bridge this gap in mentalhealth care for uninsured New Yorkers. Since its inception in September 2007,TherapySafetyNet has developed into a coalition of psychologists and social

workers in private practice, each of whom agrees to work with a limited numberof uninsured clients at reduced fees according to a sliding scale.

TherapySafetyNet offers private practitioners an organized way to fulfill theethical aspiration to devote some portion of one’s professional work for minimalcompensation. Over the past four years, 52 clinicians have participated asprofessional members of TherapySafetyNet. Our current membership consists of

12 clinicians, four of whom serve as Referral Coordinators on a weekly rotation.Each of our professional members is licensed by the state of New York and iscommitted to social responsibility, including caring for those who lack insurancecoverage for mental health. TherapySafetyNet is neither a mental health clinicnor a group practice. Each participating clinician maintains full autonomy overhis or her private practice while agreeing to basic terms of membership,including agreeing to work with at least one eligible client at the lowest point of the sliding scale. Participating clinicians agree to maintain the reduced fee aslong as the client remains uninsured.

As a coalition of clinicians in private practice united by a common interest inhelping an under-served population, TherapySafetyNet operates by way of the volunteer efforts of its participating clinicians. An estimated 1,000 volunteerhours have been contributed thus far to TherapySafetyNet’s operations,including web design, public relations, and referral coordination activities. Thecosts of TherapySafetyNet’s operations are covered by annual dues payments by participating clinicians.




Demographics of Prospective Clients

Prospective Clients

Since its inception in 2007, TherapySafetyNet has recorded 300 uniqueoutcomes from prospective clients who have requested our services.

To request a referral from TherapySafetyNet, prospective clients are nowrequired to complete a secure application form on our website,

www.TherapySafetyNet.org. In the first four years, 307 requests for services havebeen recorded on the current application form, as well as four requests recordedon an earlier version of the application. Some of these requests were duplicatesfrom the same individual, which accounts for the fact that the absolute numberof records in our set of applications is higher than the number of outcomes

recorded.Prior to formalizing the application process, prospective clients were offered thechoice of completing the online application form or sending an email toTherapySafetyNet to request a referral. Demographics of those clients whoinquired by email are not available; however, the outcomes of email inquiries areincluded in this analysis.

An unknown number of prospective clients referred themselves directly toparticipating therapists who accepted them into their practices underTherapySafetyNet’s auspices. Participating therapists provided us with

information about the outcomes of only eight such direct referrals, but it ispossible that more occurred for which outcome data was never reported. In theinterest of developing a more consistent application process and obtaining moreaccurate measurements of our service, we removed contact information fromtherapist profiles on our website so that all requests for services must now bemade through the secure application form.

Demographic information as reported here is based on a subset of 224completed responses to the current application form.

When completing the application form, prospective clients agreed that theprotected health information they choose to provide about themselves may bereviewed by any of the mental health professionals who participate inTherapySafetyNet.




Age

Requests for reduced fee services have come from a relatively young population.A full 86 percent of inquiries were from people under the age of 40, and 53percent were from people under the age of 30, as shown in Figure 1.

Figure 1. Age distribution.

This distribution may be reflective of a disproportionate number of youngpeople lacking health insurance, as well as the fact that TherapySafetyNet is an

online service. Given the fact that Medicare eligibility begins at age 65, it is notsurprising that not a single request has come from prospective clients age 65 orolder.




Gender

A gender difference was observed among completed applications. Prospectiveclients were 70 percent female and 30 percent male, as shown in Figure 2.

Figure 2. Gender distribution.

This disparity in the gender of prospective clients may be reflective in part of thefact that our membership consists mostly of female clinicians. We would like toincrease the representation of male clinicians, as some men may have a

preference for working with a male therapist.




Residency

The vast majority (97.4%) of prospective clients were New York state residents,showing that in most cases TherapySafetyNet is reaching the population weintend to serve, as shown in Figure 3.

Figure 3. New York state residency status.

When responding to the handful of prospective clients residing in states otherthan New York, Referral Coordinators encouraged them to find comparableresources in their home states.




Insurance Status

While TherapySafetyNet’s mission is to provide psychotherapy referrals foruninsured people, approximately 16 percent of inquiries came from prospectiveclients who do have health insurance, as shown in Figure 4.

Figure 4. Insurance status.

Prospective clients with insurance were not eligible for reduced fee servicesthrough TherapySafetyNet. Referral Coordinators either offered insured

individuals assistance in accessing their benefits or referred them to aparticipating clinician who was in-network for their insurance policy.




Presenting Concerns

To match prospective uninsured clients to the specialties of participatingclinicians, applicants were asked both to write a narrative description of theirconcerns and to make a selection from a list of 46 problems. Prospective clients

were free to check as many items from the list as they felt applied to them. Fourconcerns were most frequently endorsed: relationship issues (58.1%), anxiety disorders/phobias (49.2%), stress management (46.4%), and depression (45.3%).The top fifteen concerns are shown in Figure 5.

Figure 5. Self-reported concerns.

This list of concerns is identical to that from which participating clinicians may indicate their top specialties, thus allowing Referral Coordinators to matchprospective clients’ presenting problems with participating therapists’ areas of expertise.




Referral Sources

Making our services known to the vast population of uninsured New Yorkers hasbeen one of our greatest challenges. When asked how they heard aboutTherapySafetyNet, 68 percent of prospective clients stated they foundTherapySafetyNet by way of an Internet search, as shown in Figure 6.

Figure 6. Referral sources.

When a prospective client found TherapySafetyNet by way of an Internet search,this was usually the result of paid keyword advertising. Professional membershipdues have paid for over $1,500 in advertising costs. Our public relations effortsare aimed at reducing these costs by increasing free forms of online visibility as

well as word-of-mouth referrals. Thus far, only 32 percent of applicants reportedthat they heard about TherapySafetyNet through referral sources other thanInternet searches, including referrals from professionals, recommendations fromfriends, and links from other websites.




Outcomes of Prospective Client Inquiries

The outcome data reported here are based on 300 applications that prospectiveclients submitted to TherapySafetyNet between September 2007 and August2011. These applications included email inquiries, direct referrals, andprospective clients' responses to both old and new versions of the client inquiry application.

Eligibility Screening

Referral Coordinators determined each prospective client’s eligibility for areduced-fee referral to a participating TherapySafetyNet clinician on the basis of the following criteria:

1. The application was complete.

2. The prospective client was a New York state resident.

3. The prospective client reported that he or she did not have healthinsurance, or if they were insured, their health plan was one of thefew that are allowed by law to exclude mental health benefits, suchas Healthy NY and specific Group Health Incorporated (GHI) plans.

4. The fee that the prospective client reported they could afford persession was equal to or greater than the lowest fee on our slidingscale.

In February 2011, two additional criteria were introduced:

5.

Self-reported gross income was less than $60,000 per year.6. The prospective client was willing to provide proof of income in the

form of their most recent tax return.

With the introduction of these two additional criteria, we initially askedprospective clients to provide proof of income prior to their first meeting withthe therapist to whom they were referred. Very few prospective clients were

willing to provide us financial documentation sight unseen. Therefore, in June2011 we made a further modification to the referral process such that the income

verification step was included in the initial consultation with the therapist to whom the client was referred.




Eligible Prospective Clients

On the basis of the eligibility criteria listed above, 115 (38.7%) prospective clients were determined to be eligible for our services, as shown in Figure 7.

Figure 7. Eligibility for reduced fee referrals: Was this prospective client eligiblefor a reduced fee referral to a TherapySafetyNet clinician?

Of the 115 prospective clients determined to be eligible, 103 (89.6%) werereferred to a participating TherapySafetyNet therapist for reduced feepsychotherapy, as shown in Figure 8.

The majority (71.4%) of prospective clients expressed no preference for aparticular therapist among our membership. In such cases, the ReferralCoordinator issued an email to all members with a brief description of the client,

with identifying information removed. If multiple therapists expressed aninterest in accepting the referral, the Referral Coordinator assigned a therapistfrom among those responding whom they believed would be the best match.




In the minority of cases (28.6%) in which a prospective client expressed apreference for a specific therapist, the Referral Coordinator contacted therequested therapist, and if he or she agreed to accept the referral, then the client

was assigned to that therapist. If the requested therapist did not accept the

referral, the Referral Coordinator contacted all participating therapists toattempt to find another match.

Figure 8. Outcomes of eligible prospective clients: Was this eligible, uninsuredclient referred to a participating TherapySafetyNet therapist?

The remaining 12 prospective clients, while technically eligible, were notreferred to one of our participating therapists for a variety of reasons, including

lack of fit between the client’s presenting problems and therapists’ areas of expertise, scheduling incompatibility, and other factors that preventedcompletion of the referral process. For example, some clients only wanted to beseen by a psychiatrist, and no psychiatrists are included among our participatingclinicians. In such situations, Referral Coordinators offered the prospectiveclient other referral options tailored to their needs.




Ineligible Prospective Clients

As a free referral service, TherapySafetyNet has assisted many prospective clients with securing local mental health services, whether the ultimate disposition wasa referral to one of our participating clinicians or a referral to outside community mental health services. In response to each application for services, weattempted to find the best possible outcome while also ensuring that ourmembership was receiving referrals appropriate to their practices.

As shown earlier in Figure 7, 182 prospective clients (61.3%) were not eligible fora reduced-fee referral to a participating TherapySafetyNet clinician. A variety of factors may disqualify a prospective client, including incomplete applications,having health insurance, not being a New York resident, having too high anincome, or not being able to afford the lowest fee on the sliding scale. Outcomesof ineligible inquiries are presented in Figure 9.

Figure 9. Outcomes of prospective clients not eligible for TherapySafetyNet.




Insured Prospective Clients

Although TherapySafetyNet is designed to assist uninsured clients, 60 inquiries were received from prospective clients who reported that they do have healthinsurance. We have encountered many people who have health insurancecoverage but are unaware that psychotherapy is covered by their policy. In theseinstances, the Referral Coordinator responded by offering information abouthow to access their mental health benefits. Of the insured prospective clients

who completed the application, 40 were offered assistance in how to access theirbenefits. Another 15 were referred to participating TherapySafetyNet clinicians

who happened to be participating providers with the prospective client’sinsurance policy. In these situations, the prospective client was not eligible forreduced fee services, but was offered the option of working with one of ourparticipating clinicians according to the terms of their insurance policy,including any applicable deductibles and co-payments. Remaining insured

prospective clients did not complete the application, and thus it was not possibleto respond to their inquiries.

Uninsured Prospective Clients Referred to Community Resources

Among 78 of the applications received, the prospective client reported that themost they felt they could afford per session was less than the lowest fee on oursliding scale. In such instances, the Referral Coordinator attempted to ascertain

whether the prospective client could afford a bit more. If so, the referral processcontinued. However, in the vast majority of cases, the prospective client eitherdid not respond to our question or responded by affirming that they were unable

to afford the lowest fee on the sliding scale. We therefore offered theseprospective clients a list of other low-fee mental health services in thecommunity.

TherapySafetyNet is focused on serving uninsured New Yorkers. As shownearlier in Figure 3, some applications were from prospective clients living inother states. In 10 instances of out-of-state applications, the Referral Coordinatorsuggested the prospective client search for comparable resources in their homestate.

Starting in February 2011, TherapySafetyNet began requiring that prospectiveclients demonstrate financial need for our services. Since that time, 18prospective clients were determined ineligible because they were unwilling toprovide proof of income to determine their eligibility. An additional sevenindividuals self-reported income that was too high to be eligible for our slidingscale, and thus conceivably could afford full-fee services even though they werenot insured.




Remaining instances of ineligible prospective clients involved incompleteapplications, many of which included no valid contact information, such that it

was impossible for Referral Coordinators to ask for additional information todetermine eligibility.

Discussion

Outreach

Considering that an estimated 1.2 million uninsured people are living in New York City, 300 completed applications in four years suggests TherapySafetyNet isreaching only a small fraction of the population we intend to serve. One of ourbiggest challenges has been to make our referral service more widely known. Tothis end, we have conducted outreach to other organizations that may encounteruninsured New Yorkers, such as the National Alliance on Mental Illness (NAMI).Other outreach efforts include our Internet presence, which includes listings

with organizations that serve local artists, such as The Field, Dance Elephant,and the Stage Directors and Choreographers Society. TherapySafetyNet’sFacebook page (Facebook.com/therapysafetynet) receives anywhere from 25 to 50

visitors per week, and we have recently added a feature that allows prospectiveclients to complete an application for services directly on Facebook. Beyondthese efforts to make our referral service known, our need to increase our public

visibility remains strong.

Professional Membership

TherapySafetyNet has experienced considerable turnover among our coalitionmembers. In the beginning, some participating therapists seemed not tounderstand fully how TherapySafetyNet differs from other websites that presentdirectories of therapists in private practice. For some time, we faced differencesin expectations—some therapists were willing to reduce their fees slightly, butnot far enough to meet the actual needs of uninsured people. By now, we haveaddressed this discrepancy through introduction of the sliding scale as well asmore rigorous membership requirements, including a face-to-face interview toinsure that clinicians joining our coalition understand the scope of our mission.

Further Study

This report has focused on the outcomes of applications for services thatTherapySafetyNet has received. Only recently has our evaluation processexpanded to include following up with participating therapists to determine whathappened after the referral was made. From a small sample of 30 referrals, 80percent of clients referred to a participating clinician attended the initial




consultation. We will continue to track these outcomes over a larger sample of referrals in the coming year.

Conclusions

Over four years, 15 to 20 prospective clients contacted TherapySafetyNet eachmonth for help securing a referral for affordable therapy. About one-third of these applicants were determined to be eligible for our services and werereferred to a participating clinician for psychotherapy at a reduced fee. Theremaining two-thirds were referred out. Those prospective clients who wereineligible because they had health insurance were educated as to how to accesstheir benefits, while those who were ineligible and uninsured were referred toother low-cost mental health resources in the community.

Since its inception, TherapySafetyNet has served a valuable role in metropolitanNew York by assisting prospective clients in finding mental health services they

can afford. Of the 300 outcomes recorded since 2007, we have referred 103uninsured clients to participating psychologists and social workers in privatepractice at significantly reduced fees, thus connecting uninsured New Yorkers

with psychotherapy of a quality that would otherwise be inaccessible andunaffordable.

TherapySafetyNet’s team of Referral Coordinators has provided an additionalservice to the community by serving as a clearinghouse of resources andeducation for prospective clients seeking mental health services. These outcomeshave included referring 58 uninsured people to other mental health services inthe community and assisting 55 insured people with accessing their insurancebenefits for psychotherapy. These findings point to the need to make criteria forTherapySafetyNet eligibility more transparent on our website. Additionally, we

will be posting listings of other community mental health resources for theuninsured and information about how insured people may access their benefitsfor mental health.

TherapySafetyNet will continue our mission of connecting uninsured New Yorkers with socially responsible therapists. We eagerly await changes to thehealthcare system that may ultimately render our services obsolete once every New Yorker has the insurance coverage required to address their mental health

needs.

Reference

New York State Department of Health (2009). Uninsured New Yorkers Urged to Sign up for Health Insurance During 'Cover the Uninsured Week.' PressRelease.

Therapy Safety Net Outcome Evaluation

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