Table 2.

Consequences for patients due to institutional and administrative barriers to accessing mental health specialists

	Lack of Access to Mental Health Specialists	Lack of Coordination of Care with Mental Health Specialists
Potentially compromised care	“We don’t have access to a private psychiatrist here so a lot of times we just play the psychiatrist. We don’t have it here so we deal with it ourselves” (1055) “I’m like ‘oh wow, you want to see a specialist? Next appointment 6 months? Well I guess we’re working together for a while here until we get this taken care of or worked through’ and if I had more time it would be beneficial” (1012) “You end up acting like a poor man’s psychiatrist many times in a situation where you recognize you probably don’t have enough training to do optimally what would be in the best interest of the patient. But at least temporarily until you can make some contacts and get things rolling sometimes you end up having to temporize in that way.” (1013)	“We have no control over who they see. I never get any feedback in terms of when patients are seen—I mean I don’t want all the details but in terms of medications or suggestions.” (1016) “There was a patient who I saw who I was concerned about one of the psych medications they were on. I called the psychiatrist because I didn’t want to stop the medication without his approval and I got a phone call back a month later after multiple calls.” (1020) “They’ve stopped us from being able to refer to psychiatry. We used to be able to say ‘I really want you to see someone who would be able to help, I’m going to write a referral.’ Now it’s like everybody’s a carve- out. Somebody else now has to decide… (1012)
Delayed care	“It’s very hard to get psychiatric help for elderly patients, it’s virtually almost impossible… we have a number of psychiatrists that just take cash on the barrel. They don’t want to take Medicare rates, they don’t want to take HMO rates.… The psychiatrists—there are not that many of them-- they charge full freight, and don’t want to take Medicare and plus I just don’t think they deal with elderly demented patients enough…the elderly I don’t think are a real interest.” (1017) “Psychiatrists are more of a problem. There aren’t enough of them, many of them are either committed within some program that they’re working for; they’re very restricted in terms of the insurances they take. For instance, I see MediCal patients, there’s no way for me to directly refer a MediCal patient to a psychiatrist even if I think they have an acute need.” (1073)	“I don’t feel extremely qualified to make a complicated psychiatric diagnosis and sometimes I would like that hand holding and guidance and it’s very tough to get (1073).” “It would be more helpful to have better backup on some of these patients that are difficult. I think doctors are loathe to declare somebody incompetent, but for their own safety sometimes you just got to do it. Some times it would be nice to have somebody agree to look over things, it’s not there, psychiatric backup isn’t there (1017).”