By Taylor Knopf
Adam, who has a history of childhood trauma and treatment-resistant depression, had never felt understood by any of his mental health providers.
“Appointments were 15 to 30 minutes tops, and I felt that I was just part of an assembly line … like one in, one out,” he said. “I felt like no one wanted to get to know me, to find out what was going on.”
All they had time for, it seemed, was to add another psychiatric drug to mask his symptoms.
“Then when I said it didn’t work or I felt worse, they ripped me off of it and then started me on a new medication,” said Adam, who is identified by first name only to protect his privacy.
Unfortunately, Adam’s experience isn’t unique. More health providers are finding themselves in medical practices that only allow for short appointments — where there isn’t time to understand the full scope of what a patient with mental health issues needs.
When the COVID-19 pandemic hit, Adam, a 48-year-old fitness trainer, lost almost all his clients. His mental health spiraled.
“I was pretty severely depressed and not sleeping and had just a ton of anxiety, and I felt like it wasn’t ever going to get better,” Adam said. “So I was getting ready to give up, and then I found Cedar Oaks. And that changed everything.”
At Cedar Oaks Clinic, a mental health practice in Wake Forest, Adam found people who he said took the time to listen and understand him.
“They’re the most kind and caring providers I’ve ever had in my entire life,” he said.
The clinicians at Cedar Oaks say they take a holistic approach to mental health care, which for Adam includes talk therapy, health coaching and Spravato, a ketamine-derived therapy for treatment-resistant depression. Under the supervision of his provider at Cedar Oaks, Adam has come off of his previous high doses of psychiatric drugs, which he believes were causing some of his previous symptoms. He said he’s never felt better.
Based on his own progress, Adam moved his teenage son’s treatment to Cedar Oaks. His son was recently diagnosed with autism, after being misdiagnosed as a child. His son had been in therapy for two years, but Adam said he hadn’t noticed a difference. Now, Adam said, he’s watched his son actually listen and practice the techniques he’s learning from his health coach at Cedar Oaks.
More than 300 patients say they feel similarly and have left positive Google reviews on Cedar Oaks’ page, praising the clinic for its compassionate and understanding staff. The clinic’s providers have specialties ranging from behavior analysis to recreational therapy to health coaching, and they take a team approach to patient care.
The clinic uses nontraditional approaches to treat patients in the community and prevent psychiatric hospitalizations. This includes six-week intensive programs for high-need patients, as well as crisis care that includes same-day appointments for current patients as needed. These services are designed to stabilize patients, keep families together and provide an alternative to emergency room visits or long inpatient stays.
With innovation comes billing challenges, which Cedar Oaks has had to navigate to sustain its model.
Stories of human connection
Cedar Oaks is the brain child of Natasha Donnelly, a psychiatric nurse with a doctorate degree in suicide prevention, who founded the clinic in 2021. After years of working in psychiatric facilities across North Carolina and in her home country of England, Donnelly said she repeatedly saw the same gaps in care. She invested her own savings to launch the clinic, determined to create a more collaborative and patient-centered environment.
Her doctoral research centered on analyzing hundreds of accounts from suicide attempt survivors, searching for the factors that led them to want to keep living.
“I reanalyzed the data when I set up the clinic to find out what was in that data set that would be needed for a clinic like this to truly listen to those voices,” she said. “The stories were that of human connection. And if one human being can make somebody feel better, what about a team of well-trained, responsible, research-led, authentic people. What could that give back?”
Connection and collaboration are the two guiding principles of Cedar Oaks’ model of care, Donnelly said. She described the approach as intentionally team-based, with staff members constantly communicating across their specialties. If she prescribes a new medication, for example, other team members interact with the patient in different settings and report back on changes they observe, from shifts in blood pressure to irritability at home or changes in social engagement at school.
“We talk together all the time,” Donnelly said. “You’re not working in a silo here.”
The clinic has grown to 30 staff members and has served roughly 3,000 patients, some of whom drive from neighboring counties. Many of the staff members worked in inpatient psychiatric settings or community behavioral health agencies before joining the clinic. They use talk therapy, medication management, psychological assessments and crisis stabilization, along with intensive six-week tracks designed for children and adults. Some staff use play and activity-based approaches with younger patients, while others make visits to children’s schools, provide parent coaching or help establish daily routines for patients.
The clinic also provides care for people with treatment-resistant depression, such as Adam, through a ketamine program. The clinic has providers who specialize in working with older adults, patients with eating disorders and substance use disorders.
“We challenge ourselves,” Donnelly said. “Just stable is not enough. Living your best life is what we want.”
Collaborative environment
A common theme throughout conversations with Cedar Oaks providers is that they feel supported and connected to one another in a way they said they’ve never experienced at other jobs.
Social worker Courtney Myrick said she often brings her work into the community, visiting schools to talk with teachers and administrators about her clients. She said she likes to walk outside with her patients or meet them at a park. What makes her experience at Cedar Oaks different from her previous job, she explained, is knowing she has a team to back her up.
For example, if she’s working with a child who has social anxiety, she said she’ll tell the team that she’s going to walk through the office and say “hi” to folks to help build the child’s confidence. Sometimes the administrative staff, some of whom are peer support specialists, will join her to play games or do exercises with patients.
“I don’t feel like a bother when I ask, because at the end of the day, we are all providers, but we all have people that we need additional help with,” Myrick said.
Psychiatric nurse Umi-Aisha Thomas said she came from a position at an inpatient facility where people were too busy to communicate and work together. “You want to collaborate with the provider, you ask questions, but they don’t have enough time to kind of sit there and talk to you,” Thomas said.
Thomas said Cedar Oaks has an “amazing ambience” and is unlike any work environment she’s been part of in the past 15 years.
“It’s not easy to bring a group of professionals together that share the same idea and collaborate and just communicate and just have respect for one another,” she said. “And I came from an inpatient setting where you don’t see it.”
Psychologist Felicia Kelly echoed that sentiment. She conducts psychological assessments and was burned out at her last job, where she said she worked in isolation.
“Now, I have a team that I can collaborate with. We can sit down and discuss the clients and what they need. It doesn’t just stop with numbers,” she said. “The energy is different. It feels different. It’s bright. Everyone smiles.”
According to staff, that sense of collaboration translates into better care for patients as well. Psychiatric nurse practitioner Shari Scott said the team-based approach helps build trust with patients, which is particularly helpful when someone comes in in distress. Because the patient has a rapport with many providers, they feel comfortable with whoever is available at that moment.
“All of these people are familiar and have been part of the journey,” she said.
Preventing hospitalizations
Unlike traditional outpatient settings, Cedar Oaks also offers same-day services for children and families in crisis, which often circumvents the need to go to a behavioral health urgent care or a hospital emergency room.
“If a child has a bad day at school, the parent just puts them in the car and can bring them to us, and then we can walk through it,” Donnelly said. Patients can wait upstairs in private rooms that have lounge chairs, aromatherapy and snacks until a provider is available.
“We can do things as much as we can in the outpatient setting,” she said. “We have very few hospitalizations. We can stabilize here.”
That flexibility has allowed the clinic to divert situations that might otherwise lead to admission at a psychiatric hospital. Donnelly recalled one patient with severe postpartum depression who spent the whole day at Cedar Oaks under close monitoring.
“I was able to prescribe some medication, and then she could sit with us for the day to make sure it stabilized, to make sure it worked, and her family could come in and out,” Donnelly said. “By the evening we reassessed, and she was able to go home.”
Cedar Oaks also offers six-week intensive programs designed for patients, children and adults, who need more than traditional outpatient care yet want to remain in their homes and communities during treatment. During these intensives, multiple providers see the patient for several hours each week, creating an individualized treatment plan for them and their family that can include therapy, school visits, parent coaching, recreational therapy, medication and health coaching.
Some families of children who have complex behavioral health needs who have considered residential inpatient facility placement have opted instead for these intensives with good results, said Madalyn Miller, a recreational therapist at Cedar Oaks who previously worked at a residential psychiatric facility.
“We’ve had young ones who are falling apart in the community, and they’ve done our six weeks, and they’re back in school and thriving,” Miller said. “And sometimes it might take two six-week intensives.”
They have intensive tracks for adult patients, as well, which can help people with substance use disorder, bipolar disorder or those adults recently diagnosed with autism who are adjusting to life with a new diagnosis.
Staff say the intensives can be a turning point for many. Some children who had been unable to attend school have returned to class and even started participating in extracurricular activities, while adults have used the structure to stabilize and rebuild daily routines.
“The most rewarding thing for us is that on their last day [of the intensive program], they have a day where they can invite family and friends in and they tell them their story, and what helps them and who they are,” Donnelly said. “And there’s a great pride in that.”
One challenge: While patients and staff find these effective, not all aspects of the intensive six-week programs are billable to insurance payers.
Challenges of funding out-of-the-box ideas
Billing traditional insurance payers for a model built on flexibility and unconventional services has been a challenge. Donnelly initially set out to serve Medicaid and Medicare populations, but she quickly ran into obstacles with Medicaid.
“We didn’t have our treatment plans in the right format for them, and it was like, ‘But look at what we’re doing and look at the outcomes,’” Donnelly said.
She contrasted that with her experience working in inpatient psychiatric facilities, where she often saw staff generate nearly identical plans for everyone. “They’re nonspecific, they’re not person-centered and they’re basically a waste of trees,” she said. “But they meet the criteria to get through it every single inspection.”
Hospitals get lots of money from the state and insurers, and they have no incentive to be innovative, Donnelly argued.
“With a model like ours, it doesn’t fit into the box,” Donnelly said. To fill the funding gap, the clinic has begun offering pro bono sessions. Staff donate their time; meanwhile, Donnelly is working to establish a foundation to support the charitable wing.
Donnelly dreams big. Her team is looking into starting a peer support cafe and volunteer program designed to give patients opportunities for connection outside of the clinic. Some of the teenage patients who have grown up participating in programs at Cedar Oaks have started a peer support group that meets for game nights and other activities.
As Donnelly looks for ways to fund all these non-billable programs, there is one legislative change that could save the clinic tens of thousands of dollars a year. Cedar Oaks has many nurse practitioners — nurses with advanced training — who must have an expensive collaborative agreement with an overseeing physician.
Due to a North Carolina law passed in the 1970s, advanced practice nurses running their own practices must pay a physician for “supervision” that boils down to a quarterly signature in many cases. The supervising physician doesn’t need to approve any treatment decisions or medications. The physician doesn’t need to be in the same building, the same city or even the same county as the advanced practice nurses.
Donnelly said the clinic pays $1,000 per month for each advanced practice nurse to an off-site, overseeing physician. However, staff members say they get more out of collaborating with their colleagues in the building than they do through these agreements.
For years, state lawmakers have considered a bill dubbed the SAVE Act that would eliminate the need for advanced practice nurses to pay for these collaborative agreements. While the bill is introduced with strong bipartisan support year after year, it has yet to become law.
If the SAVE Act were to pass, Donnelly said the clinic could use the money to support its innovative programming and provide more pro bono care to patients.
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