Health Nurses in Integrated Care

The Effective Use of Psychiatric Mental

Health Nurses in Integrated Care: Policy Implications for Increasing Quality and Access to Care

Kathleen R. Delaney, PhD, PMHNP, FAAN

Madeline A. Naegle, PhD, CNS-PMH, BC, FAAN

Nancy M. Valentine, RN, PhD, MPH, FAAN, FNAP

Deborah Antai-Otong, MS, APRN, PMHCNS-BC, FAAN

Carla J. Groh, PhD, PMHNP-BC, FAAN Laurah Brennaman, PhD, RN, CEN

Abstract

In the last ten years primary care providers have been encouraged to implement integrated models of care where individualsmedical and mental health needs are addressed holistically. Many integrated models use Psychiatric Mental Health (PMH) nurses as case managers and select exemplars use PMH Advanced Practice Nurses (APNs) as providers. However, the potential value of PMH nurses in integrated health care remains unrealized by health care planners and payers, limiting access to services for the populations most in need of comprehensive care approaches. This current situation is partially fueled by insufficient knowledge of the roles and skill sets of PMH nurses. In this paper, the PMH RN and APN skill sets are detailed, demonstrating how effective use of these nurses can further the aims of integrated care models. Finally, outlined are

Address correspondence to Kathleen R. Delaney, PhD, PMHNP, FAAN, Rush College of Nursing, 600 S Paulina St, Chicago, IL 60612, USA. Email: [email protected]

Madeline A. Naegle, PhD, CNS-PMH, BC, FAAN, Substance Related Disorders Sequence, PAHO/WHO Collaborating Center for Geriatric Nursing Education, New York University College of Nursing, New York City, NY, USA. Email: [email protected]

Nancy M. Valentine, RN, PhD, MPH, FAAN, FNAP, Practice, Policy and Partnerships, Institute for Healthcare Innovation (MC 802), UIC College of Nursing, Chicago, IL, USA. Email: [email protected]

Deborah Antai-Otong, MS, APRN, PMHCNS-BC, FAAN, Department of Veterans Affairs, Washington, DC, USA. Email: [email protected]

Carla J. Groh, PhD, PMHNP-BC, FAAN, College of Health Professions, McAuley Health Center Womens and Gender

Studies, University of Detroit Mercy, Detroit, MI, USA. Email: [email protected]

Laurah Brennaman, PhD, RN, CEN, Nurse Educator, SEED Global Health, Peace Corps, Kampala, Uganda.

Journal of Behavioral Health Services & Research, 2017. 300309. c) 2017 National Council for Behavioral Health. DOI

10.1007/s11414-017-9555-x

barriers and enabling factors to effective use of PMH RNs and APNs and attendant policy implications.

SAMSHA defines integrated care as the systematic coordination of general and behavioral health care.1 This service model involves integration of mental health, substance use and primary care services into various clinical, structural, and financial arrangement with an emphasis on a patient-centered approach and population health.2 Evidence supports the potential of integrated care to mitigate the tremendous unmet need for mental health services and address the medical comorbities and wellness issues of persons with serious mental illness.3 Given their broad-based education in medicine and behavioral health, psychiatric mental health (PMH) nurses are a natural fit for integrated services particularly models ground in care management and a wellness approach.4

PMH nursescapabilities in integrated care environments, however, seem to have little visibility to federal mental health agencies. This remains despite years of effort by nurse leaders and professional organizations to document basic nurse and advanced practice nursing clinician roles alongside those of psychiatrists, psychologists, psychiatric social workers, and family counselors.5 In many federal behavioral workforce reports, PMH registered nurses (RNs) and advanced practice nurses (APNs) receive little mention.6 Psychiatric nurses may be referenced briefly but are then categorically excluded in final recommendations for the development of the national behavioral health workforce.7 Behavioral workforce reports that do include nurses often fail to differentiate between the skill sets of the RNs and APNs,8 yet the difference is critical. PMH RNs are educated at the associate or bachelor level and practice under a scope of practice that allows them to assess, address, and care manage behavioral health issues. PMH APRNs are nurses educated at the masters or doctoral level whose scope of practice allows them to provide psychotherapy, as well as

diagnose, manage, prescribe for, and treat mental health problems.9

PMH RNs and APNs are significant professional talent pools with potential for robust contributions to evolving integrated models of care.10 Almost one third of US citizens live in areas underserved by mental healthcare providers.11 The quality and accessibility of patient care for underserved populations could be improved with better utilization of these providers.12 A clear explanation of the skill sets of RNs and APNs and their effective utilization in integrated care settings sets the stage for the exploration of the issues surrounding the use of these professionals in healthcare planning. Lastly, policy recommendations are suggested that are designed to promote the effective use of PMH RNs and APNs in integrated care.

How PMH RNs Can Be Used Effectively in Integrated Care

The broad-based education PMH RNs receive confers a unique clinical skill set for assessing, managing, and evaluating behavioral issues and the medical co-morbidities frequently developed by individuals with psychiatric disorders.1315 A keen sense of significant indicators and knowledge of pertinent questions inform RNssurveillance of physical and psychiatric conditions. An exemplar is the observationof symptoms suggesting nephrotoxicity secondary to Lithium therapy. In this instance, to even ask the essential assessment questions, the provider must understand the physiology of the renal system and the potential adverse reactions to medications. As noted in a study of RN work in community teams, the purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision-making16) marks the nurseswork. This clinical reasoning process is a skill specific to the nursing role developed in clinical mentorship and reflective teaching methods.17

PMH nurses understand that working with individuals with mental health issues and physical comorbidities demands approaches that weigh the bidirectional contributions of each of these issues.18 Psychotropic medications, while contributing to positive outcomes, also contribute to obesity, insulin sensitivity, diabetes, and increase risk factors for cardiovascular disease.19 Behaviors associated with serious mental illness (i.e., poor sleep, poor eating) create additional impacts on physical conditions. Health promotion, therefore, becomes a complex endeavor that requires nursesknowledge of medical conditions, the pathophysiology of these illnesses, and how behavioral issues confound the physical situation.

RN training in assessment, treatment, and evaluation is transportable to a variety of settings. Applying these skills in multiple settings supports the care continuum, meeting specific healthcare needs relevant across inpatient, outpatient, and home-based care. By knowing illness in various stages of acuity nurses can assist in assessing the interactions of medical and behavioral conditions across the care spectrum.20 RNs also have skills to recognize different intensities of need which can then be matched with the appropriate intensity of services.21

A final element of the PMH RN training critical for integrated care is the disciplinary foundation of the nurse-client relationship.22 Relationship building is important for behavioral health care where client engagement can be a significant problem.23 PMH RNsskills in promoting a relationship, including the capacity to be present and appreciate the patients concerns, create a common understanding of individuals self-defined illnesses and their views of health and recovery.24 An integrated care system puts all of these RN skills to use.

PMH RNs are active in several models of integrated care, but at this point, there are only isolated reports of how they function within these roles and how their skill sets are utilized. One study detailed how PMH nursing skills (assessment, physical health monitoring, pharmacology, and disease management) were critical to integration of a medical focus into traditional assertive community treatment (ACT).25 The literature on integrated care, particularly collaborative care models, describes PMH RNs as functioning as care coordinators in the treatment of complex comorbid medical and psychiatric conditions.26,27 The next step is detailing these roles and an increased focus on their outcomes.28

How PMH APNs Are Used Effectively in Integrated Care

Advanced practice PMH nurses are educated at the graduate level (masters or doctoral) and credentialed to deliver the full range of mental health services from screening, assessment, diagnosis, treatment, and partnering for recovery.5 This broad scope of practice encompasses the diagnosis and management of serious mental illness (SMI), including pharmacotherapy and psychotherapy, monitoring co-existing medical conditions, and screening for emerging physical problems.9 This skill set is foundational to integrated care models for complex populations29 and undergirds best practices to underserved populations.30,31

Drawing on preceptored field experiences, PMH-APNs are also valuable in wellness initiatives incorporating a holistic perspective in their health promotion efforts.32 Recognizing that selfmanagement, the hallmark of many wellness programs, is difficult for individuals with SMI,33,34 PMH nurse researchers have demonstrated that increasing a clients self-efficacy and empowerment is key to acceptable and feasible self-management plans.35

The transportability of PMH APN skills to various settings and modalities increases their utility. One such area is Telemental health (TMH), a model that offers cost-effective, coordinated, and integrated mental health service to individuals in remote and rural settings.36 The Department of Veterans Affairs Health Administration (VA) established TMH and documented more than 500,000 encounters with individuals in remote settings (20062010), services which reduced hospitalizations by coordinating and integrating mental health and primary care services.37,38 In this study, PMH APNs or psychiatrists provided the individual psychotherapy within medication management.37

With the growth of integration of behavioral health and primary care services, PMH APNs developed and established exemplar practices in these models.39,40 These clinical models were mainly nurse-led faculty practices in colleges of nursing developed to educate students and deliver services to underserved populations.30 Intermountain Health is an example of a large, managed care network in which PMH APNs have been leaders in designing patient-centered cultures of care and effective stepped-care models.4143 In these models, PMH APNs demonstrate the organizational and systems knowledge to promote innovation in service model design, particularly for vulnerable populations.44

Workforce Utilization Trends That Enable PMH and PMH APNs to Expand

Roles in Integrated Care

Size of the RN workforce

The RN workforce is approximately 3.1 million; it is estimated that currently 4% of nurses work in behavioral health.45,46 RNs, therefore, are the largest provider group that can be tapped for integrated care delivery. Because nurses work in all settings where health care is delivered, e.g., hospitals, schools, and outpatient clinics, opportunities for RNs roles in integrated care are potentially limitless.

Adopting the expanded RN role

Primary care is taking the lead in creative ways to expand nursesroles. A significant national healthcare trend in registered nurse roles has added functions such as case management, care transition, assessment, and triage.4749 Experts suggest that in collaborative care, integrated models can also expand the role of the PMH RN care coordinator to take oversight of prevention, followup, and coordination with primary care nurses.50 Care coordination by PMH RNs in communitybased care settings has resulted in better recognition of medical conditions, reduced costs, and improved quality of life.51,52 These early positive outcomes and use of nurse-managed protocols should lend additional support to an expanded RN role, particularly when translating evidencebased practices to routine care.53

Greater use of team-based models of care

Structuring care around interdisciplinary/interprofessional teams is an important element of integrated care models.54 Meta-analyses of collaborative care models support improved patient outcomes with team-based care, and the use of care managers to provide self-management

support.55,56 Selected states are delineating RN care coordination functions and the APN role as a direct provider in Medicaid Health Homes, a model of care designed for individuals with complex health/behavioral health needs.57,58 Data supporting the effectiveness of team-based care models should facilitate greater use of PMH RNs and APNs in integrated care3 and in sites that have the potential for behavioral health integration, e.g., long term care, student health services, and critical care.5961 As integrated services are developed to deliver care along the life span, there will be a growing need for providers licensed to deliver the full range of mental health services, including prescribing.62

Population health

A population health focus demands that a healthcare organization be accountable for the health outcomes of the defined patient groups within populations it serves.63,64 In line with a population health focus, in one proposed primary care re-organization, the team is intentionally constructed with skill sets matched to health needs of care complexity in patient subgroups.65 Large healthcare systems such as Geisinger have embraced this idea and are effectively using RNs and APNs in population health efforts.66 Prioritizing community and individual well-being demands providers such as nurses who are skilled in systems of care and methods that address issues related to social determinants of health.67

Expertise in evidence-based screening

When screening for alcohol and drug use, nurses have demonstrated their use of Screening, Brief Intervention, Referral, and Treatment (SBIRT) in a variety of setting.68,69 Training in SBIRT now extends from nursing curricula to continuing education and institution-based training.70,71 A national effort to educate nurses on SBIRT is now underway and should produce a workforce uniquely prepared to use evidence-based screening for epidemic national substance use problems.

The importance of relationship-based solutions to reduced attrition

A complex mix of perceived need for treatment and barriers which limit access to services results in premature withdrawal from mental health care.72 Attrition from mental health services is high, estimated as a 50% failure to return for treatment or adhere to treatment recommendations delivered within specialty mental health services.73 Treatment engagement strategies are better understood, 74 but effective approaches specific to individuals with SMI have been slow to emerge.75 Nurses have the interpersonal skills to enact what consumers value, i.e., clinicians who convey a sense of respect, acknowledge that what consumers say matters and that embrace a

partnership model designed to reach solutions.76,77

Challenges to Effective Use of PMH RNs and APNs in Integrated Care

Confusion about nursing roles

While PMH RNscare coordination role is frequently referenced in the literature,78,79 RN activities are poorly delineated and not linked to the value and positive outcomes generated. While the literature suggests that the PMH RN community role involves care coordination, complex

relationship building, medication management, and purposeful surveillance,16,80 the lack of detail about RN role activities in integrated care hampers wider and systematic use of nurses.

A few isolated state reports depict generalist APNs,81 and there are even few depictions of the PMH APN community workforce, their scope of practice, and outcomes of their care.82 While the skill set of PMH APNs is clearly defined in scope of practice and national competencies,9,83 few articles describe the competencies as applied in practice.31,84 Although the value of APNs in primary care is increasingly acknowledged by healthcare leaders,8587 there is scant literature describing roles and activities of the PMH APN.88

Assessing the size of the PMH APN workforce

Research on the mental health workforce continues to depict the PMH NP workforce as small and declining in numbers,89,90 despite data indicating the reverse. Factoring in upcoming retirements, the recent trend of approximately 1200 PMH NPs passing the national certification exam each year benchmarks the specialty to be on target to reach year 2025 estimates of 17,900 PMH NPs in the workforce.91 Another point of confusion between reporting agencies is about the size of the PMH NP workforce; estimates range from 9000 to 19,000.92 When the size of the workforce is based on PMH certified APNs, the current total number is 14,780 PMH APNs. This includes 5826 masters prepared PMH nurses with clinical specialist certification (adult and child combined) and an additional 8954 masters prepared nurses with PMH NP certification (adult and lifespan).93 While the PMH APN workforce is small compared to the others groups in the core mental health professions (e.g., psychology (104,480 psychologists), social work (110,010 social workers), and marriage and family therapists (29,060 therapists)92, by 2025, PMH APNS will approach the size of the psychiatrist workforce.62 Together psychiatrists and PMH APNs will likely be the two groups providing psychiatric consultation in integrated models, particularly around treatment of individuals with complex presentations and pharmacotherapy.

Policy Implications for Strengthening the PMH RN and APN Role

Several policy implications if adequately addressed should facilitate effective use of PMHRNs and APNs in integrated care.

Support research on RN and APN roles in effective integrated care teams In order to bring to scale the wide variety of integrated models in the literature, more data on effective and efficient staffing models are needed.86 As team-based models of care proliferate, PMH RN and APN roles and contributions to overall value and quality must be clear.28,54 The Centers for Medicare and Medicaid Services should support cost-analysis studies with a focus on staffing models, outcomes of specific integration approaches for particular populations, and the effectiveness of stepped models of care that attempt to match risk levels with appropriate interventions.43 Data from such research will inform the future design and scale of integrated care models that include multiple mental health provider professionals.

Collect data on state level network adequacy of mental health providers Much of the study of the adequacy and effectiveness of the behavioral healthcare workforce is occurring at the state level. State studies clarify where the greatest shortage areas exist and possible targeted solutions to address identified needs.94,95 To understand the need for psychiatric providers, state healthcare workforce centers, state boards of nursing, and state Medicaid offices should support workforce studies, and evaluate service demand and network adequacy of mental health providers and services. State oversight should also include monitoring insurance panels to assure that they do not exclude any single provider group as primary mental healthcare providers.96

Eliminate billing policy that contributes to the invisibility of PMH RNs and PMH APNs Considering the importance of care management, state Medicaid agencies, Medicare intermediaries, and commercial insurance payers should implement codes that allow for billing of these services. Care management services that are bundled into managed care reimbursements fail to recognize and track specific ambulatory RN care skills and their outcomes.97 Current billing regulations permit billing for services delivered largely by the APN with a sign off by an MD to be billed under the physician identifier, so-called incident tobilling. The Centers for Medicare and Medicaid Services should eliminate the practice of incident to billing because it generates unnecessary costs and prevents APNs billing under their own National Provider Identifier.

Advocate for all nurses to practice to the full extent of their license In 2014, the Federal Trade Commission advocated for limiting physician oversight of APNs.98 Granting independent authority to PMH APNS has the potential to address the shortage of psychiatrists (particularly in rural regions of the country) and to assure care for disadvantaged populations.31,99 Currently, 22 states and the District of Columbia allow APNs to practice independently of physicians. All states should adhere to the gold standard for APN practice of independent practice and licensure. Consistent state rules around scope of practice issues would facilitate a greater understanding of the PMH APN roles particularly in with insurers and would contribute to building service networks for rural and underserved populations.

Implications for Behavioral Health

Each of the core mental health professions has a unique set of competencies they bring to integrated care.100 However, PMH APNs fill a critical gap in the workforce needed to provide the full scope of mental health service including prescribing,91,95 particularly for individuals in rural areas or who rely on federal insurance for psychiatry services, an insurance which may not be accepted in fee for service psychiatry.101 There is also a need for PMH RNs who have the skill set to provide essential care management for individuals with complex health conditions3 and create care environments that build service engagement and reduce attrition. The effective use of nurses holds great promise for the successful expansion of team-based integrated care and greater provision of services to those in need of mental health care.

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