10/28/14 HRSA FUNDED OBJECTIVES PSYCHIATRIC NURSE PRACTITIONERS IN NORTH CAROLINA: INTERPROFESSIONAL EDUCATION, PRACTICE, AND INTEGRATION OF CARE

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1 PSYCHIATRIC NURSE PRACTITIONERS IN NORTH CAROLINA: INTERPROFESSIONAL EDUCATION, PRACTICE, AND INTEGRATION OF CARE Victoria Soltis-Jarrett, PhD, PMHCNS/NP-BC Professor & Coordinator of the PMNNP Program UNC-Chapel Hill School of Nursing HRSA FUNDED Health Resources and Services Administration Advanced Nursing Education Grant Number D09HP25939 Public Health Service Act, Title VIII, Section 811 Public Health Service Act, Title VIII, Section 811(a)(1), (42 U.S.C. 296j(a)(1)), as amended by section 5308 of the Affordable Care Act of 2010, Public Law OBJECTIVES At the end of this presentation, participants will be able to: Define the role of a Psychiatric-Mental Health Nurse Practitioner (PMHNP) Describe how PMHNPs are educated and trained to be co-located in Primary Care, Acute Care and Extended Care Settings Identify models of implementing integrated health in NC Define how PMHNPs will be transforming & advocating for the care of individuals/families who present to non-specialty (mental health) settings 1

2 WHAT IS A PMHNP? New role since 2000 Prior to this new role: Psychiatric-Mental Health Clinical Nurse Specialists were across the USA (since 1950 s) PMHNP was created to meet the unique needs of individuals with mental health problems, psychiatric illnesses and communities lacking access to mental health services Graduate degree required Board Certification required (new law in June 2015 in NC)* THE ROLE DESCRIPTION A PMHNP provides: Comprehensive psychiatric evaluations & assessments across the lifespan Implements a variety of interventions including: Medication evaluations & prescribing of medications; Individual, group/family psychotherapy; Screening for medical problems & illnesses Consultations for individuals, families and communities for health promotion; Consultations for schools, nursing homes, home care Mental health education PMHNP WORK IN TEAMS WITH OTHERS Psychiatrists & other physicians Community agencies that support individuals & families Colleagues in social work, psychology Colleagues in nursing Colleagues in pharmacy, PT, RT, OT 2

3 PMHNP ARE NURSES Registered nurses who obtained a bachelor s degree in nursing Practiced as a health care professional Educated holistically (body/mind/spirit) Further education (GRADUATE) and complete: Master of Science in Nursing; Doctor of Nursing Practice and/or Doctor of Philosophy PMHNP ARE VERSATILE Acute care Chronic or extended care Community or Primary care Nontraditional care* MEETING THE NEEDS* Nurses in NC rural communities UNC- Chapel Hill SON PMHNPs who work in community mental health centers PMHNPs who are embedded in the Primary Care, Extended Care or Acute Care area 3

4 WHO ARE THE PMHNP IN NC? Psych NP-NC (2005-present) at UNC-CH School of Nursing has graduated over 100 NEW PMHNPs in NC (N=115) Focus (2005-present) has been on the specialty clinics (increasing access to mental health services) in rural and remote regions of NC Robust & Sustainable Program that will continue to serve NC New project: Psych NP-NC IEPIC will embed PMHNPs in Primary, Acute and Long term care settings across NC WHY DO WE NEED THE PMHNP IN PC? Barriers to mental health care Multiple barriers have interfered with meeting the mental health needs in North Carolina The most striking barriers The lack of psychiatrists across NC (and decreasing across the US) The lack of specialty psychiatric-mental health clinicians who can provide integrated behavioral health care in PRIMARY and ACUTE care clinics and LONG TERM care settings Roughly, one-third of the state s 100 counties do not have any psychiatrists. Of those counties lacking mental health care, 33% are without general (adult) psychiatrists and 75% do not have enough child psychiatrists. MENTAL HEALTH & PRIMARY CARE 70% of individuals who present to Primary Care (PC) in NC, present with a mental health problem Frequently does not get screened, assessed or treated Why? Stigma, fear & ignorance Lack of clinicians educated in the specialty area of psychiatric-mental health Lack of trust on the part of the community 4

5 OBJECTIVES OF PROJECT Objective 1: Recruit, enroll and retain 20 MSN or Post-MSN students per year from rural and remote counties in NC, of which a minimum of 50% come from minority/ disadvantaged backgrounds (MDB), and/or reside in medically underserved areas (MDB/MUA); of which a minimum of 25% (5) have a commitment to providing integrated behavioral health in primary and extended care (PC/ EC) settings in NC.(BHPr Goals 1-3, SAMHSA/HRSA, 2007). OBJECTIVES OF PROJECT Objective 2: Develop and implement a sustainable, integrated, interprofessional (IP) education curriculum for all students in the PMH-NP program that will enable students to practice on IP teams that provide integrated behavioral health for individuals/families who suffer from multiple chronic conditions (MCC) in primary and extended care (PC/EC) settings (IECPE, 2011). OBJECTIVES OF PROJECT Objective 3 Develop and implement a model interprofessional clinical preceptorship, in collaboration with the UNC School of Medicine Department of Psychiatry (UNC-SOM-Psych), which PMH-NP students will work within IP teams to apply behavioral health integration (BHI) skills and psychiatric-mental health treatment to individuals/families with multiple chronic conditions (MCC) that will be applied to rural family medicine and specialty clinics, county health departments, and/or assisted living/nursing homes upon graduation. 5

6 OBJECTIVES OF PROJECT Objective 4 Develop preceptorships in community clinical practice sites for PMH-NP students in primary/extended care (PC/EC) settings in the rural & remote areas of NC through partnerships with the NCORH and CCNC EDUCATION, TRAINING & PRACTICE Broad Overview of Psych NP-NC IEPIC INTEGRATED BEHAVIORAL HEALTH CARE In the broadest use of the term, integrated behavioral health care can describe any situation in which behavioral health and medical providers work together. 6

7 OVERALL: BENEFITS OF INTEGRATING CARE Offers a promising, viable, and efficient way of ensuring that people have access to needed mental health services Minimizes stigma and discrimination, while increasing opportunities to improve overall health outcomes INTEGRATED CARE VS COLLABORATIVE CARE In collaborative care, patients perceive that they are getting a separate service from a specialist, albeit one who collaborates closely with their health care provider. In integrated models, behavioral health care is part of the primary care and patients perceive it as a routine part of their health care. WORKING WITH ACUTE, PRIMARY & EXTENDED CARE AREAS EC PC Acute/ ED 7

8 COLLABORATIVE PARTIAL INTEGRATION FULLY INTEGRATED STEP 1: CHOOSE YOUR MODEL GOAL is to Develop & Implement The Model of Best Practice MODELS Coordinated Integrated Models Co-located Reverse colocation EXAMPLES OF INTEGRATED CARE: COMMON THEMES Medical home or health care home Health care team Stepped care Four quadrant clinical integration 8

9 THEME #1: MEDICAL HOME Synonymous with caring for and case managing the chronically ill* The medical home concept is also one of the centerpieces in the current national health care reform efforts Criteria developed for medical homes THEME #2: HEALTH CARE TEAM The doctor-patient relationship is replaced with the health care teampatient relationship Members of the health care team share responsibility for a patient s care, and the message to the patient is that the team is responsible. A visit is arranged with various members of the team: physician, nurse practitioner or physician s assistant, nurse, care coordinator, behavioral health consultant, and other health professionals. VISIT IS SCHEDULED WITH EACH NP or Physician BH Patient Case Manager Pharmacist 9

10 THEME #3: STEPPED CARE Causes the least disruption in the person s life; Is the least extensive needed for positive results; Is the least intensive needed for positive results; Is the least expensive needed for positive results; and Is the least expensive in terms of staff training required to provide effective service SERIES OF RELATIONSHIPS: FOCUSED ON PATIENT- CENTERED QUALITY HEALTH OUTCOMES Greater Community Individuals served Billing and coding Providers Front desk/ Greetings Phone/ Appoint ments IDENTIFYING ROLES & DUTIES EXAMPLE Front desk Triaging/Making appointments Screening tools Weight, BP, BMI Goal=to have as much info as possible BEFORE the patient gets to the health care team providers 10

11 THEME #4: FOUR QUADRANT CLINICAL INTEGRATION The final concept is referred to as four quadrant clinical integration, which identifies populations to be served in primary care versus specialty behavioral health. The Four Quadrant Clinical Integration Model was developed by the National Council for Community Behavioral Healthcare. QUADRANT I Patients in Quadrant I have low behavioral health needs and low physical needs and are typically served in primary care BH Needs Physical Needs QUADRANT II Quadrant II patients have high behavioral health needs and low physical needs and are typically served in specialty behavioral health programs with linkages to primary care. BH Needs Physical Needs 11

12 QUADRANT III Quadrant III have low behavioral health needs and high physical needs, and they are served in primary care or in the medical specialty system BH Needs Physical Needs QUADRANT IV Quadrant IV patients have both high behavioral health needs and high physical needs. These patients are typically served in both specialty behavioral health settings and primary care, with a strong need for collaboration between the two. BH Needs Physical Needs STAGGERING STATS 70% of patients seen in primary care present with complaints that are directly related to a mental health problem. 85% of primary care patients report recurring or chronic depression and/or anxiety. Safety net care systems play a large role in serving individuals who are at higher risk for behavioral, mental, and other health conditions and for those who develop chronic conditions. 12

13 CHARACTERISTICS OF QUADRANT IV Lower medication adherence Higher incidence of co-occurring chronic medical conditions e.g. Metabolic syndrome, Cancer High incidence of co-occurring alcohol and drug abuse problems Lack of a stable medical home More complex medical plans IT TAKES A VILLAGE Health policy Workforce Coordination of effort Coding and billing Education and training of workforce Decreasing turf wars Educating the public Breaking down barriers QUESTIONS? Thank you! vsoltis@ .unc.edu 13