Crisis in the Mental Health Care Workforce Are Advanced Practice Nurses Part of the Solution?

1
Crisis in the Mental Health Care Workforce Are
Advanced Practice Nurses Part of the Solution?

• Nancy P. Hanrahan, PhD, RN, CS
• Assistant Professor
• Center for Health Outcomes and Policy Research
• University of Pennsylvania School of Nursing

2
Objectives

• Trends Mental Health System
• System Frayed and ineffective for SMI
• Workforce Inadequate
• Are APNs a Solution?

3
Comparing Inpatient and Outpatient Trends
Percent Change from Previous Year 1976-2000
INPATIENT n2,329-2,478
OUTPATIENT n1,151-2,068
Source Published and unpublished inventory data
from the Survey and Analysis Branch, Division of
State and Community Systems
Development, Center for Mental Health Services
4
Mental Health WorkforceTrends 1972-1998
Source Published and unpublished inventory data
from the Survey and Analysis Branch, Division of
State and Community Systems Development, Center
for Mental Health Services
5
Need a Workforce Competent in Medical And
Psychiatric Care for Quality Outcomes

• Individuals with Serious Mental Illness
• Only a third with SMI receive treatment
• High incidence of physical comorbidities that are
  overlooked by CMHCs.
• Inadequate follow-up
• Higher mortality rates

6
SERIOUS MENTAL ILLNESS S/ HIV A SERIOUS PUBLIC
HEALTH PROBLEM

• HIV Positive
• .9
• 2.8
• 4.6
• 3.7

• Group
• General Population
• Schizophrenia
• Affective Disorder
• Serious Mental Illness (SMI)

7
Older Adult Utilization of Mental Health
Services5 National Sample gt65 yearsN185,403
Data Source Medpar File, Outpatient File,
Carrier File

• 9 (185,403) mental disorder diagnosis
• 47 had more than one mental disorder diagnosis
• 83 had more than one major medical problem (CVD,
  Diabetes)
• 7 (709,606) mental disorders
• 93 (14.9 mil) medical problems

• 2,055,561 individuals
• 15.7 million claims

8
Distribution of Claims for Medicare Beneficiaries
with a Mental Disorder Diagnosis
Cardiovascular Disease 2,862,989 18.45
Musculoskeletal Disease 1,530,155 9.9
Respiratory Disease 1,420,997 9.2
Endocrine Diseases 1,264,058 8.2
Neurological Disease 1,118,685 7.2
Neoplasms 1,023,404 6.6
Genitourinary system 973,966 6.3
Digestive System Disease 724,793 4.7
Mental Disorders 717,609 4.6
Integument Disease 375,452 2.4
Infectious Diseases 181,919 1.2
Other Medical Diagnoses 3,320,049 21.4
Total Claims 15,514,076 100
9
Distribution of Claims by Diagnosis and Provider
  PCP APN Psych MD Psych Phd SW
Affective D/O 21 35 56 47 53
Anxiety D/O 12 7 5 9 10
Dementia 25 31 14 8 6
Organic Brain Syndrome 16 8 2 3 1
Psychotic D/O 15 12 17 7 6
Sub. Related 5 1 1 1 1
Other 6 6 4 25 23
10
Are APNs a Solution to Rural Mental Health
Workforce Shortages?

• N8642 Certified APNs
• Purpose
• Examine the rural and urban distribution of
  certified APPNs and determine the potential for
  APPNs to be a solution to the rural mental health
  workforce shortage.
• Survey of 50 states
• Scope of practice, state regulation (Rx
  authority) and curriculum for psychiatric mental
  health nursing programs
• Findings
• APNs have a higher distribution per population in
  the rural areas than psychiatrists (13 vs.6.6)
• 20 states have at least 20 rural APN practice
• Despite low numbers of APNs, training and scope
  of practice fit an urgent need in rural areas

11
APNS WHAT WE KNOW

• EDUCATION Masters degree and PhD
• N16,606 CNS/NP Psychiatric Specialty (8,654
  cert)
• N88,000 Nurse Practitioner, Primary Care
  Specialty
• Scope of practice Integration of
  bio-psycho-social
• Expertise Surveillance (comorbidity,
  medication/SE)
• SETTINGS Institution, Community, and Home
• Trends
• Rate of growth will be the same for psychiatrists
  by 2010 with 300 new nurses per year
• Restricted scope of practice, lack of reciprocity
• Education Changes Psychiatric Nurse Practitioner
• Prescriptive Authority
• Nurse Practitioners 50 States
• Clinical Nurse Specialists 34 States

12
Major Trends In The Mental Health Workforce

• Fewer trained professionals with an increase in
  the use of MHW
• How does the substitution affect outcomes,
  access, and quality?
• What is the evidence that a particular competency
  level is associated with better outcomes?
• Poor workforce data
• Reimbursement incentives drive the type of
  provider and the intervention

13
Recommendations

• Any meaningful reform of mental health care
  delivery will have to overcome current barriers
  to effective utilization of providers
• These barriers serve no useful purpose and in
  fact contribute to our health care problems by
  preventing the full deployment of competent and
  cost-effective providers who can meet the needs
  of a substantial number of consumers.
• Practice acts should ensure that they are based
  wholly on competency
• Fund interdisciplinary training
• Revise payment and practice laws to allow all
  demonstrably competent providers to diagnose,
  treat, and prescribe on their own licenses.