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Source Published and unpublished inventory data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Source Published and unpublished inventory data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
9
Distribution of Claims by Diagnosis and Provider
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.