Slide 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
Slide 2
Objectives
 Trends:
 System:
Mental Health System
Frayed and ineffective for SMI
 Workforce:
 Are APNs
Inadequate
a Solution?
Slide 3
Comparing Inpatient and Outpatient Trends
Percent Change from Previous Year 1976-2000
1976 1978 1986 1990 1992 1994 1998 2000
1976 1978 1986 1990 1992 1994 1998 2000
400%
80%
60%
40%
Staffing
Expenditures
Episodes of Care
300%
200%
20%
100%
0%
0%
-20%
INPATIENT n=2,329-2,478
-40%
-100%
OUTPATIENT n=1,151-2,068
Source: Published and unpublished inventory data from the Survey and Analysis Branch, Division of State and
Community Systems Development, Center for Mental Health Services
Slide 4
Mental Health Workforce
Trends 1972-1998
MHW
MSW/LCPC
RN
Psych-MD
Psych-PhD
250000
200000
150000
100000
50000
0
1972
1976
1978
1986
1990
1992
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Source: Published and unpublished inventory data from the Survey and Analysis Branch,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
Slide 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
Slide 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)
Slide 7
Older Adult Utilization of Mental Health Services
5% National Sample >65 years
N=185,403
Data Source: Medpar File, Outpatient File, Carrier File
2,055,561 individuals
15.7 million claims

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

Slide 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 %
717,609
4.6 %
Integument Disease
375,452
2.4 %
Infectious Diseases
181,919
1.2 %
3,320,049
21.4 %
15,514,076
100 %
Mental Disorders
Other Medical Diagnoses
Total Claims
Slide 9
Distribution of Claims by
Diagnosis and Provider
PCP
APN
Affective D/O
21%
Anxiety D/O
12%
Dementia
25%
Organic Brain
Syndrome
Psychotic D/O
16%
Psych Psych SW
MD
Phd
35%
56%
47% 53%
7%
5%
9% 10%
31%
14%
8%
6%
8%
2%
3%
1%
15%
12%
17%
Sub. Related
5%
1%
1%
Other
6%
6%
4%
7%
6%
1%
1%
25% 23%
Slide 10
Are APNs a Solution to Rural Mental Health
Workforce Shortages?
N=8642 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
Slide 11
APNS WHAT WE KNOW

EDUCATION: Masters degree and PhD
–
–
–
–


N=16,606 CNS/NP Psychiatric Specialty (8,654 cert)
N=88,000 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
Slide 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
Slide 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.