Slide 1
Slide 2
Objectives
Crisis in the
Mental Health Care
Workforce
„ Trends: Mental Health System
Are Advanced Practice Nurses
„ System:
Frayed and ineffective for SMI
Part of the Solution?
„ Workforce: Inadequate
Nancy P. Hanrahan, PhD, RN, CS
Assistant Professor
Center for Health Outcomes and Policy Research
University of Pennsylvania School of Nursing
Slide 3
„ Are APNs a
Slide 4
Mental Health Workforce
Trends 19721972-1998
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
80%
60%
40%
Staffing
Expenditures
Episodes of Care
250000
300%
200000
200%
150000
MSW/LCPC
RN
Psych-MD
Psych-PhD
100000
100%
0%
50000
0%
-20%
INPATIENT n=2,329n=2,329-2,478
-40%
MHW
400%
20%
Solution?
-100%
0
OUTPATIENT n=1,151n=1,151-2,068
1972
Slide 5
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Source: Published and unpublished inventory data from the Survey and Analysis Branch,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
Source: Published and unpublished inventory data from the Survey and Analysis Branch, Division of State and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 6
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 followfollow-up
– Higher mortality rates
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)
1
Slide 7
Slide 8
Older Adult Utilization of Mental Health Services
5% National Sample >65 years
N=185,403
Distribution of Claims for Medicare Beneficiaries
with a Mental Disorder Diagnosis
Cardiovascular Disease
2,862,989
18.45 %
Data Source: Medpar File, Outpatient File, Carrier File
Musculoskeletal Disease
1,530,155
9.9 %
2,055,561 individuals
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 %
„
„
„
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
Mental Disorders
Other Medical Diagnoses
Total Claims
Slide 9
Slide 10
Are APNs a Solution to Rural Mental Health
Workforce Shortages?
Distribution of Claims by
Diagnosis and Provider
PCP
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%
2%
8%
3%
1%
15%
12%
17%
Sub. Related
5%
1%
1%
Other
6%
6%
4%
Affective D/O
21%
N=8642 Certified APNs
APN
7%
„
– Examine the rural and urban distribution of certified APPNs and determine
the potential for APPNs to be a solution to the rural mental health
health
workforce shortage.
„
Findings:
– APNs have a higher distribution per population in the rural areas
areas
than psychiatrists (13% vs.6.6%)
– 20 states have at least 20% rural APN practice
1%
1%
25% 23%
– Despite low numbers of APNs, training and scope of practice fit an
urgent need in rural areas
Slide 12
APNS WHAT WE KNOW
„
Survey of 50 states:
• Scope of practice, state regulation (Rx authority) and curriculum
curriculum for psychiatric
mental health nursing programs
„
6%
Slide 11
Purpose:
Major Trends In The Mental
Health Workforce
EDUCATION:
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 biobio-psychopsycho-social
Expertise: Surveillance (comorbidity, medication/SE)
„
SETTINGS:
SETTINGS: Institution, Community, and Home
„
Trends
„ 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
– Rate of growth will be the same for psychiatrists by 2010 with 300
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
and the intervention
2
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 costcost-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.
3