Role of the Psychiatric Mental
Health Nurse Practitioner in the
Future of Health Care
Kathleen R Delaney, PhD, PMH-NP
Rush College of Nursing
Thank You!
Change is coming in health care
Climate for change: High spending/ poor
outcomes
Federal government reports set the stage
Affordable Care Act is the lightening rod
Becomes the language everyone is
speaking:
Access
Prevention
Cost-effectiveness.
Pressures on mental health care have
never been greater
Over the last couple of years, 2.2 billion dollars has
been taken out of the Mental Health system.
Lutterman
The squeeze is coming in two directions:
Cuts in the face of increased demand
Major areas of Change in MH Care
• Managed care will become ubiquitous in Medicaid
programs in order to improve quality and to contain costs.
Self directed type management via performance adjusted
care and capitation
• Integration of care will become ubiquitous in Medicaid
programs, and social services will likely be included.
Integration of services should be paid for through carve out
funding in order to protect behavioral health services.
• Disease prevention and health promotion programs will
become ubiquitous in Medicaid programs to save
downstream costs, and these services will be provided to
enrolled persons who do not have a current disease
condition, as well as to those who do.
• Manderscheid, 2012
A good hockey player skates to
where the puck is, a great
hockey player plays where the
puck is going to be.
Wayne Gretzky
Pivotal Moment for PMH Nursing To
Establish their Role In Emerging Models
Guild reason: 350,000 Behavioral Health
Specialists looking to find a place
Moral reason: Have the educational
preparation of make these systems
effective, equitable and responsive
Premise: Armed with an understanding the
reform playing field, where change is
occurring- we can effectively deliver core
messages about our practice
Emphasizing why PMH nursing skills fit with
emerging models in MH care
Knowing
Direction of
Health Care
Reform:
Integrated care
Who is pushing the agenda and what is their power?
Why is it here to stay?
Find an area driving cost?
IDENTIFY A Population
Identify some Key Process driving costs
Find Potential Savings: Cost off set data
Making outpatient mental health care available
can offset the cost of expensive inpatient care
Between 1989 and 1992, the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS) expanded its yearly outpatient psychiatric
care expenditures from $81 million to $103 million which resulted in a net
savings of $200 million because of greatly reduced psychiatric hospitalization.
Patients with mental illness are heavy users of medical services
A recent six-year analysis of the Hawaii Medicaid population demonstrated
patients seeking mental health treatment during the study period a
accumulated physical health care costs 250% higher than those patients
not seeking mental health intervention.
Mental Health Burden on Emergency Departments
Between 1992 and 2001:
While the annual number of overall ED visits increased by 20%,
the number of mental health-related visits increased by 40%.
Total visits due to mental illness increased by 28%, from 49 to 63 per 1000 visits
by 40%.
Locate Indicators of Success: Exemplars
Exemplars: MARRY MESSAGE WITH DATA
Quality Improvement via Health Information Technology
Patricia Dennehey, DNP, FNP, RN
Volume: In 2010 GHS served 3,202 unduplicated clients
(UDC) for 17,112 visits (UDS) (40% primary diagnosis
mental /behavioral health visit).
Services Provided: Four integrated modalities: Primary
Care; Mental Health: mental health evaluation and
counseling, therapy and medication management, substance
abuse group visits; Complementary Care: acupuncture,
chiropractic, and HIV/AIDS: HIV risk reduction counseling,
testing and linkages (CTL).
Two Indicators that demonstrated improvement in 2010:
Immunization rates from 7% of clients to 27%
Hemoglobin A1c improvements N=194 patients ,
Average A1c = 7.7 (down from 8.0 in June)
In 2010 Glide was funded through
HRSA Bureau of Health
Professionals (BHP) Division of
Nursing as one of ten funded
NMHCs nationally and a second
grant to open a Wellness Center at
GHS. In 2008 HRSA BHP Division
of Nursing awarded GHS for
“Expansion of GHS NMHC
“(D11HPO9564) for five years (2.7
M). The total of HRSA BHP
funding for the past three years is
5.7 M !
Build an Incentive Structure:
The federal government pays FQHCs for the cost of care they provide to
Medicare and Medicaid patients, turns out to be the actual cost of care
so it is a higher rate. (not a fixed rate price)
Deliver Core Message
about our practice
Fit of our skills with the
emerging issue
Message: Our educational preparation and
core capabilities fit with the integration of
health care and medical care
•
•
•
•
•
•
Medical
Psychiatry
Relationship
Neuroscience
Psychotherapy
Prevention
Message: Why PMH NPs Fit with
Integrated Care
• The broad base of sciences they operate from creates an innate integrated science base
• Creates critical competencies for integrated care
•
Capable of monitoring the Axis III conditions, thus
manage an integrated treatment plan
•
Understand medical follow up instructions
•
Understand how medical and behavioral issues
create intensity of need/intensity of services
•
Address health issues with understanding of how
SMI brings with it behaviors that impact how issues
addressed, i.e. poor sleep, poor eating.
Capable of driving a
treatment culture of
Person-Centered Care
Patient-centered care
Health care that establishes a partnership among practitioners, patients,
and their families (when appropriate) to ensure that decisions respect
patients’ wants, needs, and preferences and that patients have the education
and support they need to make decisions and participate in their own care
IOM
TRIPLE AIM
Improving the experience of care,
Improving the health of populations,
Reducing per capita costs of health care
Mental Health Care: Patient centered
care is interwoven with recovery
Recovery process and methods not so developed for inpatient care
Recovery is the common language of Mental Health Care
Hope is both triggers and sustains recovery
Four key attributes of patient-centered care
"Whole-person" care
Coordination and communication
Patient support and empowerment
Ready access
Bechtel, 2011
Recovery and Patient-Centered Care are
familiar to PMH Nurses : Take a twist
Holistic
Strength-Based
Respect
Hope
Built on continuous healing
relationships.
Provided in a healing
environment of comfort,
peace, and support.
Patient safety is a visible
priority.
A prerequisite of any environment which aims to
nurture hope is the cultivation of compassion
Spandler and Stickley, 2011
Compassion not so much a trait….
In providing Safety,
Care
Support
Encouragement
Affection-
We create a compassion context
Vision: MH system that provides compassionate
contexts so clinicians Educate -Encourage- Empower
Anthony, 2006
Bring the best and latest research to mental
health consumers: never ending flow of
information
Many Consumers have found the fire they
need to see hope –via relationship and
attitude we provide constant
encouragement
Consumers can then use this information to
make their own decisions- empower
The issue will be how can we kindle these
elements by establishing the contexts
necessary for education, encouragement
and empowerment
The first characteristic of professional nursing is
the focus on the patient. ..
The exclusive focus on the patient is to get to
know the patient’s view of self and the
predicament- the way it looks to the patient- so
that the patient can see it too.
Peplau
We have particular skills at creating
presence and resonance
•
With affect mirroring the nurse
matches the patients affect
•
Via eye contact and non verbal
language the nurse connects to the
affective level of presentation
•
Via gaze and mannerisms the PMHNP and patient also share intent
•
These processes set up collaborative
communication ; the fine tuning of
responses where eye contact, facial
expressions and gestures are in sync,
allowing both the infant and parent
to “feel felt” by the other
I am here available, listening
Message: we shape opportunities for Attunement
Each moment with a
patient is an
opportunity for
attunement,
mirroring,
mentalizing- pay
attention on
purpose to the
patients state of
mind
Patient Centered-Care : Appreciating how stories
weave into a Patient’s narrative
Our interpersonal processes also
centers on how nurses empower
people by helping them tell their story:
“exploring and developing the
meanings and values the person
attaches to or associates with his or her
experience”
Phil Barker
Two Emerging Elements bring a new language to the
Interpersonal Process
Patient Centered Care
Interpersonal Neuroscience
And bring us back to Peplau
Other half of the argument:
PMH-APNs are well equipped to shape
compassionate environments necessary for
patient centered care
• Know the patient and how to access narratives
of illness, meanings and what is important
• Know how to navigate between every day
needs and the broader picture of treatment
• Know how to instill the therapeutic optimism
requisite for recovery
• Understand how stigma operates
PMH-NPs : Envision yourself as a
disruptive influence on health care
landscape
• Build effective integrative care models
• Becoming a specialist in prevention and
journeying with individuals to seek health
• Partner with inpatient nurses to build
innovative transition models
• Bring DNP students into your practice to build
the data systems that will work for you- to
demonstrate your work and build evidence for
integration “done right.”
What’s Tomorrow?
• Nurse Navigators, PMH emergency room
specialists- that are not necessarily APNs
• Care Coordination Roles
• Bringing mental health expertise to
communities so they might build mental
health
• Disruptive innovations that deliver greater
access to care at reduced cost
• Outcomes focused on the patient experience
Evidence to support effective integrated care
Does integrated care address systemic barriers to SMI population achieving health and
wellness
Do some models support better integration of services and information
Are Health Care providers’ attitudes and behaviors around stigma reduced
Are the consequences of life style and medication side effects on health
effectively addressed
What are effective mechanisms for addressing these systemic issues
Co-location of physical and mental health services
Use of case managers or other staff to undertake a co-ordination or liaison role
between services.
Programs aimed at reducing the stigma of mental illness.
-How to respectfully consider the cognitive deficits and consequences of SMI
healthcare skills training to people with SMI
peer supporters.
-How to develop population health and health promotion approaches targeted at SMI
-How to deal with issues of social inclusion
Brown et al, 2010
Summary
Pivotal moment in health care:
Learn to read policy landscape
Integrated Care
Clear about our Message
• What is needed in these systems of care
• Message embraces our fundamentals
•Articulate the fit of your skills and service system