ABSTRACTBackground: This is a case study of an advanced practice nurse (APN) practice response to2003 Medicare D-associated payer changes.Description: Case study of changes in population/services after implementation ofMedicare D policy considerationsStudy design: Case study with data at 3 time points and analyzed using descriptive statis-tics/central measures of tendency/dispersionResults: Largest changes found to affect public sector recipients/practice solvencyConclusions: Unintended consequences of healthcare policy change affect APN prac-tice/health of vulnerable populations. Recommendations for entrepreneur APNs includesupportive policy in addition to business preparation, education, and tools that generate safestrategies for alternate income streams during policy/payer changes.

Keywords: APN, APN entrepreneur, behavioral health, Medicaid waiver, Medicare, Medicare D,private practice, reimbursement strategies, TennCare

© 2010 American College of Nurse Practitioners

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Kathleen McCoy, Michael Carter, Patricia D. Cunningham, Patricia M. Speck, and Cynthia Rector

Effects of Medicare Changes on aBehavioral Health APN Practice

Private practices run by psychiatric mental health(PMH) advanced practice nurses (APNs) havebecome more accepted in Tennessee, increasing

from 0 to 3 in 2003 in the Upper Cumberland Region,effectively changing the local options for mental healthcare. Traditionally, the area had been served by a commu-nity mental health center and a handful of psychiatrists,with a clear need for more providers. New practicesopened by APNs availed the citizens of Tennessee toreceive the services of APNs as established by law anddefined within the Nurse Practice Act, with prescriptiveauthority since 1996.1

The dynamics of establishing a practice and the day-to-day operations are similar to those of other professions,although APN practices have distinct differences. NewAPN practices are relatively novel in concept as well aslow numbers, compared to physician (psychiatrist), socialwork, and psychologist practice counterparts, and there-fore have fewer established support resources to drawupon. Challenges often rise from payer differences, lack ofparity between professions providing the same or similarservices, and methods to generate funds to establish andcontinue a practice, all of which are highly influenced bypolicy. PMH APNs can provide psychodynamic servicesand medication management, services that are often eitherinadequate or unavailable in rural communities.

This case study documents the experiences of a sin-gle APN behavioral health practice faced with navigat-ing policy and payer changeswhile meeting the needs ofpatients and preserving thefinancial solvency of the prac-tice during sweeping, political-ly generated payer changes andtheir unintended consequences

The practice/study site waslocated in rural Tennesseewithin a poverty zip code. Thepractice was a non-grant-fund-ed, single provider offeringAPN services including psychodynamic therapy andmedication management. Primary care and specialtyproviders referred to the practice. The practice used tradi-tional paper charts, billing created paper and electronicclaims, and income came from fees for services.

Historically, Tennessee implemented steps to reformMedicaid in 1994 with a program known as TennCare.

TennCare was a demonstration project from the 1965Medicaid program and continues as a jointly fundedcooperative between federal and state governments, help-ing states provide healthcare to eligible persons.2

TennCare was designed to enroll traditional Medicaid-eligible clients and expanded to include working poorand people who were ineligible for other private insur-ance because of pre-existing illnesses.3 The program washighly successful in enrollment but soon saturated avail-able funding and was restructured.2 Effective April 29,2005, massive cuts to TennCare rolled back eligibility tothe initial 1994 requirements (Donaldson, personal com-munication, September 6, 2009).4,5

Concurrently, in 2005, the Medicare PrescriptionDrug, Improvement and Modernization Act of 2003compelled adjustment of individual state Medicaid andMedicaid waivers to comply with Medicare-D expan-sion, which included prescription benefits.6 Thesechanges affected healthcare delivery before, during, andafter the changeover period, which was betweenJanuary 1 and April 30, 2006. Tennessee was in a uniqueposition because, since 1994, the Title XI MedicaidWaiver of 19947 expanded eligibility exponentiallythrough incremental waivers for inclusion. A complexcascade of changes in reimbursement streams occurredas payers tried to sort interconnected medicine andservice coverage. This change was coupled with theBureau of TennCare providing inconsistent communica-

tion about eligibility status,8

leading to a groundswell ofpublic uncertainty.

Public doubt about eligi-bility led to increasing work-loads in healthcare provideroffices, massive increases inmissed appointments, nonad-herence, attrition from prac-tices, and ultimately, for some,psychiatric distress.Additionally, during the

Medicare-D start up and the TennCare enrollmentchanges between April 29 and December 31, 2005,most dual-covered patients were denied medicationcoverage.9 TennCare, Medicare, and other third-partypayers were the dominant players in the practice payermix. The practice attempted to assimilate Buppert’smodel of APN practice solvency, which urged a bal-

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Current reimbursementpolicies do not offer

clinicians incentives at anylevel to meet psychiatric

care needs in rural settings.

ance of income streams by balancing the mix ofpayers.10 Despite the balance of multiple payers, theestablished streams were upset by new policies andinterconnectedness of payers that resulted in incomeshrinkage, requiring modifications in practice delivery.Thus, the case study practice, which received 224 payerpanels, had challenges with consistent reimbursement.11

During this time of program change, innovative stepsto cover the medication needs of patients were takenby the APN practice.

OBJECTIVESThe objectives of this case study were to chronicle theresponse of a PMH APN-owned practice to policy-gener-ated changes that impact com-plex and enmeshed reimburse-ment streams while accommo-dating patient needs. The practicepayer review covers 14 monthsand includes baseline data beforethe 2005 TennCare changes andat 2 other points and follows thedynamic transition to re-stabiliza-tion with Medicare-D in place.The case study isolates uniquepatient needs during payerchanges and specific APN-prac-tice challenges, while specifyingessential skills sets generic to PMH APN private- practicemanagement over and above clinical skill. These essentialabilities include specific business skills, political navigation,and process acumen, which may not be included in aca-demic preparation.

LITERATURE REVIEWHistoricalNumerous studies support expansion of PMH care bothas a specialty and integrated into primary care, includingThe Milbank Quarterly12 and the National Conference forCommunity Behavioral Healthcare.13 The support gainedmomentum with former Surgeon General Satcher’s14

vision and mission to improve public responsibility fornational mental health. In the 1990s the AnnapolisCoalition purposed to define provider preparation bydetermining generic skills needed by all mental healthproviders15 and an action plan in which to operationalizethe workforce.16 The New Freedom Commission

Report17 promoted the vision further with a blueprint totransform the entire behavioral healthcare delivery systemas endorsed in commentary by Hoge et al.16 and Druss etal.18 Whitcomb19 urged acceptance of APN providers inall settings as a means to meet the national crisis of unmetand growing healthcare needs. Widespread fragmentedcare and inadequate reimbursement in community behav-ioral healthcare delivery are described in a review of liter-ature13 that outlines delivery and payment problems ofthe current payment structure.

APNs are subject to federal and state laws and thirdparty payer policy(s), which vary in all 50 states. Com -plicating the momentum for inclusive behavioral healthcare, APNs are typically included but at lower reimburse-

ment rates for the same or simi-lar physician services.10

Kaiser Family Foundationhas tracked declining fees formental health; historically payerissues emerge as salient enoughto block even the best efforts tocoordinate care.20 The recentMedicare-D restructuring ofmedication payers has shifted theburden a bit, causing adjust-ments in state funding for thesame services as shown in theshifts of declining coverage for

the working uninsured during that time.4 The quality ofbehavioral health has reduced, as evidenced by the NationalAlliance for the Mentally Ill (NAMI) State Report Cards,which show that there has been continued overall reduc-tion of PMH services since 2006.

In 2006, Tennessee held an overall grade C and hasregressed to a current overall grade of D21 in the assess-ment. The Mental Health Parity Act will help private-pay recipients, but it has little current effect on public-sector recipients with the exception of settingprecedent.22 Despite an overabundant supply of patientsneeding services, few private psychiatric practices areaccepting public-sector patients. Archaic Centers forMedicare and Medicaid Services (CMS)23 and ruralPMH payer strategies continue to sanction rural PMHprovider claims, resulting in a 50% reduction of feesreimbursed. These current reimbursement policies do notoffer clinicians incentives at any level to meet psychiatriccare needs in rural settings. New healthcare reform initia-

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APN education, practicestartup, and continuationexpenses are inherently

affected by governingpolicies and intimatelyinfluenced by the purse

strings attached.

tives are specified in the Nursing Community letter toPelosi and Reed,24 capturing and synthesizing concernsand solutions from over 30 nursing organizations toeffect changes that would mobilize the ability of nursing,including APN practices, to serve the larger needs ofAmericans through broad, sweeping policy initiatives,including behavioral health considerations.

Nurse EntrepreneurshipEBSCO, OVID, Pub Med, and CINAHL host searcheswere performed using the words “nurse-owned practice,”“advance practice nurse,” and “nurse entrepreneur” yield-ing 8 articles, with none exploring individual APN prac-tice data in non-grant-fundedprivate practices. There werepublications exploring the sub-ject breadth, including philo-sophical materials and clinicaland practice guidelines. Nopublications were found relatedto services rendered andfee/reimbursements collected inprimary care or in non-grant-funded PMH practices. AGoogle search using the same terms did not yield addi-tional publications.

An additional search of readings was conducted relat-ed to general business concepts, nurses, and APN businessventures. The results yielded readings from business,nurse-based businesses, and publications concerningbehavioral health and scholarly journals. The authorsexcluded literature from comparative disciplines such asmedicine (psychiatry), social work, and psychologybecause of discipline-specific differences in reimburse-ment, policy, and practice that influence profit.

STUDY DESIGNThis is a case study of an APN-owned behavioral healthpractice responding to the economic dynamics and pres-sures from dramatic external policy changes. The changesoccurred between January 30, 2005, and March 31, 2006.The study examines the manner in which the practiceoperated before external changes, evolved through a tran-sitional period, and modified its day-to-day operations inresponse to payer changes.

This project was submitted to Institutional ReviewBoard, and exemption was granted and approved for a

retrospective review of active charts and billing mate-rials. The retrospective review included records gener-ated during the specific time identified for the mostaffected period by policy changes. The project usedprotected health information in de-identified andaggregate form; no human subjects were included.

A case study carefully modulates accounts of events,seen through multiple points of view to understand thecontext of each contribution, and focuses on a singleunit, such as a single PMH APN practice.25 This casestudy integrates coincidental events within a confluenceof time that affected the manner in which business wasconducted to serve a targeted group of consumers. The

time period under studyincluded 90 days immediatelybefore the first 90-day periodof TennCare disenrollment onMay 1, 2005: January 31–April30, 2005. The second 90-dayperiod was July 3–September30, 2005, a period of intensepayer adjustment. The third 90-day period was January1–March 31, 2006, the first 90

days of Medicare-D. All time periods were associatedwith swift policy-generated changes in reimbursementfor behavioral health clients. The practice was dependentupon income (and loss thereof) influenced by the chang-ing financial streams from payers during these changes.No specific instruments were created for this study, anddata were recorded into Excel spreadsheets.

The study compared three sets of data collected fromactive charts and billing materials at three different timeperiods. Period 1 data covered the 90 days before theTennCare changes and were considered a baseline forreimbursement. These data were entered into an Excelspreadsheet. Period 2 data included a 90-day transitionperiod to reflect the post-TennCare change. The seconddata set added items that included the changes inTennCare status. Period 3 data reflect the adjustment tothe TennCare changes with Medicare-D information andinclude a 90-day transition period between the secondand third data sets.

The three data sets were examined for progressivelychanging information commensurate with programchanges. The Excel sheet design captured demographicinformation in aggregate form. The data sets are grouped

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APN knowledge should beexpanded to include

development of multipleincome streams necessary

to protect practice solvency.

for demographics and payer status. Descriptive statisticswere used to summarize gender, age, referring agent,missed appointments, and insurer data. Where measuresof central tendency were applicable, descriptors werecompared in each data set. The implications of policychange have been inferred according to dates of policychanges and shifts in the population served. Changes inthe practice were recorded in a chronologic narrative toreflect changes in payer streams.

RESULTSSample Characteristics within the PracticeThe study includes 263 patients, 170 females and 93 males.There were 214 adult patients 18 years or older and 49pediatric patients age 17 or younger. The average age of allpatients was 37.6 years; the average age of a pediatric patientwas 11.5 years. Of the 214 adult patients, there were 154females and 60 males, with the average age at 44.5 years.The standard deviation for all ages is 17.28 years.

The most frequent referral source (N = 164) wasPrimary Care, with remaining referrals acquired fromspecialists (N = 99). There were 445 recorded no-shows, averaging 1.7 no-shows per patient during thespecified data collection times. No-shows ranged from 0for 74 patients and 12 for one patient. The standarddeviation of all patient no-shows was 1.848. Of thetotal patients, 35% (N = 92) were co-managed or case-managed with agency oversight (e.g., Department ofChildren’s Services).

Table 1 clarifies payer-source differences applicable toeach time period. The most evident shift is the progressivereduction of TennCare-covered patients across time, reduced

to half by the study end. Dually covered patients reducedfrom 32 to 29, and private-pay patients increased from 43 to52. Medicare-only patients increased slightly and thenreturned to baseline. Self-pay patients doubled from 5 to 10,then decreased to 4 after being absorbed into other payers.Veterans Administration (VA) patients remained unchanged.

Table 2 breaks out medication supply. Of 29 patientsapproved for patient-assistance program (PAP) medica-tions, five did not follow up to receive their medicines,an attrition rate of 0.17. Sixteen patients actively partici-pated in the PAP, and 13 were absorbed back into otherbenefits. By March 31, 2006, of 263 patients, 176received some type of medication supply or discounttotaling 0.617, nearly two-thirds of the group.

The practice office generated five involuntary admis-sions during the last data collection period, with two re-admissions in this period. During the study, the involun-tary inpatient admissions totaled eight in 9 days, exceed-ing the historical practice total.

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Table 1. Payer Sources Before, During, and After Changes*

Collection 1 Collection 2 Collection 31/31/05 to 7/03/05 to 1/1/06 to

Payer 4/30/05 9/30/05 3/31/06TennCare 45 46 23

Dual covered 32 35 23(TennCare & Medicare)

Private pay 43 52 52

Medicare & private pay 8 8 8

Medicare 4 6 4

Self-pay 5 10 4

Veterans Administration 2 2 2

* Demographics of payer sources of subjects divided into three time frames

Table 2. Medication Supply Sources Throughout Study*

Patient recipientsPatient assistance program 29

Samples/discount coupons 176

Medicare D 41

Medicaid 37

Private insurance/self-pay 56

Veterans Administration 4

*Note: There was overlap of insurance and coupons/samples. Some patientsreceiving any payer coverage of services or medicine received samples/coupons/vouchers as a result of expressed duress of medication, coverage, co-pays, etc., and rising costs of brand-name medicines. Numbers do nonecessarily equal N of 263 because of overlap of medication supply sources.

CASE CONCLUSIONS Champion efforts were required of the APN and staff tomaintain optimal service and care to patients in the midstof multiple external changes. The largest attrition rateemerged from TennCare patients who self-selected out ofcare when benefits were lost, regardless of multipleoptions offered by the practice. Examples of assistance arefee reduction, medicine samples, and PAP, all made avail-able by the practice. Despite changes in payer status, thetypical diagnostic profile of the group and breakdown byage and gender remained consistent, demonstrating thatthe mentally ill need continuous care.

Confusion related to benefit changes resulted inincreased attrition in all payer groups. Medication acqui-sition was a central patient need, and patient destabiliza-tion was common during payer changes in all payergroups. No-shows for appointments resulted in a reduc-tion in the billable hours and accounts receivable, when 9of 10 patients did not show during the period of majorpolicy shift. No-shows increased overhead because of anincrease in patient distress, acuity, and need for continu-ous care for non-billable support services.

RECOMMENDATIONS AND POLICY CONSIDERATIONSThe expenses of APN higher education, practice startup,growth, and continuation are inherently affected by thepolicies governing each and are intimately influenced by thepurse strings attached. APNs must have a financial safety netbefore practice startup, and financial backing may not be soeasily found or sustained during payer lapses from policychanges. Reimbursement limitations slow down the captureof such to satisfy overhead. Higher education makes effortsto empower graduates withpolitical and business acumen,but political changes oftenrequire the ability to support apractice while waiting for payersto readjust for extended periods.This situation again requires afinancial cushion that may bevery difficult to secure, depend-ing upon myriad influences,including the state of the econo-my. This leads the authors to conclude that broad-sweepingpolicy changes are essential to support the growth of indi-vidual APN practices, especially those serving primarilymental health patients.

In this case study, policy shifts undermined the statusquo for APN private practices with unintended conse-quences. To better prepare future APN entrepreneurs fordynamic changes in health policy that influence practice,core competencies within nursing curriculums shouldinclude more knowledge and skill for business ownership.Understanding and recognizing the potential for vulnerabil-ity with shifting political and policy winds, and embeddingprevention and intervention strategies in APN practice busi-ness plans from startup and throughout the life of the entre-preneurial effort, are crucial to building and maintaining apractice. Pools of entrepreneurial APNs should organize incollaborative supportive organizations with a common goalof supporting individual practice success and promotingindividual practice longevity.

APN knowledge should be expanded to include diversepayer sources and development of multiple income streamsnecessary to protect practice solvency when payer changesresult from policy and legislation. Optimizing payment andreimbursement streams will strengthen the APN position inthe healthcare delivery system, but more importantly, suc-cessful APN practices will improve access and equity to themost vulnerable populations with comorbid and mentalhealth diagnoses. Sweeping policy changes that support edu-cational reimbursement, fund support for individual practicestartup and continuation, and improve reimbursement (par-ticularly in light of the 50% payment of rural mental healthservices by Medicare) need to be incepted for APNs willingto treat this underserved population.23

APNs historically serve the poor, underinsured, anduninsured, the most vulnerable populations.26 Control byoutside interest groups (e.g., insurance companies, hospi-

tal/healthcare corporate struc-tures, organized medicine) andlawmakers (e.g., legislated super-vision requirements and policylimitations in Medicare andMedicaid) puts the health ofthese populations at risk. APNsas entrepreneurs in underservedand disadvantaged communitiesimprove equity and ultimatelythe health of those served by

successfully adjusting to incremental policy change.Supporting changes by exploring, exposing, and neutraliz-ing moves that incrementally decrease control on APNpractices27 helps meet healthcare needs of the underserved.

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The financial and policybarriers for APNs effectively

deny equity in care to patientswho are most vulnerable and

disadvantaged.

In light of the increasing physician shortage, theauthors believe it is unacceptable to oppose the efforts ofnursing and other professions that meet gaps in health-care for underserved Americans.19 This commentary isdirected at both acceptance of the increase in numbersand the scope of APN practices, especially those who areor will be in private entrepreneurial practices.

POLICY CONCLUSIONSHealthcare provider practices are expensive to developand to operate. Services in office-related billing are avail-able, at an increase to overhead. In addition, reimburse-ment for APNs is markedly less than that awarded tophysicians who provide the same or similar care. Officecosts are similar for physicians and APNs, but disparity inreimbursement results in a lack of parity for practiceoperation.23 Effectively, this lack of parity in reimburse-ment and infrastructure startup and maintenance costswill ensure APNs incur substantial financial risks whileserving in impoverished areas with disadvantaged andnever-served populations who have complex co-morbidmental health and medical needs.28

The financial and policy barriers for APNs effectivelydeny equity in care to those most vulnerable and disadvan-taged. Laws, rules, and regulations, along with funding poli-cies, must change to accommodate the APN’s practice inoptimal and varied settings and in settings of the APN’schoosing.27 Until then, APNs remain in a chokehold, pre-vented from fair payment for their services as a discipline.APNs are essentially shut out of providing financially reli-able health care as a result of complex, ever-changing, andnoninclusive regulations. Furthermore, patients, particularlythose with comorbid mental health diagnoses or tenuousprivate health insurance, will experience more vulnerabilitybecause there is a lack of equity in healthcare delivery thatstems from the limitations and barriers inherent in contem-porary payer strategies.

This being said, nothing short of policy promotingsweeping changes will effectively turn around the currentpractice challenges facing APNs in private practices,whether the practices are mental-health focused or oth-erwise. Hope seems to be dawning with recent health-care reform initiatives inclusive of the broad interests ofnurses, from education to practice equity. One compre-hensive document is the Nursing Community ConsensusLetter on Health Care Reform to Pelosi and Reed.24

Contained therein are the seeds to remediation of initial

practice cost defrayment through reduced overhead anddiscriminatory reimbursement, as well as broadly sup-portive policy changes.

References

1. Tennessee Board of Nursing. Rules of the Tennessee Board of Nursing.2009; 1st - 4th:Chapter 1000-1004-1001 to 1000-1004-1003. Available athttp://tennessee.gov/sos/rules/1000/1000-04.20090625.pdf. AccessedSeptember 4, 2009.

2. TN CODE 71-5-102. TennCare. 71-5-1022009.3. Ozmibnkowsk R, Aizer A, Smith G. The value and use of the Qualified

Medicare Beneficiary program: Early evidence from Tennessee. Health andSocial Work. 1997;22(1):12-19.

4. Kaiser Family Foundation. Tennessee: Distribution of the nonelderlyuninsured by federal poverty level (FPL), states (2006-2007), U.S. (2007)2007. Available at http://www.statehealthfacts.org/profileind.jsp?ind=136&cat=3&rgn=44. Accessed September 4, 2009.

5. Mann C, Artiga S, Guyer J. Assessing the role of recent waivers in providingnew coverage. 2003. Available at http://www.kff.org/medicaid/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=28336. Accessed August 27, 2009.

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13. Mauer B. Background paper: Behavioral health/primary care integrationmodels, competencies, and infrastructure. 2003. Available athttp://www.machc.com/Documents/Reports/Intergrative%20Behavioral%20Health%20Care/Supplemental%20Tools/SectionI%20Intergrative%20Care.pdf. Accessed August 27, 2009.

14. Satcher D. Closing the gap: A national blueprint to improve the health ofpersons with mental retardation: Report of the Surgeon General'sconference on health disparities and mental retardation in U.S. 2002.Available at http://www.surgeongeneral.gov/topics/ mentalretardation/retardation.pdf. Accessed Sept. 4, 2009.

15. Hoge M, Paris M, Hoover A, et al. Workforce competencies in behavioralhealth: An overview Administration and Policy in Mental Health andMental Health Services Research. 2005;32(5-6):593-631.

16. Hoge M, Morris A, Daniels A, Stuart G, Huey L, Adams N. An action planfor behavioral health workforce development: A framework fordiscussion. 2007; 347. Available at http://208.106.217.45/pages/images/WorkforceActionPlan.pdf. Accessed September 4, 2009.

17. Mental Health Commission. President’s New Freedom Commission onMental Health. President's New Freedom Commission on Mental Health.2007. Available at http://www.mentalhealthcommission.gov/. AccessedOctober 23, 2009.

18. Druss B, Goldman H. New freedom commission report: Introduction tothe special section on the President's New Freedom Commission Report2003. Available at http://psychservices.psychiatryonline.org/cgi/reprint/54/11/1465.pdf. Accessed September 3, 2009.

19. Whitcomb M. The shortage of physicians and the future role of nurses.Acad Med. 2006;81(9):779-780.

20. Kaiser Daily Health Policy Report. New York Times Examines DecliningFees for Mental Health Therapists Coverage and Access 2006. Availableat http://www.kaisernetwork.org/daily_reports/ print_report.cfm?DR_ID=36242&dr_cat=3 Accessed September 17, 2009.

21. Aron L, Honberg R, Duckworth K, et al. Grading the states 2009:Overview: A report on America’s health care system for adults withserious mental illness. 2009. Available at http://nami.org/Content/

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23. Centers for Medicare & Medicaid Services. Medicare Part B PhysicianAssistant, Nurse Practitioner & Clinical Nurse Specialist Billing Guide2004. 2004. Available at http://www.acnpweb.org/files/public/Medicare_PartB_PA_NP_CNS_Billing_Guide_Sept04.pdf. AccessedSeptember 4, 2009.

24. AANAC, Academy of Medical-Surgical Nurses, American Academy ofNurse Practitioners, et al. Nursing Community Consensus Letter on HCRConference. Washington D.C.: Nursing Community; January 6, 2010.

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26. Policastro D. Hearing on health reform in the 21st century: Proposals toreform the health sysytem. Committee on Ways and Means. 6 ed.Washington D.C.: American Nurses Association; 2009:5.

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Kathleen McCoy, DNSc, APRN, PMHNP-BC,PMHCNS-BC, FNP-BC, is an assistant professor in theDepartment of Primary Care & Public Health GraduateProgram at the University of Tennessee Health Science CenterCollege of Nursing in Memphis. She is triple ANCC certifiedas a family psychiatric mental health nurse practitioner, a clini-cal nurse specialist in adult psychiatric and mental healthnursing, and as a family nurse practitioner. She can be reachedat Kathleenmccoy1@gmail.com. Michael Carter, DNSc,DNP, APN, FNP-BC, FAAN, is a University DistinguishedProfessor in the College of Nursing. Patricia D. Cunningham,DNSc, APN, PMHNP/CNS-BC, FNP-BC, is an associateprofessor and coordinator of the family psychiatric DNP optionin the college. Patricia M. Speck, DNSc, APN, FNP-BC,SANE-A/P, DF-IAFN, FAAFS, FAAN, is an assistantprofessor in the family psychiatric DNP option at the college.Cynthia Rector, MD, is the medical director of Lifecare FamilyServices in Nashville, TN.In compliance with national ethical guidelines, the authorsreport no relationships with business or industry that wouldpose a conflict of interest.

AcknowledgmentThe authors would like to thank and acknowledge Ms. GailSpake for her invaluable contribution and editorial revisions tothis manuscript.

1555-4155//$ see front matter© 2010 American College of Nurse Practitionersdoi:10.1016/j.nurpra.2010.02.025

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