Slide 1

Crisis in the Crisis in the Mental Health Care Mental Health Care

WorkforceWorkforce Are Are Advanced Practice Nurses Advanced Practice Nurses

Part of the Solution?Part of the Solution?

Nancy P. Hanrahan, PhD, RN, CSNancy P. Hanrahan, PhD, RN, CSAssistant ProfessorAssistant Professor

Center for Health Outcomes and Policy ResearchCenter for Health Outcomes and Policy ResearchUniversity of Pennsylvania School of NursingUniversity of Pennsylvania School of Nursing

Slide 2

ObjectivesObjectives

Trends: Mental Health SystemTrends: Mental Health System

System: Frayed and ineffective for SMISystem: Frayed and ineffective for SMI

Workforce: Inadequate Workforce: Inadequate

Are APNs a Solution?Are APNs a Solution?

Slide 3

-40%

-20%

0%

20%

40%

60%

80%

1976 1978 1986 1990 1992 1994 1998 2000

StaffingExpendituresEpisodes of Care

-100%

0%

100%

200%

300%

400%

1976 1978 1986 1990 1992 1994 1998 2000

Comparing Inpatient and Outpatient Trends Percent Change from Previous Year 1976-2000

INPATIENT n=2,329-2,478INPATIENT n=2,329-2,478 OUTPATIENT n=1,151-2,068OUTPATIENT 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Source: Published and unpublished inventory data from the Survey and Analysis Branch, Division of State and Community Systems Development, Center for Mental Health Services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 WorkforceMental Health WorkforceTrends 1972-1998Trends 1972-1998

0

50000

100000

150000

200000

250000

1972 1976 1978 1986 1990 1992 1998

MHW MSW/LCPC RN Psych-MD Psych-PhD

Source: Published and unpublished inventory data from the Survey and Analysis Branch, Division of State and Community Systems Development, Center for Mental Health Services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 Need a Workforce Competent in Medical And Psychiatric Care for Quality OutcomesAnd Psychiatric Care for Quality Outcomes

Individuals with Serious Mental IllnessIndividuals with Serious Mental Illness – Only a third with SMI receive treatmentOnly a third with SMI receive treatment

– High incidence of physical comorbidities High incidence of physical comorbidities

that are overlooked by CMHCs. that are overlooked by CMHCs.

– Inadequate follow-up Inadequate follow-up

– Higher mortality ratesHigher mortality rates

Slide 6

SERIOUS MENTAL ILLNESS S/ HIV SERIOUS MENTAL ILLNESS S/ HIV A SERIOUS PUBLIC HEALTH PROBLEMA 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 ServicesOlder Adult Utilization of Mental Health Services5% National Sample >65 years5% National Sample >65 years

N=185,403N=185,403

2,055,561 individuals2,055,561 individuals

15.7 million claims15.7 million claims

9% (185,403) mental disorder 9% (185,403) mental disorder diagnosisdiagnosis

47% had more than one mental 47% had more than one mental disorder diagnosisdisorder diagnosis

83% had more than one major 83% had more than one major medical problem (CVD, medical problem (CVD, Diabetes)Diabetes)

7% (709,606) mental disorders7% (709,606) mental disorders 93% (14.9 mil) medical 93% (14.9 mil) medical

problemsproblems

Data Source: Medpar File, Outpatient File, Carrier File

Slide 8

Distribution of Claims for Medicare Beneficiaries Distribution of Claims for Medicare Beneficiaries with a Mental Disorder Diagnosiswith 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 %

Mental Disorders 717,609 4.6 %Integument Disease 375,452 2.4 %

Infectious Diseases 181,919 1.2 %

Other Medical Diagnoses 3,320,049 21.4 %

Total Claims 15,514,076 100 %

Slide 9

Distribution of Claims by Distribution of Claims by Diagnosis and ProviderDiagnosis and Provider

  PCP APN PsychMD

Psych Phd

SW

Affective D/O 21% 35% 56% 47% 53%Anxiety D/O 12% 7% 5% 9% 10%Dementia 25% 31% 14% 8% 6%Organic Brain

Syndrome16% 8% 2% 3% 1%

Psychotic D/O 15% 12% 17% 7% 6%Sub. Related 5% 1% 1% 1% 1%Other 6% 6% 4% 25% 23%

Slide 10

N=8642 Certified APNsN=8642 Certified APNs Purpose:Purpose:

– Examine the rural and urban distribution of certified APPNs and determine Examine the rural and urban distribution of certified APPNs and determine the potential for APPNs to be a solution to the rural mental health the potential for APPNs to be a solution to the rural mental health workforce shortage. workforce shortage.

Survey of 50 states: Survey of 50 states:

• Scope of practice, state regulation (Rx authority) and curriculum for psychiatric Scope of practice, state regulation (Rx authority) and curriculum for psychiatric mental health nursing programsmental health nursing programs

Findings:Findings:

– APNs have a higher distribution per population in the rural areas APNs have a higher distribution per population in the rural areas than psychiatrists (13% vs.6.6%)than psychiatrists (13% vs.6.6%)

– 20 states have at least 20% rural APN practice20 states have at least 20% rural APN practice

– Despite low numbers of APNs, training and scope of practice fit an Despite low numbers of APNs, training and scope of practice fit an urgent need in rural areasurgent need in rural areas

Are APNs a Solution to Rural Mental Health Are APNs a Solution to Rural Mental Health Workforce Shortages? Workforce Shortages?

Slide 11

APNS WHAT WE KNOWAPNS WHAT WE KNOW EDUCATIONEDUCATION: Masters degree and PhD: Masters degree and PhD

– N=16,606 CNS/NP Psychiatric Specialty (8,654 cert)N=16,606 CNS/NP Psychiatric Specialty (8,654 cert)– N=88,000 Nurse Practitioner, Primary Care SpecialtyN=88,000 Nurse Practitioner, Primary Care Specialty– Scope of practice: Integration of bio-psycho-socialScope of practice: Integration of bio-psycho-social– Expertise: Surveillance (comorbidity, medication/SE)Expertise: Surveillance (comorbidity, medication/SE)

SETTINGSSETTINGS: Institution, Community, and Home: Institution, Community, and Home

TrendsTrends– Rate of growth will be the same for psychiatrists by 2010 with 300 Rate of growth will be the same for psychiatrists by 2010 with 300

new nurses per yearnew nurses per year

– Restricted scope of practice, lack of reciprocityRestricted scope of practice, lack of reciprocity– Education Changes: Psychiatric Nurse PractitionerEducation Changes: Psychiatric Nurse Practitioner

– Prescriptive AuthorityPrescriptive Authority• Nurse Practitioners Nurse Practitioners 50 States 50 States

• Clinical Nurse SpecialistsClinical Nurse Specialists 34 States 34 States

Slide 12

Major Trends In The Mental Major Trends In The Mental Health WorkforceHealth Workforce

Fewer trained professionals with an increase Fewer trained professionals with an increase in the use of MHW in the use of MHW – How does the substitution affect outcomes, How does the substitution affect outcomes,

access, and quality? access, and quality? – What is the evidence that a particular What is the evidence that a particular

competency level is associated with better competency level is associated with better

outcomes?outcomes? Poor workforce dataPoor workforce data

Reimbursement incentives drive the type of provider Reimbursement incentives drive the type of provider

and the interventionand the intervention

Slide 13

RecommendationsRecommendations Any meaningful reform of mental health care delivery will Any meaningful reform of mental health care delivery will

have to overcome current barriers to effective utilization of have to overcome current barriers to effective utilization of providersproviders

These barriers serve no useful purpose and in fact These barriers serve no useful purpose and in fact contribute to our health care problems by preventing the full contribute to our health care problems by preventing the full deployment of competent and cost-effective providers who deployment of competent and cost-effective providers who can meet the needs of a substantial number of consumers.can meet the needs of a substantial number of consumers.

Practice acts should ensure that they are based wholly on Practice acts should ensure that they are based wholly on competencycompetency

Fund interdisciplinary training Fund interdisciplinary training Revise payment and practice laws to allow all demonstrably Revise payment and practice laws to allow all demonstrably

competent providers to diagnose, treat, and prescribe on competent providers to diagnose, treat, and prescribe on their own licenses. their own licenses.