REALITIES OF INTEGRATED COLLABORATIVE CARE OF CHILDREN AND ADOLESCENTS

Transcription

1 REALITIES OF INTEGRATED COLLABORATIVE CARE OF CHILDREN AND ADOLESCENTS Geraldine S. Pearson, PHD, PMH CNS, FAAN University of CT School of Medicine APNA June 23, 2013 DISCLOSURES This speaker has no conflicts of interest, commercial support, or off label use to disclose. Geraldine S. Pearson, PhD, APRN 1

2 Goals of Presentation Define collaborative practice models for APNs who work with children and adolescents Define contexts of practice from perspectives of interdisciplinary mental health practice, the discipline of nursing, and individual APN role considerations Discuss future directions and dilemmas that will impact our practice Nature of this presentation My historical and current role in a collaborative practice Focus more on public sector populations Integration of nursing within collaborative care models Discussion of a specific model of collaborative care for children and adolescents in MA & CT Time for questions and discussion at the conclusion Geraldine S. Pearson, PhD, APRN 2

3 INTERDISCIPLINARY MENTAL HEALTH PRACTICE DISCIPLINE OF NURSING INDIVIDUAL ADVANCED PRACTICE NURSE INTERDISCIPLINARY MENTAL HEALTH PRACTICE Affordable Care Act (ACA) upheld by US Supreme Court on 6/28/12 Implications for expanded care coverage, care cost reductions, fair and equitable treatment of patients, Medicare preservation, health promotion and prevention, establishment of new models of care (Hoyt & Proehl, 2012) Geraldine S. Pearson, PhD, APRN 3

4 For our psychiatrist colleagues who work with public sector populations it means a shift from treating illness and an increased focus on prevention and integrated care (Shim, et al., 2012) SCOPE OF PROBLEM Almost 50% of Americans will meet the DSM IV criteria for a disorder during their lifetime. Many of these disorders begin in childhood and adolescence. (Kessler, Berglund, Demler, Jin, Merikangas, & Walters, 2005) Approximately 25% of adolescents meet criteria for a disorder with the potential for severe impairment across their lifetime. (Merikangas, He, Burstein, et al., 2010) Geraldine S. Pearson, PhD, APRN 4

5 What does this mean for psychiatry? Not enough psychiatrists to meet the burgeoning need for psychiatric services in this country Need for more constructive, less expensive patient management scenerios Need to focus psychiatry on the sickest patients (Essock & Hogan, 2011) Physicians will need to relinquish some of their control of psychiatric practice. Geraldine S. Pearson, PhD, APRN 5

6 Increasing need for more collaborative care models, especially with public sector populations. Need for interdisciplinary collaboration between psychologists, social workers, marriage and family therapists, counselors. The need to involve consumers in planning and delivering care. PATIENT ENGAGEMENT The relationship between patients and health care providers as they work together to promote and support active patient and public involvement in health and healthcare and to strengthen their influence on health care decisions, both at the individual and collective levels (Coulter, 2011) Geraldine S. Pearson, PhD, APRN 6

7 PATIENT AND FAMILY CENTERED CARE A partnership among practitioners, patients, and their families 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, 2001, p. 7) Nurses will continue to build the framework of care that deals with mounting complexities of providing effective, accessible care with excellent outcomes while using fewer resources (Ellerbe & Regen, p. 128, 2012) Geraldine S. Pearson, PhD, APRN 7

8 Interdisciplinary COLLABORATIVE care in public sector populations will be essential! Still room for a private practice model with private pay for all disciplines. For all public sector populations: Increasingly stringent requirements for reimbursement INCREASING RELIANCE ON PRIMARY CARE PRACTITIONERS FOR BASIC PSYCHIATRIC CARE More emphasis on symptom benchmarks DSM is only partially validated to determine diagnoses Polypharmacy as the norm for all ages (Rubin & Zorumski, 2012) Geraldine S. Pearson, PhD, APRN 8

9 How do Psychiatric APNs work with their psychiatrist colleagues? To define this you have to look at the historical perspective of nursing. From earliest times nursing was regarded as secondary to the work of physicians, yet much of what Hippocrates taught was about nursing care. Shared ethical frame Physicians taught to focus on commitment to individual patient Nurses taught to be loyal to physicians, hospitals, and patients (subservience) (Storch & Kenny, 2007) THAT HAS, THANKFULLY, SHIFTED WITH THE EVOLUTION OF ADVANCED NURSING PRACTICE and GENERALIST PRACTICE Geraldine S. Pearson, PhD, APRN 9

10 Contemporary Models of Collaborative Care The Massachusetts Child Psychiatry Access project (MCPAP) Reduce barriers to primary care patients receiving behavioral health assessment and intervention A model of collaboration between pediatric primary care and behavioral health MCPAP Immediate telephonic child psychiatric consultation Face to face assessment Educational services The goal is to provide services to the entry point for many pediatric patients: primary care practitioners Geraldine S. Pearson, PhD, APRN 10

11 Other versions of this implemented in other states New state funding to implement this in CT APNs will be part of psychiatric team in partnership with the child psychiatrist providing beeper coverage, telephone consultation, and direct evaluation of pediatric patients INTERDISCIPLINARY MENTAL HEALTH PRACTICE DISCIPLINE OF NURSING INDIVIDUAL ADVANCED PRACTICE NURSE Geraldine S. Pearson, PhD, APRN 11

12 Historical Perspective Advanced practice nursing (APN) roles have been in existence since the early 1940 s Many APNs received master s degrees at a time when there was federal money to go to school and when the only advanced practice ANCC certification in psychiatricmh nursing involved the clinical nurse specialist (CNS) role In the 1990s the NCSBN (National Council of State Boards of Nursing) began to identify certification as an element of regulation of APN practice Future papers set the stage for the dialogue that determining how APNs were educated and how they would practice (Rose, & Regan Kubinski, 2010) Geraldine S. Pearson, PhD, APRN 12

13 What does ACA mean for APN s? Very positive implications for advanced practice nursing! Growing the workforce at all levels, faculty, clinical leaders, practice and academia Establishing nurse managed clinics to work in underserved communities Emphasis on primary care settings Support student loan program Educate patients about ACA (Hoyt & Proehl, 2012) ACA has implications for integrated and collaborative models of psychiatric care, across the lifespan. Our practice dilemmas will, in part, determine how we will capitalize on ACA changes in practice. Geraldine S. Pearson, PhD, APRN 13

14 LICENSURE, ACCREDITATION, CERTIFICATION, AND EDUCATION (LACE) Document was the result of the joint efforts from the NCSBN Advisory Group and the APRN Consensus Work Group Regulatory model of APN practice identifying 4 roles: nurse anesthetist, nurse midwife, clinical nurse specialist, and nurse practitioner Multiple endorsements, APNA & ISPN Influences on APN Practice LACE and implications for education and practice (or what will solve the particularly sticky debate about CNS versus NP practice?) Affordable care issues and political changes on a national and international level (or how do we reduce barriers to care and make it more accessible to our patients?) Geraldine S. Pearson, PhD, APRN 14

15 Our interdisciplinary relationships with our colleagues (or how do we negotiate our roles with the physicians we work with?) How does nursing present itself to other disciplines and to the public? Historical Shifts Nursing began to move to semi independence with changes in educational preparation (Caldwell, Sclafani, Piren, & Torre, 2012) Blind obedience to physician took a dramatic shift to independent critical thinking By the late 1970 s nurses were breaking out of old roles, Carper emphasized patterns of knowing, empirical knowledge, and increased complexity in role within health care system. (Carper, 1978; Hamric, 2001) Geraldine S. Pearson, PhD, APRN 15

16 Historical Shifts Nurse Practitioner role initiated in the 1960 s Gradual increase in role definition, scope of practice, and physician comfort Institute of Medicine has consistently recommended eliminating restrictions on NPs that impact their ability to provide care, particularly in primary care settings Physicians and physician groups, such as the AMA still struggle with the nurse practitioner role The struggle for NP autonomy has increasingly politicized the debate over quality of care and has made establishing the capabilities of NPs more important than ever. (Mullinix & Bucholtz, 2009, p. 93) Geraldine S. Pearson, PhD, APRN 16

17 How does this translate into our nursing practice? What exactly are we doing as APNs? 2009 APNA and ISPN workface survey of PMH APRNs. 1,899 respondents. Majority were providing direct services to clients More likely to be working outside of hospitals Spend more than one third of their work week prescribing Geraldine S. Pearson, PhD, APRN 17

18 ONLY A SMALL PERCENTAGE WERE PROVIDING CARE TO CHILDREN YOUNGER THAN AGE 13 YEARS. (Delaney, Hamera, & Drew, 2009) Adequacy of Education? One closed and one open ended question Did your program prepare you for your current role? 70% said yes BUT comments on the open ended part of this question, Please explain how your graduate program did not prepare you adequately for your role? resulted in much more data Geraldine S. Pearson, PhD, APRN 18

19 Comments: Need for more educational preparation to meet role demands of psychopharm and prescribing, i.e. applicable knowledge for a prescriptive practice Mismatch between preparation and current APRN practice demands or current regulations governing practice Much of this related to the time that training was obtained. Many respondents identified a slippage between the time of their training and the current practice expectations for APRNs. As a result some respondents have made the decision to go back to school and achieve certification as a PMH NP. Geraldine S. Pearson, PhD, APRN 19

20 What does this mean for our practice? The curricular changes and the move to a PMH NP role recommended by the APRN Consensus Model are occurring. Programs are trying to resolve the need for the NP curriculum without completely sacrificing the psychotherapy component that characterized CNS education. Recommendations from survey results: Keep the curriculum model relevant in today s rapidly changing practice environment Integrating emerging paradigms of mental health service delivery such as consumer and family collaboration and national initiatives to identify core competencies for all behavioral health professionals Geraldine S. Pearson, PhD, APRN 20

21 Incorporate current models for graduate nursing education, i.e. Master s Essentials (AACN, 1996), and Doctor of Nursing Practice Essentials (AACN, 2006), and lifespan approach (APRN Consensus Work Group & NCSBN APRN Advisory Committee, 2008) INTERDISCIPLINARY MENTAL HEALTH PRACTICE DISCIPLINE OF NURSING INDIVIDUAL ADVANCED PRACTICE NURSE Geraldine S. Pearson, PhD, APRN 21

22 WHAT DOES THIS MEAN FOR THE INDIVIDUAL NURSE? Decision making for the new graduate about the type of nursing practice they want to have or defining the context of their practice Changing practice for experienced APNs who are watching the healthcare landscape change around them Boundaries of the practice Relationship with psychiatrist who might be collegial, supervisory, or collaborate depending on State statute. Understanding scope of practice based on knowledge and skills. IF YOU ARE MISSING IMPORTANT SKILL SETS HOW WILL YOU GO ABOUT OBTAINING THEM? Geraldine S. Pearson, PhD, APRN 22

23 DECISION MAKING FOR THOSE ALREADY IN PRACTICE, WITH YEARS OF EXPERIENCE How will we keep ourselves current with the changing healthcare landscape? How will we be informed about political changes affecting our practice? What kind of advanced practice psychiatric nurse will we be? Conclusions relevant to today: Healthcare in general is rapidly changing and we need to SIEZE THE OPPORTUNITY AND SEEK OUT OPPORTUNITIES TO COLLABORATE Our roles are altering to meet the changes in this landscape and WE NEED TO STRENGTHEN THEM Geraldine S. Pearson, PhD, APRN 23

24 We need to drive this process by MAKING OURSELVES AVAILABLE TO NEW CARE MODELS Strive for EXCELLENCE IN PRACTICE It is a time of great opportunity while being extremely unsettled. It is an exciting time to be an ADVANCED PRACTICE NURSE Thank you! Geraldine S. Pearson, PhD, APRN 24