1. Slide 1 Crisis in the Mental Health Care Workforce Are Advanced Practice Nurses Part of the Solution? Nancy P. Hanrahan, PhD, RN, CS Assistant Professor Center for Health Outcomes and Policy Research University of Pennsylvania School of Nursing

2. Slide 2 Objectives Trends: Mental Health System Trends: Mental Health System System: Frayed and ineffective for SMI System: Frayed and ineffective for SMI Workforce: Inadequate Workforce: Inadequate Are APNs a Solution? Are APNs a Solution?

3. Slide 3 Comparing Inpatient and Outpatient Trends Percent Change from Previous Year 1976-2000 INPATIENT n=2,329-2,478 OUTPATIENT n=1,151-2,068 Source: Published and unpublished inventory data from the Survey and Analysis Branch, Division of State and Community Systems Development, Center for Mental Health Services

4. Slide 4 Mental Health Workforce Trends 1972-1998 Source: Published and unpublished inventory data from the Survey and Analysis Branch, Division of State and Community Systems Development, Center for Mental Health Services

5. Slide 5 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 follow-up –Higher mortality rates

6. Slide 6 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)

7. Slide 7 Older Adult Utilization of Mental Health Services 5% National Sample >65 years N=185,403 2,055,561 individuals 15.7 million claims 9% (185,403) mental disorder diagnosis 9% (185,403) mental disorder diagnosis 47% had more than one mental disorder diagnosis 47% had more than one mental disorder diagnosis 83% had more than one major medical problem (CVD, Diabetes) 83% had more than one major medical problem (CVD, Diabetes) 7% (709,606) mental disorders 7% (709,606) mental disorders 93% (14.9 mil) medical problems 93% (14.9 mil) medical problems Data Source: Medpar File, Outpatient File, Carrier File

8. Slide 8 Distribution of Claims for Medicare Beneficiaries with a Mental Disorder Diagnosis Cardiovascular Disease 2,862,98918.45 % Musculoskeletal Disease 1,530,1559.9 % Respiratory Disease 1,420,9979.2 % Endocrine Diseases 1,264,0588.2 % Neurological Disease 1,118,6857.2 % Neoplasms 1,023,4046.6 % Genitourinary system 973,9666.3 % Digestive System Disease 724,7934.7 % Mental Disorders 717,6094.6 % Integument Disease 375,4522.4 % Infectious Diseases 181,9191.2 % Other Medical Diagnoses 3,320,04921.4 % Total Claims 15,514,076100 %

9. Slide 9 Distribution of Claims by Diagnosis and Provider PCPAPNPsych MD Psych Phd SW Affective D/O21%35% 56%47%53% Anxiety D/O12%7%5% 9%10% Dementia25%31%14% 8%6% Organic Brain Syndrome 16%8%2% 3%1% Psychotic D/O15%12%17% 7%6% Sub. Related5%1% Other6% 4% 25%23%

10. Slide 10 N=8642 Certified APNs Purpose: Purpose: –Examine the rural and urban distribution of certified APPNs and determine the potential for APPNs to be a solution to the rural mental health workforce shortage. Survey of 50 states: Survey of 50 states: Scope of practice, state regulation (Rx authority) and curriculum for psychiatric mental health nursing programsScope of practice, state regulation (Rx authority) and curriculum for psychiatric mental health nursing programs Findings: Findings: –APNs have a higher distribution per population in the rural areas than psychiatrists (13% vs.6.6%) –20 states have at least 20% rural APN practice –Despite low numbers of APNs, training and scope of practice fit an urgent need in rural areas Are APNs a Solution to Rural Mental Health Workforce Shortages?

11. Slide 11 APNS WHAT WE KNOW EDUCATION: Masters degree and PhD 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 bio-psycho-social –Expertise: Surveillance (comorbidity, medication/SE) SETTINGS: Institution, Community, and Home SETTINGS: Institution, Community, and Home Trends Trends –Rate of growth will be the same for psychiatrists by 2010 with 300 new nurses per year –Restricted scope of practice, lack of reciprocity –Education Changes: Psychiatric Nurse Practitioner –Prescriptive Authority Nurse Practitioners 50 StatesNurse Practitioners 50 States Clinical Nurse Specialists 34 StatesClinical Nurse Specialists 34 States

12. Slide 12 Major Trends In The Mental Health Workforce Fewer trained professionals with an increase in the use of MHW 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 Poor workforce data Reimbursement incentives drive the type of provider and the intervention Reimbursement incentives drive the type of provider and the intervention

13. Slide 13 Recommendations Any meaningful reform of mental health care delivery will have to overcome current barriers to effective utilization of providers 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 cost-effective providers who can meet the needs of a substantial number of consumers. These barriers serve no useful purpose and in fact contribute to our health care problems by preventing the full deployment of competent and cost-effective providers who can meet the needs of a substantial number of consumers. Practice acts should ensure that they are based wholly on competency Practice acts should ensure that they are based wholly on competency Fund interdisciplinary training Fund interdisciplinary training Revise payment and practice laws to allow all demonstrably competent providers to diagnose, treat, and prescribe on their own licenses. Revise payment and practice laws to allow all demonstrably competent providers to diagnose, treat, and prescribe on their own licenses.