1、Development of Health Career Pathway for California Psychiatric Mental Health Nurse Practitioner Clinical Nurse Specialist,Presented by:Cynthia Harrison, BSN, MS, RN Rowena Gillo, LCSWMission College Pacific ClinicsSeptember 17, 2013,1,California is one of the most racially and ethnically diverse st
2、ates in the country, and is projected to become even more so in the coming decadesPopulation projections suggest that by the year 2030, 66% of the states population will be non-WhiteOver the next 25 years the states population is projected to grow by roughly 12 million people. Over 90% of this popul
3、ation growth is projected to occur among Californias Latino (75%) and Asian (17%) populations.These dramatic changes underscore the need to address the lack of racial and ethnic diversity among key mental health professions in the state,2,CALIFORNIAS POPULATION DIVERSITY,Source: Lok, V. and Chapman,
4、 S., UCSF Center for the Health Professions, The Mental Health Workforce in California: Trends in Employment, Education, and Diversity,A prolonged shortage of psychiatrists. Nearly 30 percent of physicians are over 60 years old - a higher percentage than any other state*Increased demand for integrat
5、ed services that are Multi-Culturally Responsive. Specifically, a need for more culturally responsive and competent provider practices to engage underserved populations+Increased demand for services that are Affordable and Accessible to the CommunityAn educational system that lacks capacity to provi
6、de the Behavioral Health workforce needed to meet future demandsHealthcare nursing professionals are not adequately prepared to work in community-based MH/Behavioral Health settings,3,CALIFORNIAS BEHAVIORAL HEALTH WORKFORCE CHALLENGES,Source: * California Health Care Foundation, CA Health Care Alman
7、ac Regional Markets http:/www.chcf.org/almanac/regional-markets +CIMH, Jarvis and Freeman Briefing Paper 4: Workforce Issues Today and in the Future Workforce Implications of Increased Demand for Mental Health and Substance Use Service, June 2012,The shortage of Registered Nurses (RNs) experienced i
8、n California is well documentedAccording to the “United States Registered Nurse Workforce Report Card and Shortage Forecast” published in the January 2012 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country between 2009 and 2030
9、. In this state-by-state analysis, the authors forecast the RN shortage to be most intense in the South and the West.*There has been aggressive effort to expand the states capacity to train new RNs Since 2000 the number of new licenses issued each year has approximately doubled The California Board
10、of Registered Nursing continues to offer a certificate to practice as a certified psychiatric/mental health nurse As of May 2012, there are 330,943 RNs with active licenses in California+,4,REGISTERED NURSES (RNs),Sources: *American Association of Colleges of Nursing , Nursing Shortage Facts Sheet h
11、ttp:/www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage +OSHPD Healthcare Workforce Clearinghouse, Registered Nurses, June 2012,Advanced practice registered nurses (APRNs) : Are nurses who have received education beyond their initial registered nurse (RN) education to work in a specializ
12、ed role in the delivery of health care services, preparing him/her for one of the four recognized APRN roles Are prepared in masters-degree programs that often carry a credit load equivalent to doctoral degrees in the other health professions.Has acquired advanced clinical knowledge and skills prepa
13、ring him/her to provide direct care to patients, as well as a component of indirect care Has clinical experience of sufficient depth and breadth to reflect the intended licenseFour types of APRNs in the United States: Certified Nurse Midwives (CNM) Certified Registered Nurse Anesthetists (CRNA) Clin
14、ical Nurse Specialists (CNS): bring specialized knowledge about the patient population, the environment, and disease management Nurse Practitioners (NP): focus on primary care activities,5,ADVANCED PRACTICE REGISTERED NURSES (APRNs),Sources: California Board of Registered Nursing http:/www.rn.ca.gov
15、/pdfs/forms/survey2010cns.pdfNational Council for State Boards of APRN Advisory Committee, APRN Joint Dialogue Group Report, July 7, 2008,Certification requires 500 hours of specified clinical experience and a masters degreeCertified psychiatric/mental health nurse requirements include education at
16、the masters level (the degree must be directly related to mental health) and two years of supervised clinical experience providing mental health counseling services Certification for Psychiatric-Mental Health Nursing and is not required for practice in the state As of February 2011: there were 2,865
17、 CNS and they are not widely distributed across the state there were 14,623 NP there were 334 certified psychiatric/mental health nursesNPs tend to work in counties that have low health care provider per population ratios Northern California has higher NP certifications per population ratios compare
18、d to Southern California The annual number of certifications issued has declined steadily since 1985,6,CNS/PMHNP CERTIFICATION REQUIREMENTS,CNS certification focuses on areas of clinical specialization in nursing practice, and provides direct patient care. The most commonly reported areas of primary
19、 focus are adult/gerontology (22.4%), and acute/critical care (20.4%)CNSs influence care outcomes by providing expert consultation for nursing staffs and by implementing improvements in health care delivery systemsCNS education focuses on how clinical care is affected by the patients personal and fa
20、mily characteristics, the environment, the nursing personnel who provide care, and the health system organizationWhile the CNS certification began as a mental health specialization, only 16.3 percent of CNSs reported psychiatrics/mental health as one of their clinical areas of specializationCNSs can
21、 not furnish or order medicationsThe CNS certification has been discontinued in California primarily due to low student enrollment rates in CNS programs. The Clinical Nurse Leader (CNL) has replaced the CNS. The CNL is an advanced clinician with education at the masters degree level, but not prepare
22、d as an advanced practice registered nurse as the APRN is currently defined. The CNL is a Generalist that oversees the lateral integration of care for a distinct group of patients and may actively provide direct patient care in complex situations *,7,SCOPE OF PRACTICE: CLINICAL NURSE SPECIALIST,Sour
23、ce: California Board of Registered Nursing http:/www.rn.ca.gov/pdfs/forms/survey2010cns.pdf *American Association of Colleges of Nursing http:/www.aacn.nche.edu/cnl/frequently-asked-questions,The Psychiatric-Mental Health Nurse Practitioner (PMHNP) is:* An advanced practice registered nurse who focu
24、ses clinical practice on individuals, families, or populations across the life span at risk for developing and/or having a diagnosis of psychiatric disorders or mental health problemsA specialist who provides primary mental health care to patients seeking mental health services in a wide range of se
25、ttingsPrimary mental health care provided by the psychiatric-mental health nurse practitioner involves the continuous and comprehensive services necessary for the promotion of optimal mental health, prevention and treatment of psychiatric disorders and health maintenance. This includes the assessmen
26、t, diagnosis, and management of mental health problems and psychiatric disorders.The psychiatric-mental health nurse practitioner is a provider of direct mental health care servicesThe scope of practice of NPs in California is regulated by the state. California requires that NPs work under standardi
27、zed procedures developed through collaboration among administrators and health professionals, including physicians and surgeons and nurses.+NPs may obtain additional certification from the BRN to furnish or order drugs or devices under standardized procedures developed with the supervising physician
28、 and surgeon.In October 2010, the Institute of Medicine recommended full independent practice for Nurse Practitioners: “Nurses should practice to the full extent of their education and training”.+,8,SCOPE OF PRACTICE: PSYCHIATRIC-MENTAL HEALTH NURSE PRACTITIONER,Source:* American Association of Coll
29、eges of Nursing http:/www.aacn.nche.edu/leading-initiatives/education-resources/PMHNP.pdf +Institute of Medicine, The Future of Nursing http:/www.iom.edu/nursing,FEBRUARY 2013: SENATE BILL 491 WAS INTRODUCED TO THE CALIFORNIA LEGISLATURE Section 1, Senate Bill 491 California Legislature found and de
30、clared the following: (b) Nurse practitioners will play an especially important part in the implementation of the federal Patient Protection and Affordable Care Act, which will bring an estimated five million more Californians into the health care delivery system, because they will provide for great
31、er access to primary care services in all areas of the state. This is particularly true for patients in medically underserved urban and rural communities. (d) Nurse practitioners will assist in addressing the primary care provider shortage by removing delays in the provision of care that are created
32、 when dated regulations require a physicians signature or protocol before a patient can initiate treatment or obtain diagnostic tests that are ordered by a nurse practitioner.Proposed Law: SB 491 would expand the scope of practice for nurse practitioners, by deleting the requirement that nurse pract
33、itioners provide certain services only under the supervision of a physician or surgeon. Specifically, the bill would expand the scope of practice of a nurse practitioner by authorizing a nurse practitioner to provide the following services independently: - Order durable medical equipment - Certify d
34、isability claims - Manage patients health status- Make changes to a plan of treatment for certain home health patients- Assess patients, synthesize data, and apply the principals of health care; - Analyze data to identify the nature of a health problem and implement appropriate treatment- Examine a
35、patient and establish a medical diagnosis - Order prescription drugs - Refer patients to other health care providers- Delegate duties to medical assistants - Order hospice care - Maintain malpractice insurance.,9,SENATE BILL 491 (SB 491),Source: California Legislative Information, SB 491 http:/legin
36、fo.legislature.ca.gov/faces/billVersionsCompareClient.xhtml,AUGUST 2013: SENATE 491 AMENDED AS FOLLOWS:Existing law, the Nursing Practice Act, provides for the licensure and regulation of nurse practitioners by the Board of Registered Nursing. Existing law authorizes the implementation of standardiz
37、ed procedures that authorize a nurse practitioner to perform certain acts, including, among others, ordering durable medical equipment, and, in consultation with a physician and surgeon, approving, signing, modifying, or adding to a plan of treatment or plan for an individual receiving home health s
38、ervices or personal care services. A violation of those provisions is a crime.SB 491 Supporters withdrew their support. Supporters believed SB 491 would increase Californians access to care, reduce paperwork burdens, and promote high-quality primary health care. SB 491 Opposition believed this bill
39、compromised patient safety. The physician groups emphasize collaborative care provided by a physician-led team is ideal. They indicate requirements for standardized protocols and physician review are in place to ensure that patient care includes the involvement and oversight of a physician who is su
40、bstantially more qualified and experienced to oversee patient care, both in depth and in years of education and training, than a nurse practitioner practicing alone.,10,SB 491 AMENDED,Source: California Legislative Information, SB 491 http:/leginfo.legislature.ca.gov/faces/billVersionsCompareClient.
41、xhtml,According to the 2012 Technical Assistance Collaborative (TAC) and the Human Services Research Institute (HSRI) California Mental Health and Substance Use System Needs Assessment : Approximately 4.3 million Californians currently without health coverage will now be eligible for health insuranc
42、e in 2014. Many of these newly insured will need mental health and substance use services.Estimated 200,000 persons in increased demand for mental health services. Estimated 115,000 persons in increased demand for substance use services.New enrollees can be expected to be more disabled and more expe
43、nsive to serve than the Medi-Cal non-disabled population, but substantially less disabled and less expensive than the current Medi-Cal disabled populationMuch of the heavy lifting for healthcare reform implementation will occur at the state and even county levelWhile experts interviewed indicated th
44、at it was “difficult” to estimate specific numbers of PNPs and CNSs needed upon the Patient Protection and Affordable Care Act (PPACA) implementation, the changing demands of this nations complex healthcare environment require the highest level of scientific knowledge and practice expertise to assur
45、e quality patient outcomes*,11,Source: *California Institute for Mental Health, Jarvis Brief Papers http:/www.cimh.org/LinkClick.aspx?fileticket=qYRw198CQAo%3D&tabid=36,FUTURE NEED,According to the National Association of Community Health Centers report Building a Primary Workforce for the 21st Cent
46、ury:Health centers are increasingly challenged to meet their primary care workforce need. Health centers currently need 1,843 primary care providers, inclusive of physicians, nurse practitioners, physician assistants, and certified nurse midwives. On top of this need, they are 1,384 nurses shortTo r
47、each 30 million patients by 2015, health centers need at least an additional 15,585 primary care providers, just over one third of whom are non-physician primary health care providers. Health centers also will need another 11,553 to 14,397 nursesTo reach 69 million patients, health centers will need
48、 at least 51,299 more primary care providers over the current number, as well as an additional 37,981 to 44,522 nurses,12,Source: *National Association of Community Health Centers http:/ NEED,Californias RN workforce is growing, but aging as the average age of working RNs is 47.2, and nearly half of
49、 the workforce is over 50 years old Over 40 percent of RNs are non-White, but the Latino population remains underrepresented Men continue to be underrepresented, making up only 14 % of Californias RN workforce Despite the large increase in nursing school enrollments, demand for education still far e
50、xceeds the supply,DRAFT,13,CURRENT STATE KEY ISSUES AFFECTING FUTURE NEED,Patient Protection and Affordable Care Act (PPACA) is expected to both increase demand for health care services resulting from expanded insurance coverage Potential for NPs to become needed providers, but barriers included the scarcity of post-graduate specialty programs and the prevailing culture of physician specialty practices The role of NPs has been somewhat limited due to the lack of legislation expanding their scope beyond the traditional scope of practice for RNs,
