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Mental disorders are the leading cause of non-communicable disability worldwide. Insufficient numbers of psychiatrically trained providers and geographic inequities impair access. To close this treatment gap, the World Health Organization (WHO) has called for the integration of mental health services with primary care. A new innovative online program is presented that increases access to mental health education for primary care nurse practitioners in designated mental health professional shortage areas. To create successful and sustainable change, an overlapping three-phase strategy is being implemented. Phase I is recruiting and educating primary care nurse practitioners to become competent and certified psychiatric mental health nurse practitioners. Phase II is developing partnerships with state and local agencies to identify and support the psychiatric mental health nurse practitioner education and clinical training. Phase III is sustaining integrated mental health care services through the development of nurse leaders who will participate in interdisciplinary coalitions and educate future students.
According to the World Health Organization (WHO) Constitution , “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. Mental health is a fundamental human right in which individuals “realize their own abilities, cope with the normal stresses of life, work productively and are able to contribute their communities” . While the burden of communicable diseases has decreased over the last decade, the burden of mental and behavioral disorders has risen to become the largest worldwide contributor to years lived with disability . Globally, suicide accounts for 50% of the violent deaths of men and 71% of those of women . Poor mental health is associated with increased risk for poor physical health. Persons with severe mental health problems are highly likely to have complicated medical problems, with depression or schizophrenia increasing the risk of premature death by 40-60% .
The majority of people with mental health problems do not get the care they need . A major barrier to care is the shortage, especially in rural areas and lower income countries, of psychiatrists, psychiatric nurses, psychologists, and social workers. Much of the burden of mental health care falls to primary care providers and clinics. Upwards of 25% of individuals who visit primary care clinics have a diagnosable mental disorder . Unfortunately, mental disorders often go untreated in primary care because they are undetected and undiagnosed . Most primary care providers do not have sufficient training to provide comprehensive person centered psychiatric care and are at risk for medicalizing the disorders they identify, treating patients with medication, even where psychotherapy, family or social services may be sufficient .
The WHO has been leading the way toward improved mental health for all through primary care, beginning with the Declaration of Alma Ata in 1978 . Primary care for mental health was defined by the WHO as first line interventions that are provided as an integral part of general health care and are provided by primary care workers who are skilled, able and supported to provide mental health care services . Primary care clinicians are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of family and community .
The WHO and World Organization of Family Doctors (WONCA)  list seven good reasons for integrating mental health care into primary care: 1) The burden of mental disorders is great; 2) Mental and physical health problems are interwoven; 3) The treatment gap for mental disorders is enormous; 4) Primary care for mental health enhances access; 5) Primary care for mental health promotes respect of human rights; 6) Primary care for mental health is affordable and cost effective and 7) Primary care for mental health generates good health outcomes. The most recent WHO mental health action plan four 2013-2020 describes a comprehensive approach to integrated mental health care . The goal of the plan is to promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights, and reduce mortality . One of the four key objectives is to provide comprehensive integrated mental health and social services in community based settings.
A key action step toward achieving this objective is human resource development, including the identification of gaps, specification of needs, training requirements and core competencies for health workers in the field, as well the development of undergraduate and graduate educational curricula. In many countries and health care systems, the integration of mental health care into primary health care will require recruitment and training of additional providers who have the knowledge and authority to prescribe psychotropic medicines . In the U.S., the mental health workforce shortage is greatest for psychiatrists and advanced practice psychiatric nurses, especially in rural areas . Rural counties express challenges in recruiting and retaining psychiatrists. Patients that have limited access to community based behavioral health services often find themselves with no other option than to seek care in the hospital setting. Across Maryland, a relatively small eastern U.S. state, there is limited access to mental health services . Fifteen of 24 whole counties in Maryland have a federal mental health professional shortage area (HPSA) designation and the majority of those counties are geographically rural . Baltimore city, where the Johns Hopkins School of Nursing is located, has five partial federal mental health professional shortage designations .
Recruitment and education of primary care nurse practitioners from designated mental health professional shortage areas is the goal of an innovative online training program in Maryland. Because nurse practitioners have the authority to prescribe and nurse practitioners are often the providers of primary care services in underserved geographic regions of the state and for underserved populations, the Johns Hopkins School of Nursing developed an innovative curricula designed to train primary care nurse practitioners in the competencies needed to provide comprehensive mental health care services in a variety of integrated care settings. The program was developed and implemented with funding from a state sponsored, Maryland Higher Education Commission training grant, the Nurse Support II (NSPII), that has the purpose of expanding the capacity to educate nurses through nursing education programs at Maryland institutions. The program is currently being rolled out in three phases. An intersectoral approach and collaboration will enhance the success.
The aim of Phase 1 is to train primary health care nurse practitioners in HPSAs to better serve individuals with mental health needs within their communities. With the grant money received from the state of Maryland, we developed an accelerated online psychiatric mental health nurse practitioner program. The online program addresses health problems in underserved communities by training existing nurse practitioners who carry a caseload of patients with mental health needs. These nurse practitioners do not have to leave their jobs, families and communities to learn mental health care skills - we bring the education to them via online education and local clinical training. The online educational format will help retain the practitioners in their communities once they receive the additional training. The nurse practitioner graduates will be eligible to apply for certification as Psychiatric Mental Health Nurse Practitioners (PMHNPs), will have the competencies to provide comprehensive mental health services in integrated care settings and will have an understanding of integrated mental health care models that will benefit their communities.
The aim of Phase II is to align state and local resources to support existing primary care nurse practitioners in designated shortage areas to obtain post-graduate PMHNP training. This intersectoral approach involves the state Department of Health and Mental Hygiene’s Office of Access to Primary Care, the State Board of Nursing, local agencies, especially those funded by the state, the Johns Hopkins School of Nursing and potential philanthropic donations. Action steps that need to be taken include collaborating with state agencies to engage stakeholders in understanding and addressing current and future supply and demand for mental health services, track mental health workforce needs, develop financial incentives for nurse practitioners to return to school and develop and foster University - Mental Health system relationships for precepted clinical training and employment. The state currently offers a loan repayment program for physicians and physician assistants who agree to work in designated shortage areas, but not for nurses or nurse practitioners.
The third phase and long-term goal is the strengthening of a comprehensive integrated mental health care system that meets the mental health needs of the communities served by the PMHNP graduates. Successful integrated mental health care systems are dependent upon collaborative practice, defined by the WHO as health care that “occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers and communities to deliver the highest quality of care across settings” . The Johns Hopkins School of Nursing Post-graduate PMHNP program aims to produce graduates who are “collaborative practice ready” by weaving a focus on integrated healthcare and collaborative practice throughout the educational program, including expert speakers from nursing, psychiatry, psychology, and social work and seeking clinical training opportunities in collaborative practice settings. This includes building in the knowledge and skills inherent in the four collaborative practice competency domains identified by the Interprofessional Education Collaborative Expert Panel : 1) values and ethics for interprofessional practice; 2) roles and responsibilities; 3) interprofessional communication; and 3) teams and teamwork.
Sustainability will also result from increasing the number of nurse practitioners qualified to provide mental health services and clinical teaching in mental health professional shortage areas. Availability of PMHNPs who can precept future students will improve workforce and access. Educational content on leadership and a teaching project assignment are built into the curriculum to facilitate this role. The evidence shows that collaborative practice and integrated health care systems produce better health outcomes [2, 5, 11], however understanding the specific impact of the Johns Hopkins Post-graduate PMHNP program will require the collection and evaluation of data regarding the PMHNP certification pass rates of graduates, employment settings and locations, employer and community perceptions of the value of PMHNP, roles in health care teams and availability and willingness to teach future students.
Potential challenges to the success of the program include finding the right primary care nurse practitioners for the mental health training. Program failure is common when community health care providers are recruited to underserved areas for the wrong reasons, or when there is insufficient intrinsic and extrinsic motivation or support for them to stay in their communities. Motivators that encourage recruitment and retention of health care providers in rural communities include extrinsic motivators such as better pay and loan repayment options or forgiveness and intrinsic motivators such as greater independence and a varied caseload . We will be working on setting up training and partnerships within the communities of these nurse practitioners, however without the support of the community stakeholders (health care agencies and psychiatric providers), this will be difficult.
With the new Affordable Care Act, we are expecting mental health care to become more accessible to millions of Americans. With a huge influx of patients with mental health needs, there will be a greater need to strengthen the horizontal intersectoral comprehensive mental health systems. This will be the most difficult, but most important challenge of this project. We can train a practicing primary care nurse practitioner to be a competent psychiatric mental health nurse practitioner, but this is just one person. Mental health for all includes living conditions and environments that support healthy lifestyles with freedom from severe stress. Only an intersectoral approach to mental health care can help achieve these long-term goals.
In line with the WHO call for psychiatrists to take action , psychiatric nurses can facilitate the implementation of the WHO mental health plan. As members of professional associations we can assist in the development of progressive national policies and legislation and mental health service reorganization. As leaders of mental health in their countries, we can join interdisciplinary coalitions to advocate for change. As service providers, we can provide evidence based mental health care in integrated care systems. As teachers and trainers, we can educate other nurses, staff, and community health workers to reduce stigma and barriers to detection and improve the delivery of mental health services. As educators, psychiatric nursing faculty and schools of nursing have a large role to play in the development of curricula and in forging clinical training partnerships with primary care and mental health service agencies in underserved geographic areas and for underserved populations. As a component of evidence based care, psychiatric nurses can participate in the collection of essential information, the evaluation of patient and program outcomes, and the implementation of state and national mental health initiatives.
The author confirms that this article content has no conflict of interest.
The development of the Johns Hopkins University School of Nursing post-graduate psychiatric mental health nurse practitioner program was supported by a Nurse Support Program (NSP II) grant that was funded by the Maryland Health Services Cost Review Commission and administered by the Maryland Higher Education Commission.