Can Nurses Be the Cornerstone of Integrated Care?
Feature article: Can Nurses Be the Cornerstone of Integrated Care?
Grantee Feature: Nurses: The Right Fit for Tri-County Community Mental Health Center’s Team
Quick Tips: 5 Ways Nurses Can Advance Bidirectional Integration
Featured resource: Core Competencies
Gail W. Stuart, PhD, RN, FAAN, Dean and Distinguished University Professor, College of Nursing, Medical University of South Carolina; President, Board of Directors, Annapolis Coalition on the Behavioral Health Workforce
The broader healthcare field has been talking about providing integrated care for some time now, but how can we move “integrated” from a descriptive adjective to an action verb?
The answer connects to understanding how the largest group of healthcare providers can aid in this movement. There are more than 3.1 million registered nurses in this country who provide care in every community and in a wide variety of settings. They are often the first provider you see if you need healthcare services.
Some of these nurses have graduate degrees and assume the role of Advanced Practice Registered Nurses (APRNs). The largest majority of APRNs are primary care nurse practitioners, and some are specialists in psychiatric-mental health nursing.
For a moment, however, let’s focus on those nurses who do not have advanced education in behavioral health. The behavioral health specialty workforce, in general, is few in numbers and we clearly need more of every type of mental health provider (Hoge et al, 2014), including advanced practice psychiatric nurses (Hanrahan et al, 2012). But I believe that we will never truly achieve integrated care if we rely solely on the specialty workforce.
What is needed is greater preparation in mental health and substance use issues among all nurses, including those without graduate degrees and those who are pediatric, adult and family nurse practitioners in primary care settings.
If all nurses on the front line of care had essential skills in recognizing, assessing, briefly treating and appropriately referring those with mental health and substance use problems, we might begin to move “integration” into that action mode of truly making a difference.
What essential skills need to be taught?
We are not far from where we need to be. For registered nurses, Essential Psychiatric Mental Health and Substance Use Competencies for Registered Nurses have been identified. At this level, all registered nurse programs must increase their focus on:
- motivational interviewing to engage individuals in self-care
- focused and universal screening for and identification of mental health and substance use issues
- incorporation of SBIRT to screen for substance use disorders
- use of behavior change interventions including elements of cognitive behavioral strategies
- effective triage of behavioral health problems based on level of severity and available resources, and
- appropriate referral to specialty providers.
Those educational programs preparing nurse practitioners to work in primary care should seek to achieve the Core Competencies for Integrated Behavioral Health and Primary Care. These need to become the core of all graduate programs in nursing preparing primary care providers.
Can we think outside the box?
What about the 3.1 million nurses who are currently in the workforce and no longer in school? Let’s open the doors for them to new ways of life-long learning.
Working with other healthcare providers, we could offer “boot camps” focused on essential skills for integrated care; certificates of added qualification using online modules that can provide “anytime, anywhere” learning in integrated care; and focused sessions that master the use of telehealth and other mobile technologies to reach people in rural and underserved communities.
Even more creatively, we can plan and implement a new type of graduate program in integrated care that is truly interprofessional in nature, and focuses on team as well as individual competencies (Feldman & Feldman, 2013).
The possibilities are exciting if we can take the opportunity to move forward rather than seeing the dynamic between academia, credentialing bodies, and professional guilds as a barrier.
Hoge, M, Stuart, G, Morris, J, Flaherty, M, Goplerud, E, Parris, M. Mental health and addiction workforce development: taking plans and strategies to scale, submitted Health Affairs, 2013; 32 (11); 2005-2012.
Hanrahan, N, Delaney, K, Stuart, G. Blueprint for developing the advanced practice psychiatric nursing workforce, Nursing Outlook, 2012; 60: 91-106.
Feldman, M, Feldman, S. The primary care behaviorist: a new approach to medical/behavioral integration, J Gen Intern Med, 2013, 28 (3), 331-332.
Christian Barnes-Young, Project Coordinator, Primary Behavioral Health Care Integration, Tri-County Community Mental Health Center
Tri-County Community Mental Health Center is one of 17 community mental health centers in South Carolina’s Department of Mental Health, and serves three rural counties in the northeastern region of the state. The population that Tri-County serves is rich with culture and hardworking people, yet it also has high rates of health disparities. The area is a “hotspot” for obesity, high blood pressure, diabetes, hyperlipidemia, and chronic obstructive pulmonary disease (COPD). Clients with complex presentations have come to be the expectation instead of the exception.
It takes a special person to effectively care for individuals with both serious mental illness and chronic health conditions. In Tri-County’s Primary and Behavioral Health Care Integration (PBHCI) program, two of those special people are nurses. As a SAMHSA PBHCI grantee, Tri-County tried several staffing models of integration. Tri-County decided the best fit for their needs was to have family nurse practitioner Sylvia Watts as the contract primary care provider with the support of an embedded licensed practical nurse, Amanda Steen. Watts’ time is covered by Chesterfield General Hospital, Tri-County’s contract partner for primary care, and Steen’s is covered by Tri-County.
Tri-County’s goal is to provide customer-oriented care. With the extensive needs that clients of our PBHCI program have, a nurse’s willingness to adapt to change is an indispensable asset. Due to the large geographic area Tri-County serves, many clients have to arrange for transportation for their appointments. That means the team, including Watts, needs to maintain a flexible schedule to accommodate clients or see those who were not able to make it to their appointments on time. Steen’s attention to detail and coordination of various professionals’ schedules—psychiatrists, care coordinators, mental health professionals, peer support specialists, and other nurses—ensures that client needs get met efficiently and effectively.
Professionalism, empathy, and physical endurance are characteristic of the nursing profession. The people Tri-County serves face high rates of unemployment and poverty, and many are uninsured. Watts’ background in nursing helped her realize that if these clients did not receive primary care, they would rely on emergency rooms at hospitals to address their healthcare needs. The nurses in our PBHCI program maximize patient assistance programs and call on care coordinators to locate resources to meet unmet needs.
The nurses at Tri-County’s PBHCI program are saving lives. Watts recently found a lump in a client’s breast during a routine exam, and the client received a biopsy and subsequent mastectomy at no cost.
“Nursing services have been indispensable to our PBHCI program,” says Michael Rooney, Executive Director of Tri-County Community Mental Health Center. “Watts and Steen deliver high-quality healthcare services with compassion and excellent rapport with individuals with mental illness, and embody the nursing traits of diligence, compassion, and good communication.”
The value of nursing is not overlooked by the leadership of Tri-County or its contract partner for primary care, Chesterfield General Hospital. “Cost is a concern for all providers in today's challenging healthcare environment. To combat some of those challenges and yet ensure high quality care is received by the patient, hiring a nurse practitioner for the PBHCI program was an obvious choice,” said Jeff Reece, Market CEO of Chesterfield General Hospital, adding, “Watts has done an exceptional job in that role.”
Nurses are an essential part of our PBHCI team. They play a critical role in addressing the whole health needs of the people we serve.
What role do nurses play on your integrated care team? Share your story, email firstname.lastname@example.org.
Nurses can play many roles on the integrated care team. As a critical member of the team who has frequent interaction with the individual client, here are five ways nurses can help advance primary and behavioral healthcare integration efforts.
- Nurses can counteract negative attitudes and discrimination about behavioral health conditions by approaching mental health and substance use problems in the same way they deal with hypertension, diabetes, and other common medical problems.
- Nurses should routinely screen for mental illness, history of trauma, substance use, and suicide risk in all health care settings. Nurses in behavioral health settings should be paying special attention to tobacco use, blood pressure, and signs of diabetes.
- Nurses can advocate for increased access to specialized mental health care for both children and adults.
- Nurses should identify resources in their community to assist in crisis intervention and specialty treatment.
- Nurses can work to reduce the social determinants of health that contribute to behavioral health problems in their communities.
What other ways do nurses support integration? More resources for nurses working in integrated care can be found on CIHS’ Nurses page.
CIHS and the Annapolis Coalition on the Behavioral Health Workforce developed Core Competencies for Integrated Behavioral Health and Primary Care to shape workforce training, inform job descriptions, recruit ideal candidates, orient staff to the integrated care model, and complete performance assessments. Be sure to visit the workforce section of the CIHS website for up-to-date resources relevant to all parts of the integrated care team.
On Wednesday, June 11, SAMHSA will hold a public listening session to seek public input on potential changes to the regulations for the Confidentiality of Alcohol and Drug Abuse Patient Records Regulations, 42 CFR Part 2. This session will be held in Rockville, MD, and via conference phone, to obtain direct input from stakeholders on updating the regulations to support use in integrated care.
HRSA has announced a funding opportunity for academic, government, public, private and nonprofit institutions to apply for the Center for Integrative Medicine in Primary Care program to incorporate a competency based integrative medicine curricula and practices into existing primary care residency and other health professions training programs.
SAMHSA released a new TIP sheet on Trauma-Informed Care in Behavioral Health Services to assist behavioral health professionals in understanding the impact and consequences for those who experience trauma. It discusses patient assessment, treatment planning strategies that support recovery, and building a trauma-informed care workforce.
The Centers for Disease Control and Prevention’s (CDC) Office of Smoking and Health has released new resources designed to promote the 50th Anniversary of the first Surgeon General’s Report on Smoking and Health.
The CDC released infographics on the health consequences of smoking on vision, including how smoking is known to cause age-related macular degeneration and cataracts; both diseases are major causes of blindness. Post the infographics to your website, blog, or social networking site.
The Centers for Disease Control and Prevention classifies prescription drug abuse as an epidemic. At the same time, more than 100 million Americans suffer from chronic pain, and many do not receive adequate treatment or the appropriate options for managing pain. How can health centers and HRSA-supported safety net providers play a vital role in achieving the balance between appropriate pain management and preventing abuse of prescription medications? Creating a solid organizational infrastructure to support provision of effective chronic pain management is an essential first step. Join the CIHS webinar, Building Organizational Infrastructure to Treat Chronic Pain and Prevent Abuse of Prescription Medications on June 5 to hear expert insight from provider agencies and technical assistance authorities and learn what health centers and HRSA-supported safety net providers can do to develop infrastructure and pain management protocols.