Midlevel practitioners help workforce shortage in psychiatry

As the gap widens between the need for mental services and the availability of psychiatrists, consequently, demand for “physician extenders” has increased significantly. Across the country, nurse practitioners (NPs), advanced practice registered nurses (APRNs), and in some cases, physician assistants (PAs), are taking on more of the psychiatric case load.

The availability of these midlevel providers can be invaluable, says Joe Parks, MD, medical director at the National Council for Behavioral Health.

Parks also practices psychiatry at the Family Health Center, a federally funded community health center (CMHC) in central Missouri, where an advanced practice psychiatric nurse and three behavioral healthcare consultants have allowed him to serve roughly eight times as many people than he could if he were treating them himself.

“We will never meet everybody’s needs seeing all of the patients ourselves,” Parks says.

By utilizing the advanced practice nurse, he can spend less time doing routine medication refills, for example, and spend more time with patients who require an in-person consultation. Before, patients waited months to see a psychiatrist.

“In this way I’m always operating much closer to the top of my credentials,” Parks says. “It’s a different kind of work for me. I work harder. I’m able to see many more people and it has really changed my practice.”

Nurse practitioners are playing a key role in extending access to mental health and substance use treatment services, but how they are utilized varies by state. According to the National Council, 21 states and the District of Columbia give NPs full practice authority so that they can diagnose, treat, order diagnostic tests and prescribe to patients without physician oversight. In other states, NPs must work in collaborative practices under the direction of a supervising psychiatrist. Other states restrict NPs ability to prescribe certain medications.

Physician assistants are also emerging as a potential source of help for psychiatric practices. In a paper published in March, titled “The Psychiatric Shortage: Causes and Solutions,” the National Council wrote that “PAs with specialty psychiatric training are a relatively new development that has tremendous potential for expansion. Since their duration of training is the shortest of the psychiatric prescribers, they represent one of the most cost-effective solutions to the shortage of psychiatric workforce.”

Talent search

Demand is increasing for midlevels. According to data from healthcare job matching site Health eCareers, there was a 17% increase in psychiatric nurse practitioner job opportunities between 2014 and 2015, making the field one of the fastest growing non-physician specialties.

Regulations are starting to shift to make it easier to integrate midlevel providers into these practices. In 2016, federal officials announced the expansion of the ability to prescribe buprenorphine to NPs and PAs with specialized training. The Veterans Administration has also extended full practice authority to NPs across the United States.

Other efforts to leverage midlevel providers to extend psychiatric care are also underway. Several national PA organizations convened a mental health summit earlier this year to identify ways that they can help address the psychiatrist shortage. The groups acknowledge that more work needs to be done to establish a framework to help train PAs for mental health and addiction treatment.

“That’s not downplaying the importance of physicians,” says Tari Dilks, PhD, associate professor of nursing at McNeese State University in Lake Charles, La. “If you can’t find a psychiatrist to collaborate with, you can’t practice in many states.”

Dilks is co-coordinator of McNeese’s Master of Science in Nursing programs and director of the psychiatric/mental health track for the Intercollegiate Consortium for a Master of Science in Nursing partnership and has an active private practice.

She believes that full practice authority will eventually reach all 50 states, and several more are already moving in that direction. Parks, however, thinks that there is a lot of value in collaborative practices that aren’t related to the abilities of NPs.

“I really think we’re better off in collaborative practices,” he says. “Everybody is, including the psychiatrist and the patients.”

The potential to help expand the psychiatric workforce is significant. In 2014, there were 140,000 APRNs, and 13,815 psychiatric mental health APRNs specializing in psychiatry, according to the American Psychiatric Nurse Association (APNA). In addition, approximately 1,000 physician assistants are prescribing psychiatric medications in the U.S. according to the American Academy of Physician Assistants (AAPA). The National Council believes that board certified psychiatric pharmacists can also help meet the demand for services.

NPs and leadership

In psychiatry and in subspecializations like substance use treatment, there is what Genie Bailey, MD,  calls “a real market for midlevel providers.”

Bailey is a board certified psychiatrist and director of research and medical director of the dual diagnosis unit at Stanley Street Treatment and Resources in Fall River, Mass. The dual diagnosis unit is run by a skilled nurse practitioner who functions as the unit chief (backed up by a medical director).

“The NP is making clinical decisions, diagnoses, prescribing on her own,” Bailey says. “There is access to her medical decision making in the EMR, but she practices pretty much on her own.”

The facility’s detox center is also run by a nurse practitioner where NPs have been “instrumental in extending treatment to the underserved,” Bailey says.

In Massachusetts, the NPs must have a psychiatrist of record sign an agreement that outlines expectations, restrictions and practice scope. The state requires regular meetings, but doesn’t specify the frequency of those meetings. The bulk of the agreement is determined by the psychiatrist and the NP.

Dilks thinks integrated practice situation with NPs providing psychiatric services in conjunction with psychiatrists and primary care physicians will be the most effective model.

“I have patients without primary care providers, and it’s difficult to get them to go to one,” Dilks says. “There are also primary care doctors that can’t get patients to go to a psychiatrist because of the stigma. If you are co-located, then you can provide more comprehensive care.”

For example, in Louisiana, Dilks cites a nurse practitioner in family practice who established a federally qualified health center (FQHC) that provides psychiatric, dental and medical health services in the same location. It can save on costs and overhead, while also driving care coordination.

Bailey says the movement toward NPs is certainly driven by cost and reimbursement.

“In mental health and substance abuse, psychiatric nurse practitioner reimbursement means that the facility can break even,” she says.

Cultural and financial obstacles

While patients largely view the NPs and other midlevels as equal to their doctors, there are still psychiatrists resistant to this model of care. In some cases, the psychiatrists are entrenched in their own independent practices and prefer it that way. Others may see these lower-cost alternatives as a threat to their reimbursements.

But most recognize the need to extend care by any means available.

“We have a shortage of psychiatrists and primary care doctors, for that matter, and we have a population with a need for care,” Bailey says. “We have smart, motivated, intelligent people who are trained in this area of expertise. They can do quite well, and they cost less.”

In some cases, resistance can be met with better education.

“There are psychiatrists that don’t want to practice in this manner,” Parks says. “But we never trained them how to do this. They aren’t trained to work on a team. Around 44% of them are in cash-only practices. They can run their own offices, but they’ll never meet all the patient needs that way.”

Bailey, who has been working with NPs in various settings for decades, sees the integration of NPs and other practitioners in psychiatry as a must.

“We need physician extenders,” she says. “I’ve always been of that mindset, that they aren’t taking things away from me. They are building the workforce.”

NPs can also provide some unique services. In many cases, they are trained in psychotherapy as well as medication management, a skillset that is on the decline among psychiatrists.

Funding and training are critical

Funding and reimbursement remain some of the biggest hurdles for expansion of psychiatric practices via NPs and PAs in most states. At Parks’ practice, the advanced psychiatric nurse is covered, but the behavioral health consultants he works with are only spottily covered for certain billing codes, so it would be difficult to sustain the model outside of an FQHC, he says.

State law also varies, so that NPs in Washington state, for example, have much more latitude in their practices than their counterparts in Louisiana and elsewhere. Additionally, some hospitals may not allow admitting privileges to NPs.

Prescribing can also be complicated by pharmacy benefit management services. While an NP may be able to prescribe in their home state, if the prescription is fulfilled by a third-party service in a different state the prescription might be denied.

“I would write a prescription in Louisiana, but it would get sent to Missouri, and they couldn’t fill it because NPs in that state can’t write for it,” Dilks says. “It requires a collaborator, so you use that physician’s DEA number. It’s a complex issue that requires some creative thinking.”

The National Council has recommended that nurse practitioners, physician assistants and clinical pharmacists with specialty psychiatric certifications play an even larger role in psychiatry to meet what is becoming a critical shortage of providers.

Training will be an important part of that expansion. Currently, programs vary when it comes to the level of psychiatric training.

“Everyone is trying to find a way to make this work, and a lot of it has to do with finding the right person who can thrive in the job, do it competently, and who enjoys doing it,” Bailey says. “The training programs vary tremendously. Some have a lot of psychopharmacology training, and others have very limited experience and don’t feel comfortable working in this environment.”

A number of colleges are expanding mental health curriculum within their nurse practitioner programs, including Florida Atlantic University and Ursuline College.

In its report, the National Council recommended more regional and state collaborations to increase the geographical distribution of NP and PA psychiatric specialty programs, and to incentivize professional mental health NP program development in high-need regions. They also recommend collaborating with the Health Resources and Services Administration (HRSA), APNA, AAPA and other organizations to map out the development of specialty training programs for professional mental health NP fellowships and specialty training programs to certify PAs in psychiatry.

“Many specialties have a physician assistant with them, and I think that’s a very appropriate model for psychiatry,” Parks says. “There are about 1,000 psychiatric physician assistants, but just eight post-graduate training programs. And those are the kinds of programs that could be set up by a large FQHC or a big CMHC.”

As the need grows more critical, Parks says more psychiatric practices are going to need to embrace this model, and states will need to drop restrictions on what NPs and PAs can do within those practices.

Parks himself was driven by the unmet needs he saw at his own integrated practice. “It’s a personal, ethical choice, and I felt an increasing level of obligation to all the patients I haven’t see yet,” Parks says. “I miss those happier visits and the long-term relationships with the patients who have already received care, but more people are getting effective treatment, and there is less suffering.”

Brian Albright is a freelance writer based in Ohio.