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The Emerging Role of Nursing in the Delivery of Psychiatric Care

Although we have always known that mind and body are connected, there is now increased understanding that mental and physical health are closely intertwined. Recent studies indicate an interaction between symptoms of mood and anxiety with exercise, diet, and overall health, as well as chronic diseases such as diabetes, gastrointestinal illnesses, and cardiac disease (Kiecolt-Glaser, Derry, & Fagundes, 2015). Another body of research has shown that early life trauma results in increased risk for obesity, cardiac disease, cancer, and substance use as well as depression, suicidal behavior, and psychiatric hospitalization (See ACEs Study at CDC.gov). Beyond these relationships, many of the pharmacologic treatments utilized to address behavioral health carry the risk of producing metabolic syndrome, a combination of weight gain, increased cholesterol, and the development of diabetes. These factors reinforce the emerging consensus that behavioral providers must attend to the individual’s total health. We can no longer label our clients’ physical health as someone else’s problem.

Across the country the medical and mental health communities have developed new approaches to the total care of the individual. These efforts have been described as “integration” or “co-location” (Raney, 2015). In practice, the models take several general forms. First, there are new expectations that primary care providers monitor behavioral health parameters such as depression and anxiety. Regulatory expectations dictate the administration of instruments such as the PHQ-9 measure for depression. Subsequent interventions in the primary care setting include pharmacologic treatments coupled with counseling and consultation. A complementary, although less popular model entails locating primary care providers in mental health settings for ease of access. In contrast to these approaches, other groups have co-located full medical and mental health services in the same delivery system. In our area, mental health and primary care providers have embarked on an intensive effort to enhance collaboration and develop integration.

In addition to integration models, in New York’s statewide Health Homes program, individuals with chronic medical and psychiatric conditions receive care management to best coordinate services delivered by community medical and psychiatric providers. As part of all of these efforts, agencies around our area and across New York State are working to develop electronic record systems that can, with proper privacy protections, share information between behavioral and medical providers.

As the drive toward integration unfolds, mental health agencies themselves are enhancing their capabilities to monitor and manage physical health needs. This has taken on a number of dimensions. Mental health providers are increasing their surveillance of the metabolic impact of treatments with more regular laboratory studies of diabetes indicators and cholesterol, periodic weight monitoring, and regular blood pressure measurements. Coupled with increased surveillance is an expectation of more consistent outreach to primary care providers to obtain critical information regarding diagnosis, laboratory results, and prescribed medications. This data is now regularly summarized in the “Continuity of Care Document,” the so-call “CCD,” that is an integral part of all electronic medical records. This document facilitates the rapid transmission of information between providers. As regional and statewide networks solidify, providers will be able to exchange this document (with proper consent) to coordinate care.

With an eye to the need for increased comprehensive evaluation and monitoring of clients, mental health agencies are now adding additional professionals to their teams, with a specific emphasis on nursing. At Westchester Jewish Community Services (WJCS) we have integrated three levels of nursing care—licensed practical nurses (LPNs), registered nurses (RNs), and psychiatric nurse practitioners (PNPs) into our teams. LPNs undergo a one-year training program and are licensed by the State. They are trained to gather and monitor health information, administer medication, and provide health education. At our agency LPNs meet with new clients to obtain a health history, measure vital signs, and record medications prescribed by outside providers. This information is then entered directly into the EHR. The system utilizes this information to identify possible interactions between medical conditions, allergies and all prescribed medications. As part of the initial evaluation, LPNs reach out directly to primary care providers and specialists in the community to obtain records.

Beyond the initial health screening, LPNs re-evaluate our clients on a regular basis to assess vital signs, weight, and ongoing health issues. With their medical training they can also assist in obtaining prior authorization of pharmacologic agents. In addition, LPNs co-lead health education and wellness groups. Wellness is an area that, until recently, has largely been neglected. These groups focus on promoting improved health behaviors and optimal engagement in both medical and psychiatric treatment. In addition, LPNs participate in tobacco use identification, education, and referral. There is now ample evidence that individuals with mental illness are at greater risk for tobacco use and concomitant health problems.

Registered nurses (RNs) have 2-4 years of training and are licensed by the State. In WJCS group homes they play a central role in the care of the more than 100 individuals with developmental disabilities. RNs evaluate health needs, administer medication and supervise others to provide medication administration, coordinate care between our providers and medical specialists in the community, and work with our psychiatric providers to develop, administer, and assess the impact of psychiatric treatments. Their role is particularly critical given the wide-ranging health needs of people with developmental disabilities.

Health homes, another dimension in the drive toward integration, utilize care managers to work with individuals who suffer from chronic psychiatric and medical conditions. At WJCS an RN leads our Health Homes Adult Care Management program. Using her medical expertise, she assesses eligibility for services based on medical conditions, interprets medical tests and treatment plans, and directs care managers in the scheduling of tests and follow-up care, all tasks that require her nursing training. Currently she is overseeing the care management of 240 individuals.

Psychiatric nurse practitioners and family psychiatric mental health nurse practitioners (PNPs) are uniquely qualified to address both psychiatric and medical needs of individuals with mental illness. PNPs have a two-year Masters’ degree beyond the Bachelor of Nursing degree. They receive comprehensive education in psychiatric disorders and psychopharmacology. Based on the orientation of the training program, PNPs develop expertise in the psychiatric management of children, adolescents, and adults. With their licensure they can prescribe medication under the umbrella of a collaborative relationship with a psychiatrist.

Because most PNPs have usually spent several years as RNs working in psychiatric settings such as inpatient units, partial hospitals or day programs, and emergency settings, they have a special hands-on appreciation for psychiatric illness. But beyond this, their medical training equips them to evaluate individuals across all dimensions and coordinate with medical providers. PNPs at WJCS carry full caseloads, perform comprehensive diagnostic evaluations, provide ongoing treatment with psychotropic medications, monitor health conditions by gathering vital signs and ordering laboratory studies, and coordinate with outside primary care providers and specialists. Through collaboration with WJCS psychiatric staff they receive ongoing supervision and training to enhance their expertise and extend their services to special populations such as children and individuals with developmental disabilities. This truly comprehensive approach to individuals with mental illness has resulted in improved health for WJCS clients.

Going forward, nursing will play an expanding role in the delivery of integrated mental health and psychiatric care. With their unique blend of medical and psychiatric training and experience, they are well positioned to care for the whole person.

Dr. Levin is Medical Director, Westchester Jewish Community Services, and Assistant Clinical Professor of Psychiatry, Columbia University. He can be contacted at WJCS via email at alevin@wjcs.com.

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