- Email: [email protected]
Establishing a Web-Based Academic Toolbox for Primary Behavioral Care
ORIGINAL RESEARCH
Establishing a Web-Based Academic Toolbox for Primary Behavioral Care Kathleen T. McCoy, DNSc, PMHNP-BC, E. Erwin Story, MBA, BBA, Kathleen Gaffney, MSN, PNP-BC, and Patricia D. Cunningham, DNSc, PMHNP-BC
ABSTRACT Background: Doctorate of nursing practice (DNP) students and faculty request additions to their curricula to prepare them in the basic mental health and substance use disorder (MH/SUD) care needs in generalist care settings. Objectives: Demonstrate effectiveness of resources gathered to facilitate safe and effective care to patients in generalist settings through a web-based Toolbox for Primary Behavioral Care Study Design: Faculty-designed/posted web-based resources for treatment and referral of common MH/SUD disorders. Results: A web site was organized and made accessible to all DNP students and faculty. Conclusion: Since 2008, posted resources assist in guiding safe practice with regular updates congruent to evidence-based guidelines. Keywords: academic toolbox, ambulatory care toolbox, evidence-based guidelines, primary behavioral care, primary behavioral care toolbox, web-based tools © 2011 American College of Nurse Practitioners
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he Institute of Medicine (IOM) promotes the democratic provision of healthcare for mental health, substance-use disorders (MH/SUD), and general health conditions. A fundamental change is required in how providers think and respond to these conditions if care is to be provided equally. The World Health Organization (WHO) and the IOM1 substantiate the longstanding trend that most antidepressants are prescribed and managed by primary care providers (PCPs). The American Psychiatric Association (APA) consistently finds that one-third of emergency department presentations are related to MH/SUD.2 Paralleling these trends is the current decrease of rural mental health providers, especially those with prescriptive authority. Integration of MH/SUD knowledge into the non-psychiatric/mental health nursing specialties is a daunting task. There has and continues to be a nursing faculty shortage, cited by Rother and Lavizzo,3 which poses difficulties in www.npjournal.org
teaching students psychiatric mental health content, presentations that exist in most settings, especially primary care, on any given clinical day. Additionally, chronic problematic reimbursement strategies, as outlined by Mauch et al.,4 continue to be an issue, leaving students and professionals perplexed with MH/SUD reimbursement complexities. Non-psychiatric/mental health advanced practice registered nursing (APRN) students and faculty requested support and additions to their curricula to adequately prepare them in the basic MH/SUD care needs in generalist care settings. The requests emphasize student and faculty desire to become skilled in evaluation, appropriate treatment, referral, and billing strategies in serving MH/SUD patients in primary care settings. BACKGROUND To answer the prevailing concerns, graduate faculty in the doctor of nursing practice (DNP) psychiatric/mental health The Journal for Nurse Practitioners - JNP
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(PMH) nursing option at an academic setting developed a settings, and this linkage of high anxiety and high website for non-psychiatric/mental health APRN faculty probability of MH/SUD presentations was identified and graduate students. Carefully selected materials, gathered as universal for non-psychiatric students and some facand posted in a straightforward manner, were used to build ulty. In response to this finding, a web-based toolbox the resource. Resources were diligently chosen and limited was created for generalist students and faculty memto include web-accessible material in keeping with current bers. Of primary concern to non-psychiatric students evidence-based guidelines. A project was adopted to define and faculty are the ability to diagnose accurately, to a methodical review using Melnyk’s Hierarchy of Evidence have effective strategies to treat or refer, to serve as an to assess current health literature appropriate bridge for 5 and improve healthcare literacy. patients who need PMH care This was used to screen websites but may have access barriers,8 and resources for appropriateness and to secure reimbursement The toolbox includes to this web-based toolbox. for their efforts. resources to promote The toolbox site includes Integration of behavioral remission of mental health easily accessed resources for healthcare into primary care management and referral stratehas been long studied and recsymptoms and optimize gies to promote remission of ommended. The integration patient safety. mental health symptoms and continues to be limited by lack optimize patient safety. of reimbursement knowledge, Emphasized are essentials of decreasing availability of practice management, provider knowledge, skills, and colMH/SUD prescribing professionals, and PCPs’ lack of laboration. Provided are the philosophical underpinnings knowledge. The need for integration is fueled by perand decision-making criteria for this approach. ceptions of social stigma.4 Stigma of receiving care from The purpose of this article is to demonstrate how the a PMH professional continues to be felt by patients, faculty responded to and addressed the identified knowledge who generally prefer to be treated by their PCP. deficits for effective care of common MH/SUD presentaAdditionally, copayments are frequently higher for mental health services, requiring more out-of-pocket paytions in generalist settings through developing an innovative ments for patients than non-psychiatric healthcare clinical tool, a web-based Academic Toolbox for Primary services. Behavioral Care. For the purposes of this article, primary The toolbox contains easily accessible and reliable care and generalist settings will be used interchangeably. resources to assist with clinical skill formation, as well as A Health Resources and Services Administration information for concerns of treatment and referral of (HRSA) Advanced Education Nursing6 grant promoted the web-based Academic Toolbox for Primary Behavioral commonly found MH/SUD in generalist settings. Care as it suited the philosophical underpinnings of this Practice management information to assist with payers, academic setting. The college lent strong support and coding, and billing guidelines for behavioral health in preparation of students to serve in integrated care roles primary care are included and supports the additional and settings to reduce healthcare barriers and disparities effort that may accompany integrative care. APRN genthrough education of the APRN workforce.7 The grant eralists often are unaware of the billing codes permitted facilitated the vision of preparing all DNP graduates to by the Center for Medicare & Medicaid Services for provide appropriate care across generalist and other care advance practice nurses, as well as the US Department of settings to vulnerable, underserved populations. Health and Human Services Reimbursement of Mental Health Services in Primary Care Settings guidelines.4,9 CHALLENGES TO INTEGRATIVE CARE These guidelines allow APRNs to provide MH/SUD As noted, the non-psychiatric clinical world includes services in primary care, obtain reimbursement in a many patients with comorbid MH/SUD. PCP general timely fashion, and serve the community more readily discomfort levels match the high probability of with reimbursement appropriate to services provided. All MH/SUD presentations on any given day in generalist are posted online to create easy access for busy clinicians 224
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during demanding clinical days. The resources can be uploaded onto a PDA or office computer.
with integration of such services within primary care settings, was identified and addressed in 1991 by U.S. Surgeon General David Satcher.15 He further isolated many obstaLITERATURE REVIEW cles, including lack of education, training, and practice The literature review required several searches. The first guidelines. Also identified was the growing trend of fewer search focused on the need for integrative care, followed psychiatrists and PCPs graduating medical schools, and by a brief historical overview through documentation of fewer still of those specializing in pediatrics.16 healthcare policy transitions regarding integrative care; Adding to lapses in the development of generally the results also included precedent-setting examples of accepted treatment plans17 is a convergence of forces: lack integrative care models. Lastly, consensus models, estabof evidence-based guidance, a general paucity of consensus lished guidelines, jointly adopted guidelines, and evifor treatment, lack of evidence-based bodies of knowledge dence-based clinical guidelines were reviewed. Available pertaining to broad-based and common MH/SUD probweb-based guidelines were reviewed and vetted by the lems treated in generalist settings, and lack of integration of experienced DNP-PMH faculty for appropriateness of these services in generalist care settings. clinical application using Melnyk’s Rating System for “Transformation of the Workforce” is the first of 10 Hierarchy of Evidence. three key competencies planned to fundamentally change MH/SUD care, as outlined in President Obama’s New NEEDS ASSESSMENT Freedom Commission on Mental Health.18 The In 2002, the WHO estimated there were 154 million Annapolis Coalition, a collaborative education initiative, people globally suffering from depression, 91 million was founded to develop a consensus on core behavioral people affected by alcohol-use disorders, and another 15 health competencies for the mental health workforce.19 11 million affected by drug-use disorders. Nearly 44 milAdditionally, the IOM has applied the criteria for intelion Americans experience mental health problems in any grative care in “Crossing the Quality Chasm” to also 7 given year; within this group, 5% to 7% of adults have include MH/SUD.1 serious mental illness and 5% to 9% of children have The second major competency needed is an under12 serious emotional disturbances. The vast majority of standing of current policy and reimbursement shifting. those suffering with mental problems were not seriously The recent passage of the Mental Health Parity Act20 and physically ill, and healthcare utilization most frequently the Mental Health Parity and Addiction Equity Act was related to conditions such (MHPAPEA)21 exemplify the as substance abuse, stress, lack of leaps made to correct payer coping skills, and depression.13 problems and address service Diagnostic guides, The WHO’s study of global inequities. A robust consensus to treatment algorithms, and primary healthcare clinics found further improve the MHPAEA, jointly adopted guidelines that the 69% of patients with recently cited by Bazelton et mental health disorders preal.,22 and the introduction of demonstrate the way to sented with co-occurring physSenators Stabenow and Levin’s treat and refer patients ical symptoms that were the “Mental Illness Chronic Care within established primary complaint causing Improvement Act”23 are examconsensus models. them to seek health care.14 ples of positive progress and Moreover, consumers are more current momentum to affect likely to seek generalist care and mental healthcare parity and treatment, avoiding the perception of stigma in payer strategies for more equitable coverage across setMH/SUD settings.11 tings. These address public and private sector payers and expansion of MH/SUD care to broader settings. HISTORICAL OVERVIEW OF POLICY SHIFT More initiatives like these are needed to ensure more The significance of the gaps and the clear advantage of equitable health care to the general public, and the adoptreating MH/SUD problems in generalist settings, along tion of these initiates is slow going at best, leaving www.npjournal.org
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Table 1. Rating System for the Hierarchy of Evidence Criteria Level I
Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on systematic reviews of RCTs
Level II
Evidence obtained from at least one well-designed RCT
Level III
Evidence obtained from well-designed controlled trials without randomization
Level IV
Evidence from well-designed case-control and cohort studies
Level V
Evidence from systematic reviews of descriptive and qualitative studies
Level VI
Evidence from a single descriptive or qualitative study
Level VII
Evidence from the opinion of authorities or reports of expert committees
Adapted from Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare. A guide to best practice. Philadelphia: Lippincott Williams & Wilkins; 2005.
providers and consumers to fight it out claim by claim with insurers for agreed-upon expansions of coverage. The new healthcare reform bill has promise in addressing the reduction of billing and reimbursement disparities for PMH care, and disparity of reimbursement based on rural zip codes has been targeted for change. These were addressed by the Nursing Community Consensus Letter to former House Speaker Nancy Pelosi24 on behalf of Healthcare Reform. Large-scale changes loom ahead, and, hopefully, these will rectify traditional policy lapses affecting rural healthcare and disparities among consumers, patients, and their providers of service. User-friendly means to navigate these changes for both consumers and providers is a need that has been identified. The third factor is the lack of consensus and adoption of evidence-based guidelines for MH/SUD, which follows.25
The Cochrane dataset citations lend support to developing the data into integrated specialty practice guidelines.26 Evidence-based practice guidelines specific to psychiatric practice and those that blend specialties are emerging at a rapid rate. The healthcare literacy project27 helped faculty choose resources to be posted for non-psychiatric APNs who encounter MH/SUD patients in primary care settings. The rubric for ascertaining levels of evidence were adopted from the healthcare literacy project and built upon Guyatte and Renee’s28 “User’s guide to the medical literature” and Melnyk’s 2004 manuscript.10 Readers are referred to Table 1 and should keep in mind that, because of the paucity of the highest level evidence, lower levels may be posted, and where Level I evidence is cited, there may be no need for lower level evidence.
EVIDENCE-BASED PRACTICE GUIDELINES Surgeon General Satcher identified the need for consensus on practice guidelines, which he noted there to be a paucity of, especially in mental health. Requests for currently available and adopted guidelines for MH/SUD management in primary care settings were searched and posted. The Agency of Healthcare Research and Quality (AHRQ) had 1,792 guidelines for primary care, of which 520 covered mental health primary care.25 AHRQ indicates there are many developing guidelines also available for reference that are not widespread or adopted for current practice. The Cochrane Data Bases were reviewed and linked 356 of 923 guidelines for relevance to both primary care practice guidelines and specialty guidelines in 2000. Kunnamo et al.26 identified psychiatry as one of the top five specialties bridging practice with primary care, leading to jointly adopted practice guidelines.
EXAMPLES OF CLINICAL APPLICATION USING TOOLBOX CONTENTS Substance Use/Abuse Screening Patient substance use and abuse is often an area of concern and discomfort for NPs. In addition, the steady increase of primary care management of MH/SUD presentations, a decline in MH/SUD specialists, paucity of prescribing specialists, continued patient preference, and stigma-related implications demonstrate clear trends to seek MH/SUD care in primary care sites. Access to efficient, validated, and effective ways for helping patients is needed, along with the appropriate coding to bill for these services. Policy and payment trends are increasingly supportive of reimbursing primary care providers for MH/SUD-related services in their settings. These factors set the stage for directly addressing, in a cost-effective way, the needs of faculty
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and students who desire to manage MH/SUD in their settings. Beginning with an example of screening and discussing substance abuse, Level I screening, brief intervention, and referral to treatment (SBIRT) and supporting motivational interviewing (MI) as a communication intervention for SUD in primary care were posted as resources for use. The Substance Abuse and Mental Health Services Administration (SAMHSA) has established a web-based resource for SBIRT.29 As stated in a recent review, SBIRT was feasible to implement, and the self-reported patient status at 6 months indicated significant improvements for illicit drug use and heavy alcohol use, with functional domains improved across a range of healthcare settings and patients.30 The SBIRT also met the Level I criteria for evidence.30 Communicating to patients using MI in this situation has evidence but less robust. MI can have a significant effect when counseling patients, depending on the clinician, setting, and other variables.31 Although this evidence is at the meta-analysis level, indicating MI outperforms traditional advice-giving for behaviorrelated health problems, more large-scale studies are needed to prove that the mode should be implemented in primary care. MI can still be used because what high-level evidence is available. Because SBRIT and MI possess high-level evidence, lower levels of evidence are not posted, and the faculty and model are appropriate choices for students. Jointly Adopted Guidelines When higher levels are not available, jointly adopted guidelines are suitable choices when the presenting population needs to be treated across specialties. An example of this would be postpartum depression patients, for which the Edinburgh Postnatal Depression Scale (EPDS), a Level I assessment instrument, is endorsed.32 Clinicians seeking medication options for patients who are pregnant or lactating are referred to the American Congress of Obstetricians and Gynecologists (ACOG) Practice Bulletin.33 This falls into Level VII and contains broader options as a consensus of evidence for treatment based on the opinion of authorities or expert committees. The difference between the two resources is that the EPDS is a specific and targeted Level I screening tool to discern postnatal depression, and the AGOG Bulletin is broader, requiring clinical judgment to choose appropriate treatwww.npjournal.org
ments within an array of presentations at a lower level of evidence. The latter is nonetheless helpful in making choices that bridge specialties. Both of these resources are posted in the toolbox. Other Resources Additionally, there are numerous resources available in the toolbox, including but not limited to pediatric, geriatric, diversity, gender issues, and disadvantaged population care, and where available, jointly adopted guidelines are posted. In summary, the toolbox is concise with a limited but targeted set of resources that can be easily found by busy clinicians juggling practice demands. Provided are models for practice management, accepted clinical guidelines, precedent-setting case studies, and specialty concerns overlapping in primary care. Diagnostic guides, treatment algorithms, and jointly adopted guidelines demonstrate the way to treat and refer patients within established consensus models. These are then linked to billing and coding resources, management guides, and models of practice for the primary care provider managing MH/SUD issues in primary care settings. CONCLUSION The purpose of the web-based resource site was to provide easy access to materials to assist generalist student APRNs and faculty in clinical practice. This approach is in keeping with both the foundational goals of the college of nursing and the supportive HRSA grants. The toolbox resources are especially salient as graduate and doctoral students develop their practices using more integrative modes. In order to provide healthcare, we concur with the IOM: we must think about mental health and substance abuse issues differently,1 optimize current resources and human capital, and influence policy to reduce barriers, increase reimbursement, and support the versatility and portability of the generalist APRN who is able to provide MH/SUD care using the highest levels of evidence available. Generalist graduate and doctoral nursing students exposed to effective MH/SUD management in primary care settings are positioned to be ahead of the market. APRN-prepared practitioners are ready for strategic placement in this broken healthcare system. The Webbased Toolbox for Primary Behavioral Care has the potential to increase both skill and comfort level in generalist students and faculty as they care and refer MH/SUD patients who present in these settings. The Journal for Nurse Practitioners - JNP
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References 1. Institute of Medicine Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. Improving the quality of health care for mental needs and substance-use conditions. Washington, DC: National Academies Press; 2006: http://www.nap.edu/openbook/0309100445/ html/R1.html. 2. American Psychiatric Association. Who seeks emergency psychiatric care? Psychiatric News 2004;39(21):13. http://pn.psychiatryonline.org/cgi/content/full/ 39/21/13. Accessed October 26, 2009. 3. Rother J, Lavizzo-Mourey R. Addressing the nursing workforce: A critical element for health reform. Health Affairs. 2009;28(4):620-624. 4. Mauch D, Kautz C, Smith S. Reimbursement of mental health services in primary care settings. 2008. Available at: www.integratedprimarycare.com/ Reimbursement%20of%20MH%20services%20in%20PP.C.pdf" www.integratedprimarycare.com/Reimbursement% 20of%20MH%20services%20in%20PP.C.pdf. Accessed Jan 24, 2011. 5. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare. A guide to best practice. Philadelphia: Lippincott Williams & Wilkins; 2005. 6. Mynatt M.Comprehensive Advanced Education Psychiatric Nursing Program. P.Cunningham. Memphis. 2005; Health Resources and Services Administration (HRSA) Department of Health and Human Services (DHHS). p 65. 7. US Public Health Service. Executive Summary of Mental Health: A Report from the Surgeon General. 2001. http://www.surgeongeneral.gov/library/ mentalhealth/chapter2/sec2_1.html. Accessed October 28, 2009. 8. Center for Medicare and Medicaid Services. The Mental Health Parity Act. 2008. http://www.cms.hhs.gov/healthinsreformforconsume/04_ thementalhealthparityact.asp. Accessed March 20, 2009. 9. Center for Medicare & Medicaid Services. Medicare Part B Physician Assistant, Nurse Practitioner & Clinical Nurse Specialist Billing Guide 2004. http://www.acnpweb.org/files/public/Medicare_PartB_PA_NP_CNS_Billing_Gu ide_Sept04.pdf. Accessed September 4, 2009. 10. Melnyk BM. Integrating levels of evidence into clinical decision making. Pediatr Nurs. 2004. http://findarticles.com/p/articles/mi_m0FSZ/is_4_30/ai_ n17207568/. Accessed January 11, 2011. 11. World Health Organization World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the world health organization world mental health surveys JAMA. 2004;291(21):2581-2590. 12. World Health Organization. Mental Health. 2009. http://www.who.int/mental_ health/en/. Accessed October 26, 2009. 13. Kessler RC, Berglund PA, Bruce ML, et al. The prevalence and correlates of untreated serious mental illness. Health Serv Res. 2001;36(6 Pt 1):987-1007. 14. Quirk MP, Simon G, Todd J, et al. A look to the past, directions for the future. Psychiatr Q. 2000;71(1):79-95. 15. Satcher D. Closing the gap: A national blueprint to improve the health of persons with mental retardation: Report of the Surgeon General’s conference on health disparities and mental retardation in U.S. 2002. http://www.surgeongeneral.gov/topics/mentalretardation/retardation.pdf. Accessed Sept. 4, 2009. 16. Hoge M, Morris A, Daniels A, Stuart G, Huey L, Adams N. An action plan for behavioral health workforce development: A framework for discussion. 2007. http://208.106.217.45/pages/images/WorkforceActionPlan.pdf. Accessed September 4, 2009. 17. Hoge M, Paris M, Hoover A, et al. Workforce competencies in behavioral health: An overview. Adm Policy Ment Health. 2005;32(5-6):593-631. 18. Mental Health Commission. President’s New Freedom Commission on Mental Health. 2007. http://www.mentalhealthcommission.gov. Accessed October 23, 2009. 19. The Annapolis Coalition on Behavioral Health Workforce. Workforce Development: An essential element of sustainable reform. 2004. http://www.annapoliscoalition.org/pages. Accessed October 26, 2009. 20. Representative Ho. To provide parity between health insurance coverage of mental health benefits for medical and surgical services. Domenici S, trans. 1 ed2007:22. 21. National Council for Community Behavioral Healthcare. Request for Information Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). 2009. Available at: http://www.thefederalregister.com/ d.p/2009-04-28-E9-9629. Accessed Jan 24, 2011. 22. Koyanagi C, Siegwarth A. How will Health Reform Help People with Mental Illnesses? An analysis of the Affordable Care Act passed by Congress in 2010 and how it will affect people with psychiatric disabilities. Washington DC. Bazelton Center for Mental Health Law. www.bazelon.org/ LinkClick.aspx?fileticket=HJ7Q6AM8AHM%3d&tabid=218. Accessed Jan 24, 2011. 23. Stabenow D, Levin C. S. 1136, Mental Illness Chronic Care Improvement Act of 2009. 2009. http://thomas.loc.gov/cgi-bin/query/z?c111:S.1136. Accessed January 12, 2011.
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24. American Academy of Nurse Assessment Coordinators, Academy of Medical-Surgical Nurses, American Academy of Nurse Practitioners, et al. Nursing Community Consensus Letter on HCR Conference. Washington, DC: Nursing Community; 2010. 25. Agency for Healthcare Research and Quality. Integration of Mental Health/Substance Abuse in Primary Care. Evidence Report and Technology Assessment. 2008. www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/ mhsapc.pdf. Accessed November 11, 2009. 26. Kunnamo I, Varonen H, Stancliff R. Using Summaries of Cochrane Reviews as links to primary care guidelines: how many reviews were pertinent and from what specialties? Paper presented at 9th International Cochrane Colloquium Abstracts, 2001, Lyon, France. http://www.biomedcentral.com/ browse/abstracts/COCHRANE/1?arttype⫽Oral⫹presentation&page⫽3. Accessed January 12, 2011. 27. Cunningham P, McCoy K, Story E. Division of Nursing (DN), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS), Nurse Education Practice and Retention; 2007. 28. Guyatt G, Renee D. User’s guides to the medical literature. Washington, DC: American Medical Association Press; 2002. 29. Substance Abuse and Mental Health Services Administration. Screening, Brief Intervention, and Referral to Treatment. 2010. http://sbirt.samhsa.gov/ index.htm. Accessed June 1, 2010. 30. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark H. Screening, brief interventions, referral to treatment for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99:15. 31. Rubak S. Motivational Interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55(513):305-312. 32. Cox J, Holden JM, Sagovsky R. Quiz: Are you suffering from postpartum depression? The Edinburgh Post Natal Depression Scale (EPDS). 2010. http://www.womensmentalhealth.org/quiz-are-you-suffering-frompostpartum-depression/. Accessed June 2, 2010. 33. American Congress of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists. Use of Psychiatric Medicines During Pregnancy and Lactation. Obstet Gynecol. 2008;111(4):1001-1020.
All authors have worked together in the Family Psychiatric DNP Option at the University of Tennessee Health Science Center’s College of Nursing in Memphis. Kathleen T. McCoy, DNSc, APRN, PMHNP-BC, CNS-BC, FNP-BC, is an assistant professor of family psychiatric and mental health and program director of Brandman University Family Psychiatric and Mental Health NP-DNP Program, Irvine, CA; she can be reached at [email protected]. E. Erwin Story, MBA, BBA, is an HRSA grant administrator, Kathleen Gaffney, MSN, APRN, PNP-BC, PMHCNS, is an instructor, and Patricia D. Cunningham, DNSc, APRN, PMHNP-BC, CNS-BC, FNP-BC, is an associate professor and coordinator. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/11/$ see front matter © 2011 American College of Nurse Practitioners doi:10.1016/j.nurpra.2010.06.002
Volume 7, Issue 3, March 2011
Establishing a Web-Based Academic Toolbox for Primary Behavioral Care Kathleen T. McCoy, DNSc, PMHNP-BC, E. Erwin Story, MBA, BBA, Kathleen Gaffney, MSN, PNP-BC, and Patricia D. Cunningham, DNSc, PMHNP-BC
ABSTRACT Background: Doctorate of nursing practice (DNP) students and faculty request additions to their curricula to prepare them in the basic mental health and substance use disorder (MH/SUD) care needs in generalist care settings. Objectives: Demonstrate effectiveness of resources gathered to facilitate safe and effective care to patients in generalist settings through a web-based Toolbox for Primary Behavioral Care Study Design: Faculty-designed/posted web-based resources for treatment and referral of common MH/SUD disorders. Results: A web site was organized and made accessible to all DNP students and faculty. Conclusion: Since 2008, posted resources assist in guiding safe practice with regular updates congruent to evidence-based guidelines. Keywords: academic toolbox, ambulatory care toolbox, evidence-based guidelines, primary behavioral care, primary behavioral care toolbox, web-based tools © 2011 American College of Nurse Practitioners
T
he Institute of Medicine (IOM) promotes the democratic provision of healthcare for mental health, substance-use disorders (MH/SUD), and general health conditions. A fundamental change is required in how providers think and respond to these conditions if care is to be provided equally. The World Health Organization (WHO) and the IOM1 substantiate the longstanding trend that most antidepressants are prescribed and managed by primary care providers (PCPs). The American Psychiatric Association (APA) consistently finds that one-third of emergency department presentations are related to MH/SUD.2 Paralleling these trends is the current decrease of rural mental health providers, especially those with prescriptive authority. Integration of MH/SUD knowledge into the non-psychiatric/mental health nursing specialties is a daunting task. There has and continues to be a nursing faculty shortage, cited by Rother and Lavizzo,3 which poses difficulties in www.npjournal.org
teaching students psychiatric mental health content, presentations that exist in most settings, especially primary care, on any given clinical day. Additionally, chronic problematic reimbursement strategies, as outlined by Mauch et al.,4 continue to be an issue, leaving students and professionals perplexed with MH/SUD reimbursement complexities. Non-psychiatric/mental health advanced practice registered nursing (APRN) students and faculty requested support and additions to their curricula to adequately prepare them in the basic MH/SUD care needs in generalist care settings. The requests emphasize student and faculty desire to become skilled in evaluation, appropriate treatment, referral, and billing strategies in serving MH/SUD patients in primary care settings. BACKGROUND To answer the prevailing concerns, graduate faculty in the doctor of nursing practice (DNP) psychiatric/mental health The Journal for Nurse Practitioners - JNP
223
(PMH) nursing option at an academic setting developed a settings, and this linkage of high anxiety and high website for non-psychiatric/mental health APRN faculty probability of MH/SUD presentations was identified and graduate students. Carefully selected materials, gathered as universal for non-psychiatric students and some facand posted in a straightforward manner, were used to build ulty. In response to this finding, a web-based toolbox the resource. Resources were diligently chosen and limited was created for generalist students and faculty memto include web-accessible material in keeping with current bers. Of primary concern to non-psychiatric students evidence-based guidelines. A project was adopted to define and faculty are the ability to diagnose accurately, to a methodical review using Melnyk’s Hierarchy of Evidence have effective strategies to treat or refer, to serve as an to assess current health literature appropriate bridge for 5 and improve healthcare literacy. patients who need PMH care This was used to screen websites but may have access barriers,8 and resources for appropriateness and to secure reimbursement The toolbox includes to this web-based toolbox. for their efforts. resources to promote The toolbox site includes Integration of behavioral remission of mental health easily accessed resources for healthcare into primary care management and referral stratehas been long studied and recsymptoms and optimize gies to promote remission of ommended. The integration patient safety. mental health symptoms and continues to be limited by lack optimize patient safety. of reimbursement knowledge, Emphasized are essentials of decreasing availability of practice management, provider knowledge, skills, and colMH/SUD prescribing professionals, and PCPs’ lack of laboration. Provided are the philosophical underpinnings knowledge. The need for integration is fueled by perand decision-making criteria for this approach. ceptions of social stigma.4 Stigma of receiving care from The purpose of this article is to demonstrate how the a PMH professional continues to be felt by patients, faculty responded to and addressed the identified knowledge who generally prefer to be treated by their PCP. deficits for effective care of common MH/SUD presentaAdditionally, copayments are frequently higher for mental health services, requiring more out-of-pocket paytions in generalist settings through developing an innovative ments for patients than non-psychiatric healthcare clinical tool, a web-based Academic Toolbox for Primary services. Behavioral Care. For the purposes of this article, primary The toolbox contains easily accessible and reliable care and generalist settings will be used interchangeably. resources to assist with clinical skill formation, as well as A Health Resources and Services Administration information for concerns of treatment and referral of (HRSA) Advanced Education Nursing6 grant promoted the web-based Academic Toolbox for Primary Behavioral commonly found MH/SUD in generalist settings. Care as it suited the philosophical underpinnings of this Practice management information to assist with payers, academic setting. The college lent strong support and coding, and billing guidelines for behavioral health in preparation of students to serve in integrated care roles primary care are included and supports the additional and settings to reduce healthcare barriers and disparities effort that may accompany integrative care. APRN genthrough education of the APRN workforce.7 The grant eralists often are unaware of the billing codes permitted facilitated the vision of preparing all DNP graduates to by the Center for Medicare & Medicaid Services for provide appropriate care across generalist and other care advance practice nurses, as well as the US Department of settings to vulnerable, underserved populations. Health and Human Services Reimbursement of Mental Health Services in Primary Care Settings guidelines.4,9 CHALLENGES TO INTEGRATIVE CARE These guidelines allow APRNs to provide MH/SUD As noted, the non-psychiatric clinical world includes services in primary care, obtain reimbursement in a many patients with comorbid MH/SUD. PCP general timely fashion, and serve the community more readily discomfort levels match the high probability of with reimbursement appropriate to services provided. All MH/SUD presentations on any given day in generalist are posted online to create easy access for busy clinicians 224
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during demanding clinical days. The resources can be uploaded onto a PDA or office computer.
with integration of such services within primary care settings, was identified and addressed in 1991 by U.S. Surgeon General David Satcher.15 He further isolated many obstaLITERATURE REVIEW cles, including lack of education, training, and practice The literature review required several searches. The first guidelines. Also identified was the growing trend of fewer search focused on the need for integrative care, followed psychiatrists and PCPs graduating medical schools, and by a brief historical overview through documentation of fewer still of those specializing in pediatrics.16 healthcare policy transitions regarding integrative care; Adding to lapses in the development of generally the results also included precedent-setting examples of accepted treatment plans17 is a convergence of forces: lack integrative care models. Lastly, consensus models, estabof evidence-based guidance, a general paucity of consensus lished guidelines, jointly adopted guidelines, and evifor treatment, lack of evidence-based bodies of knowledge dence-based clinical guidelines were reviewed. Available pertaining to broad-based and common MH/SUD probweb-based guidelines were reviewed and vetted by the lems treated in generalist settings, and lack of integration of experienced DNP-PMH faculty for appropriateness of these services in generalist care settings. clinical application using Melnyk’s Rating System for “Transformation of the Workforce” is the first of 10 Hierarchy of Evidence. three key competencies planned to fundamentally change MH/SUD care, as outlined in President Obama’s New NEEDS ASSESSMENT Freedom Commission on Mental Health.18 The In 2002, the WHO estimated there were 154 million Annapolis Coalition, a collaborative education initiative, people globally suffering from depression, 91 million was founded to develop a consensus on core behavioral people affected by alcohol-use disorders, and another 15 health competencies for the mental health workforce.19 11 million affected by drug-use disorders. Nearly 44 milAdditionally, the IOM has applied the criteria for intelion Americans experience mental health problems in any grative care in “Crossing the Quality Chasm” to also 7 given year; within this group, 5% to 7% of adults have include MH/SUD.1 serious mental illness and 5% to 9% of children have The second major competency needed is an under12 serious emotional disturbances. The vast majority of standing of current policy and reimbursement shifting. those suffering with mental problems were not seriously The recent passage of the Mental Health Parity Act20 and physically ill, and healthcare utilization most frequently the Mental Health Parity and Addiction Equity Act was related to conditions such (MHPAPEA)21 exemplify the as substance abuse, stress, lack of leaps made to correct payer coping skills, and depression.13 problems and address service Diagnostic guides, The WHO’s study of global inequities. A robust consensus to treatment algorithms, and primary healthcare clinics found further improve the MHPAEA, jointly adopted guidelines that the 69% of patients with recently cited by Bazelton et mental health disorders preal.,22 and the introduction of demonstrate the way to sented with co-occurring physSenators Stabenow and Levin’s treat and refer patients ical symptoms that were the “Mental Illness Chronic Care within established primary complaint causing Improvement Act”23 are examconsensus models. them to seek health care.14 ples of positive progress and Moreover, consumers are more current momentum to affect likely to seek generalist care and mental healthcare parity and treatment, avoiding the perception of stigma in payer strategies for more equitable coverage across setMH/SUD settings.11 tings. These address public and private sector payers and expansion of MH/SUD care to broader settings. HISTORICAL OVERVIEW OF POLICY SHIFT More initiatives like these are needed to ensure more The significance of the gaps and the clear advantage of equitable health care to the general public, and the adoptreating MH/SUD problems in generalist settings, along tion of these initiates is slow going at best, leaving www.npjournal.org
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Table 1. Rating System for the Hierarchy of Evidence Criteria Level I
Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on systematic reviews of RCTs
Level II
Evidence obtained from at least one well-designed RCT
Level III
Evidence obtained from well-designed controlled trials without randomization
Level IV
Evidence from well-designed case-control and cohort studies
Level V
Evidence from systematic reviews of descriptive and qualitative studies
Level VI
Evidence from a single descriptive or qualitative study
Level VII
Evidence from the opinion of authorities or reports of expert committees
Adapted from Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare. A guide to best practice. Philadelphia: Lippincott Williams & Wilkins; 2005.
providers and consumers to fight it out claim by claim with insurers for agreed-upon expansions of coverage. The new healthcare reform bill has promise in addressing the reduction of billing and reimbursement disparities for PMH care, and disparity of reimbursement based on rural zip codes has been targeted for change. These were addressed by the Nursing Community Consensus Letter to former House Speaker Nancy Pelosi24 on behalf of Healthcare Reform. Large-scale changes loom ahead, and, hopefully, these will rectify traditional policy lapses affecting rural healthcare and disparities among consumers, patients, and their providers of service. User-friendly means to navigate these changes for both consumers and providers is a need that has been identified. The third factor is the lack of consensus and adoption of evidence-based guidelines for MH/SUD, which follows.25
The Cochrane dataset citations lend support to developing the data into integrated specialty practice guidelines.26 Evidence-based practice guidelines specific to psychiatric practice and those that blend specialties are emerging at a rapid rate. The healthcare literacy project27 helped faculty choose resources to be posted for non-psychiatric APNs who encounter MH/SUD patients in primary care settings. The rubric for ascertaining levels of evidence were adopted from the healthcare literacy project and built upon Guyatte and Renee’s28 “User’s guide to the medical literature” and Melnyk’s 2004 manuscript.10 Readers are referred to Table 1 and should keep in mind that, because of the paucity of the highest level evidence, lower levels may be posted, and where Level I evidence is cited, there may be no need for lower level evidence.
EVIDENCE-BASED PRACTICE GUIDELINES Surgeon General Satcher identified the need for consensus on practice guidelines, which he noted there to be a paucity of, especially in mental health. Requests for currently available and adopted guidelines for MH/SUD management in primary care settings were searched and posted. The Agency of Healthcare Research and Quality (AHRQ) had 1,792 guidelines for primary care, of which 520 covered mental health primary care.25 AHRQ indicates there are many developing guidelines also available for reference that are not widespread or adopted for current practice. The Cochrane Data Bases were reviewed and linked 356 of 923 guidelines for relevance to both primary care practice guidelines and specialty guidelines in 2000. Kunnamo et al.26 identified psychiatry as one of the top five specialties bridging practice with primary care, leading to jointly adopted practice guidelines.
EXAMPLES OF CLINICAL APPLICATION USING TOOLBOX CONTENTS Substance Use/Abuse Screening Patient substance use and abuse is often an area of concern and discomfort for NPs. In addition, the steady increase of primary care management of MH/SUD presentations, a decline in MH/SUD specialists, paucity of prescribing specialists, continued patient preference, and stigma-related implications demonstrate clear trends to seek MH/SUD care in primary care sites. Access to efficient, validated, and effective ways for helping patients is needed, along with the appropriate coding to bill for these services. Policy and payment trends are increasingly supportive of reimbursing primary care providers for MH/SUD-related services in their settings. These factors set the stage for directly addressing, in a cost-effective way, the needs of faculty
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and students who desire to manage MH/SUD in their settings. Beginning with an example of screening and discussing substance abuse, Level I screening, brief intervention, and referral to treatment (SBIRT) and supporting motivational interviewing (MI) as a communication intervention for SUD in primary care were posted as resources for use. The Substance Abuse and Mental Health Services Administration (SAMHSA) has established a web-based resource for SBIRT.29 As stated in a recent review, SBIRT was feasible to implement, and the self-reported patient status at 6 months indicated significant improvements for illicit drug use and heavy alcohol use, with functional domains improved across a range of healthcare settings and patients.30 The SBIRT also met the Level I criteria for evidence.30 Communicating to patients using MI in this situation has evidence but less robust. MI can have a significant effect when counseling patients, depending on the clinician, setting, and other variables.31 Although this evidence is at the meta-analysis level, indicating MI outperforms traditional advice-giving for behaviorrelated health problems, more large-scale studies are needed to prove that the mode should be implemented in primary care. MI can still be used because what high-level evidence is available. Because SBRIT and MI possess high-level evidence, lower levels of evidence are not posted, and the faculty and model are appropriate choices for students. Jointly Adopted Guidelines When higher levels are not available, jointly adopted guidelines are suitable choices when the presenting population needs to be treated across specialties. An example of this would be postpartum depression patients, for which the Edinburgh Postnatal Depression Scale (EPDS), a Level I assessment instrument, is endorsed.32 Clinicians seeking medication options for patients who are pregnant or lactating are referred to the American Congress of Obstetricians and Gynecologists (ACOG) Practice Bulletin.33 This falls into Level VII and contains broader options as a consensus of evidence for treatment based on the opinion of authorities or expert committees. The difference between the two resources is that the EPDS is a specific and targeted Level I screening tool to discern postnatal depression, and the AGOG Bulletin is broader, requiring clinical judgment to choose appropriate treatwww.npjournal.org
ments within an array of presentations at a lower level of evidence. The latter is nonetheless helpful in making choices that bridge specialties. Both of these resources are posted in the toolbox. Other Resources Additionally, there are numerous resources available in the toolbox, including but not limited to pediatric, geriatric, diversity, gender issues, and disadvantaged population care, and where available, jointly adopted guidelines are posted. In summary, the toolbox is concise with a limited but targeted set of resources that can be easily found by busy clinicians juggling practice demands. Provided are models for practice management, accepted clinical guidelines, precedent-setting case studies, and specialty concerns overlapping in primary care. Diagnostic guides, treatment algorithms, and jointly adopted guidelines demonstrate the way to treat and refer patients within established consensus models. These are then linked to billing and coding resources, management guides, and models of practice for the primary care provider managing MH/SUD issues in primary care settings. CONCLUSION The purpose of the web-based resource site was to provide easy access to materials to assist generalist student APRNs and faculty in clinical practice. This approach is in keeping with both the foundational goals of the college of nursing and the supportive HRSA grants. The toolbox resources are especially salient as graduate and doctoral students develop their practices using more integrative modes. In order to provide healthcare, we concur with the IOM: we must think about mental health and substance abuse issues differently,1 optimize current resources and human capital, and influence policy to reduce barriers, increase reimbursement, and support the versatility and portability of the generalist APRN who is able to provide MH/SUD care using the highest levels of evidence available. Generalist graduate and doctoral nursing students exposed to effective MH/SUD management in primary care settings are positioned to be ahead of the market. APRN-prepared practitioners are ready for strategic placement in this broken healthcare system. The Webbased Toolbox for Primary Behavioral Care has the potential to increase both skill and comfort level in generalist students and faculty as they care and refer MH/SUD patients who present in these settings. The Journal for Nurse Practitioners - JNP
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24. American Academy of Nurse Assessment Coordinators, Academy of Medical-Surgical Nurses, American Academy of Nurse Practitioners, et al. Nursing Community Consensus Letter on HCR Conference. Washington, DC: Nursing Community; 2010. 25. Agency for Healthcare Research and Quality. Integration of Mental Health/Substance Abuse in Primary Care. Evidence Report and Technology Assessment. 2008. www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/ mhsapc.pdf. Accessed November 11, 2009. 26. Kunnamo I, Varonen H, Stancliff R. Using Summaries of Cochrane Reviews as links to primary care guidelines: how many reviews were pertinent and from what specialties? Paper presented at 9th International Cochrane Colloquium Abstracts, 2001, Lyon, France. http://www.biomedcentral.com/ browse/abstracts/COCHRANE/1?arttype⫽Oral⫹presentation&page⫽3. Accessed January 12, 2011. 27. Cunningham P, McCoy K, Story E. Division of Nursing (DN), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS), Nurse Education Practice and Retention; 2007. 28. Guyatt G, Renee D. User’s guides to the medical literature. Washington, DC: American Medical Association Press; 2002. 29. Substance Abuse and Mental Health Services Administration. Screening, Brief Intervention, and Referral to Treatment. 2010. http://sbirt.samhsa.gov/ index.htm. Accessed June 1, 2010. 30. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark H. Screening, brief interventions, referral to treatment for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99:15. 31. Rubak S. Motivational Interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55(513):305-312. 32. Cox J, Holden JM, Sagovsky R. Quiz: Are you suffering from postpartum depression? The Edinburgh Post Natal Depression Scale (EPDS). 2010. http://www.womensmentalhealth.org/quiz-are-you-suffering-frompostpartum-depression/. Accessed June 2, 2010. 33. American Congress of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists. Use of Psychiatric Medicines During Pregnancy and Lactation. Obstet Gynecol. 2008;111(4):1001-1020.
All authors have worked together in the Family Psychiatric DNP Option at the University of Tennessee Health Science Center’s College of Nursing in Memphis. Kathleen T. McCoy, DNSc, APRN, PMHNP-BC, CNS-BC, FNP-BC, is an assistant professor of family psychiatric and mental health and program director of Brandman University Family Psychiatric and Mental Health NP-DNP Program, Irvine, CA; she can be reached at [email protected]. E. Erwin Story, MBA, BBA, is an HRSA grant administrator, Kathleen Gaffney, MSN, APRN, PNP-BC, PMHCNS, is an instructor, and Patricia D. Cunningham, DNSc, APRN, PMHNP-BC, CNS-BC, FNP-BC, is an associate professor and coordinator. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/11/$ see front matter © 2011 American College of Nurse Practitioners doi:10.1016/j.nurpra.2010.06.002
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