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Note of Thanks This fellowship would not have been possible without the kind assistance of many people. In particular I would like to thank Kathy Shoemaker from Exodus Recovery INC; Inese Versalekis from UCLA; Pam Marcus and her wonderful colleagues at Prince Georges Community College in Washington; Tine Hansen Turton from the National Nursing Centres Consortium in Philadelphia; Madeline Nagle from New York University; Lorraine Ahto from the Henry Street Clinic in New York; Linda Faherty from Mclean Hospital and Barbarra Cocci from Boston Healthcare for the Homeless. All these exceptional people and services consistently treated me with great courtesy and enthusiasm and I only hope I can return the favor to some of these dear colleagues on visits to Australia in future. Finally I would like to sincerely thank the Winston Churchill Trust for what can only be described as a life changing experience. I will continue to advocate widely for reform of mental health nursing services in Australia through universities, submissions to governments, presentations to professional and community conferences, lobbying and researching. I also hope to implement these findings by applying lessons learnt to my own mental health nursing practice.
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Table of Contents Introduction… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … ...4
Executive Summary… … … … … … … … … … … … … … … … … … … … … … … … … … … … … 5
Program… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … ...........6
Methodology… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … .8
Main Body
Background… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … .10
Location 1; Los Angeles… … … … … … … … … … … … … … … … … … … … … … … … ..........14
Location 2; Washington… … … … … … … … … … … … … … … … … … … … … … … … … … … 19
Location 3; Philadelphia… … … … … … … … … … … … … … … … … … … … … … … … … … … 23
Location 4; New York… … … … … … … … … … … … … … … … … … … … … … … … … ...........25
Location 5; Boston… … … … … … … … … … … … … … … … … … … … … … … … … … ........... 27
Conclusions… … … … … … … … … … … … … … … … … … … … … … … … … … … … … ...........30
Recommendations… … … … … … … … … … … … … … … … … … … … … … … … … … … … … .32
Final Note of Thanks… … … … … … … … … … … … … … … … … … … … … … … … … … … … .33
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Introduction I have been a mental health nurse for many years. My career has provided me with a wide range of experiences stretching from acute psychiatric units of major teaching hospitals to primary care clinics amongst homeless populations. For the past 5 years I have led the development of a mental health nursing charity committed to work amongst disadvantaged communities in Sydney Australia. My Churchill fellowship took place during a time of monumental change in the history of healthcare and nursing in the USA and Australia. In the USA, on the 23rd of March 2010, the Obama government passed health reform bill 3590, awarding national health insurance for the first time. This wide ranging reform printed the term “nurse managed health centre”in national legislation for the first time. It also set aside billions of dollars for primary care and signaled a new era of support for America’ s 140,000 nurse practitioners. In Australia, on the 16th of March 2010 the Rudd government passed its own historic legislation providing nurse practitioners and midwives access to the Medical Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) for the first time. The legislation was accompanied by approximately 60 million dollars set aside for nurse practitioners to provide community based services such as mental health, aged and primary care from the 1st of November 2010. Both the USA and Australia are characterized by great distances, widely distributed populations and considerable geographical and social diversity. This makes comparisons of health care provision between the two countries pertinent. In many respects historically, the issues of mental health nursing service provision in the USA run on parallel with the problems that have been identified in the Australian context. A major difference however, is that for nearly four decades, the United States Government has utilized significant legislation and policy directives to nurture the growth of advanced practice mental health nursing roles through the nurse practitioner and nurse managed centre movement. As Australia begins to enact its first national legislation in support of nurse practitioners in 2010, opportunities to learn from the USA experience may assist us to build better mental health. 4
Executive Summary Name: Toby Raeburn Position: Managing Director; ROAM Communities Mental Health Nursing; RN/Psychotherapist; Headspace Macarthur; Clinical Lecturer; University of Sydney Phone: (02) 46279089 Post: PO Box 357, Liverpool, Sydney, NSW, 1871 Email:
[email protected] Website: www.roamcommunities.org.au Project Description: This fellowship investigated nurse led mental health services amongst disadvantaged populations in the USA Overview: The fellowship afforded me the opportunity to examine services and meet mental health nurse practitioners, academics, managers and allied health professionals working amongst disadvantaged populations in Los Angeles, Washington, Philadelphia, New York and Boston. Major Findings 1) People: Australia should increase production of nurse practitioners. This fellowship confirmed the unquestionable effectiveness of nurse practitioners as providers of cost effective quality primary healthcare throughout the USA. This finding strongly suggests that the Australian federal government, the newly formed national nursing registration board and the Australian tertiary education sector should move to adopt a cohesive national plan to develop a nurse practitioner workforce st for 21 century Australia. The American tertiary education model which allows undergraduate nursing students to enroll in nurse practitioner Masters programs and thus produces nurse practitioners within a 5 year time frame provides a effective model to achieve this. 2) Programs: Australia should widen the roles of mental health nurse practitioners. The USA experience suggests Australian should begin to provide more choice to consumers by supporting and widening the role of mental health nurse practitioners. For example, in Australia people experiencing mental distress can only access bulk billed private practice mental health nursing care if they are referred by a medical practitioner. Also, people experiencing a mental health crisis can only be committed for hospital based psychiatric assessment by the police or a medical doctor. The American experience suggests widening the roles of mental health nurse practitioners promotes better access, better choice and better outcomes including reducing police involvement in the care of people with mental disorders. 3) Places: Australia should pilot “nurse managed, psychiatric urgent care centres.” Given Australia’ s difficulty caring for people with mental illness, our health workforce shortages and our rapidly ageing population, we should move quickly to invest in piloting “nurse managed psychiatric urgent care centres.”These centres have the potential to function as safety net healthcare providers in disadvantaged communities, substantially alleviate emergency hospital admissions and provide community based health workforce development sites for universities. Promotion: I will continue to actively advocate for reform of mental health nursing services in Australia through universities, submissions to governments, presentations to professional and community conferences, lobbying and researching. I also hope to implement these findings in my own mental health nursing practice.
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Program
City
Service
Contact
Los Angeles
Exodus Urgent Care Centre; Culver City
Kathy Shoemaker, RN; Clinical Director
Los Angeles
Exodus Wellness Centre, Vermont
Edith Urner; Manager Dr William Wirshing
Los Angeles
UCLA Centre for Vulnerable Populations Research
Los Angeles
People Assisting the Homeless
Dr Inese Verzemnieks RN; Assistant Professor Dr Lorna Kendrick; APRN. Sally Evans; Coordinator of Volunteers Helen; Nurse Practitioner
Los Angeles
Homeless Health Care Los Angeles
Mark Casanova; Executive Director Ron; Homelessness Advocate
Washington
Psychiatric Nurse in Private Practice Upper Marlboro
Pamela Marcus APPRN
Washington
Prince Georges Community College; Largo
Assistant Professor Diane Davis
Washington
Santé Crisis Care Centre; Maryland
Joy; Director of Clinical Services
Philadelphia
National Nursing Centre Consortium
Tine Hansen-Turton; CEO
Philadelphia
Health Annex; Family Practice and Counseling Network
Lorraine Thomas; Director
Philadelphia
Mary Howard Healthcare for the Homeless
Rhonda Fletcher
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City
Service
Contact
New York
New York University, Faculty of Nursing
Dr Madeline Nagle
New York
Henry Street Clinic
Lorraine Ahto –Director of Behavioural Health
Boston
Mclean Psychiatric Hospital
Linda Flaherty SVP for Patient Care
Boston
Boston Healthcare for the Homeless
Barbara Cocci , Director of Behavioral Health
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Methodology Establishing the background: Literature review A brief literature review regarding nurse led mental health services amongst disadvantaged populations in the USA was completed. The background included significant modern policy developments as well as historical reflection on public health policy and politics surrounding nurse led mental health services. Making contact: Sampling Contact was made with key personnel at services and universities in the United States approximately 3-6 months prior to the commencement of the fellowship. A snowball sampling approach was used. This was an effective and convenient sampling method whereby each respondent assisted me to find the next subject until there was a sufficient number for the project. It offered me convenience but at the risk of sample bias. Steps taken to reduce likelihood of sample bias included: (a) Subjects were sought from a variety of professional roles within organizations including advanced practice mental health nurses, nurse practitioners, physicians, social workers, service managers and academics. (b) Both experienced and less experienced nurses were included in the project. Listening for emerging themes: Interviews Auto ethno graphical research was gathered from nurse led mental health services using semi structured interviews and observations identifying emerging themes in the implementation of nurse led mental health services amongst disadvantaged populations. I used a case study approach to explore the work of the mental health nurse leaders interviewed. This approach allowed me to focus on different characteristics from the perspectives of advanced practice mental health nurses,
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partner clinicians, service managers and academics. A total of 23 semi structured interviews were conducted each lasting from 15 - 45 minutes with two types of foci: Nurse practitioners - This interview schedule addressed three broad areas. 1. Service and demographic details such as history of the service length of time in current post, length of nurse practitioner experience and qualifications; 2. Issues relating to their role such as details of patient consultation, types of cases seen, workload, referral patterns, research-based practice and decision making techniques. 3. The policy, funding and legislative issues surrounding their role. Allied Professionals - This interview schedule also addressed three areas. 1. The history of the service and their role in it. 2. Respondents' perspectives on the role of nurse leaders amongst disadvantaged populations: and 3. The policy, funding and legislative issues surrounding the role of nurse led services. Exchanging ideas: Education Sessions I found a helpful strategy was offering to offer education sessions on mental health amongst disadvantaged groups in Australia at some of the tertiary institutions and healthcare centres I visited. This strategy proved a useful way of engaging and exchanging ideas. I presented at the University of California, New York University and Boston Healthcare for the Homeless.
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Main Body Background –A Brief Literature Review What is a disadvantaged population? For the purpose of this fellowship disadvantaged populations were defined as subgroups of the general population who are at greater risk of developing a wider range of social and health problems than the population as a whole. These risks may be defined by health status, sex, age, ethnicity, or other factors. Examples of disadvantaged populations that mental health nurse led services are likely to serve are people in poverty or near poverty, the homeless, uninsured or underinsured, ethnic or racial minorities, immigrants, and victims of domestic violence. (Mechanic et al, 2007).
How much disadvantage is there in the USA? The scale of the disadvantage in the USA is huge. The most recent US Census conducted in 2006 showed an estimated 47 million Americans are uninsured, which is 15.8% of the population. People who are uninsured have less access to healthcare, seek health care less often, and have poorer health outcomes than their insured counterparts. (Hadley, 2007). For example, of the more than 47 million Americans who are without insurance, nearly 20% are children. Uninsured children are more likely to go without needed care, to experience worse health outcomes, and to have worse consequences of environmental conditions. (Stevens et al, 2006) At the other end of life experience, the Institute of Medicine (IOM) reports that insufficient health coverage results in approximately 18,000 unnecessary deaths each year in the United States. (IOM, 2004). The growing needs of the US population are being compounded by healthcare workforce shortages. For example, due to a decade-long decline in interest in primary care among medical students the US, the university system is currently producing less than one third of the number of graduates needed to meet the primary care needs of the population. The need for primary care services is predicted to further compound with the forecast 76 million baby boomers who will become eligible for the national aged care 10
health insurance scheme Medicare, in the next few years. (Shoob, Croft, and Labarthe 2007) These combined factors are forecast to send the demand for primary care to unprecedented levels in the next decade leaving increasing numbers of people without a regular source of care. A 2007 report from the Agency for Healthcare Research and Quality (AHRQ) found that providing primary care to those suffering from chronic disease such as mental illness could potentially prevent more than 4 million hospitalizations each year, saving billions of dollars in the process (Russo, Jiang, and Barrett, 2007). Nurse led services are playing a growing role in delivering these much needed services. In the field of primary care and mental health, these services are generally federally supported nurse managed centre’ s staffed by nurse practitioners delivering quality, affordable, accessible care. What are nurse led mental health services? Nurse led mental health services normally involve advanced practice mental health nurses (typically nurse practitioners) providing community based mental healthcare in collaboration with a team of allied health professionals. Nurse led services amongst disadvantaged populations in the USA can be traced back to the seminal work of Lillian Wald in the early 1890s who established the “Henry Street Settlement,”a primary healthcare clinic and home nursing group, serving the immigrant poor of New York. The timing of Wald’ s work correlated with the establishment of the America’ s first hospital based school for psychiatric nursing at Mclean Hospital in Boston in 1888. (Turkeltaube, 2004) Mental health nursing remained largely hospital based during the first half of the 20th century. This changed in 1946 with the passing of the United States first National Mental Health Act which brought new legitimacy, making mental health the first nursing master's degree specialty in the USA, giving rise to the “clinical nurse specialist” movement and increasing delivery of community based care. In 1965 nursing took another huge leap forward, when in response to a growing national shortage of general 11
practitioners the first nurse practitioner program providing access to children who lacked basic primary care services was set up in Colorado. The use of nurse practitioners quickly expanded across the primary care sector as an answer to the shortage of primary care physicians (Neale, 1999). Nurse practitioner (NP) programs subsequently developed their own state based regulations with master’ s level education and prescriptive authority becoming the norm, though varying slightly from state to state in accordance with relevant regulation. As numbers of nurse practitioners grew, some nurse leaders established nurse led services in the 1970’ s, 80’ s and 90’ s however they remained somewhat underutilized until the beginning of the 21st century.(Hansen Turton et al, 2009) Since the year 2000, in response to a national shortage of general practitioners and a rising crisis in health care spending, the nurse practitioner profession has experienced its greatest period of growth ever. With current numbers estimated at 140,000 nationally and with 5000 NP’ s graduating every year, nurse practitioners have positioned themselves to become the leading provider of primary care in the United States in the next decade. This growth trend has been supported by the recent Obama government health legislation which described “nurse managed health centres”in legislation for the first time. (NNCC, 2010). References Hadley, J. (2007). Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition. Journal of American Medical Association. 297,10, 1073-1084. Hansen Turton, T., Miller, M, E, T., Greiner, P, A. (2009). Nurse managed wellness centres, developing and maintaining your center. Springer Publishing Company. New York. Institute of Medicine of the National Academies. (2004). Insuring America’ s Health: Principles and Recommendations. Washington, D.C.: National Academies Press. Mechanic, D., Tanner J. (2007). Vulnerable people, groups, and populations: societal view. Health Affairs. 26, 5,1220-1230. 12
Neal, J. (1999). Nurse practitioners and physicians: a collaborative practice. Clinical Nurse Specialist. 13, 5: 252-258. National Nursing Centers Consortium. (2010). Nurse managed health clinics innovative health care reform. NNCC, Philadelphia. Russo, C. A., Jiang, H, J., & Barrett, M. (2007). Trends in potentially preventable hospitalizations among adults and children, 1997–2004. Agency for Healthcare Research and Quality. Washington. Shoob, H, D., Croft, J, B. & Labarthe, D, R. (2007). Impact of baby boomers on hospitalizations for coronary heart disease and stroke in the United States. Preventive Medicine 44(5): 447–451. Stevens, G,D., Seid, M., Halfon. N.(2006). Enrolling vulnerable, uninsured but eligible children in public health insurance: association with health status and primary care access. Pediatrics. 117, 4, 751-759. Turkeltaube, M. (2004). Nurse managed centers: increasing access to healthcare. Journal of Nursing education. 43, 2: 53-54.
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Location 1; Los Angeles California 1. Exodus Recovery Incorporated My initial contact with Exodus was through clinical director and registered nurse Kathy Shoemaker who is a member of an impressive leadership team. Founded by Dr David Worthing, in the late 1980’ s Exodus began as an inpatient drug and alcohol rehabilitation service in Culver City, Los Angeles. Since that time the organization has developed into a multi tiered wellness focused mental health service funded largely by Los Angeles and San Diego departments of mental health. Exodus currently provides a wide range of programs including psychiatric urgent care centers, wellness centers and assertive case management programs. I visited the psychiatric urgent care centre in Culver City and the wellness centre in Vermont. Emerging Themes Infectious enthusiasm- On visiting Exodus it was clear that this organisation certainly reflects its mission. Everyone I met exuded enthusiasm and compassion towards their clientele. At one point on discussing this observation with Edith Urner who manages the Vermont Wellness centre she stated that “I try and employ people who would be willing to do this sort of work for free, just like me!”I found this sort of passion infectious and it seemed to be owned not just by the leadership of the place but by the whole team. Environment supportive of wide and advanced nursing roles - The leadership team at Exodus were extremely supportive of their nurse practitioners with the founder of the service Dr David Worthing describing the organisation as “a nurse led mental health service.” Clinical director Kathy Shoemaker herself a registered nurse, stated that Exodus currently employs four nurse practitioners who were mostly placed in the organizations urgent care centres on a needs basis. I interviewed nurse practitioner Meagan who has been employed at the Culver City Urgent care centre for approximately one year. Meagan exhibited great passion for her work and agreed with others observations that the nurse practitioners in this environment performed roles equivalent to medical physicians with high levels of 14
independence and responsibility. Every year the psychiatric urgent care centre where Meagan works diverts thousands of consumers away from local emergency hospital rooms leading to significant cost savings for government. Meagan emphasised that the centre also affords a better quality of care than a hospital emergency ward and that this was shown by client feedback and client choice. As a nurse practitioner in this environment Meagan contributes immensely to its effectiveness and standards of care. She delivers first line psychiatric and medical care and facilitates referrals to local hospitals and specialist services as needed. Nurse practitioner training in the USA- Meagan is representative of a youthful cohort of nurse practitioners currently working throughout the USA. Midway through her undergraduate nursing studies she knew she wanted to become a nurse practitioner and was able to pursue her dream by extending her study for an extra two years of university practice based training. Meagan felt that experience gained through her university practice based training had been more than sufficient in qualifying her to work in the challenging environment of psychiatric urgent care and she was perceived by her fellow team members as especially valuable. This ability for nurses to graduate from university as a nurse practitioner within 5 years of entering university and at a relatively young age has been a major factor in enabling the USA to meet the public health need for nurse practitioners more effectively than the Australian experience. The Australian system typically requires nurses to complete 2-3 years of post graduate nursing experience prior to application for entry into a 2 year nurse practitioner degree. The US system produces nurse practitioner level nurses faster and younger and presents an example to Australia for how to meet the workforce demands of the 21st century. Innovative Programs - Exodus isn’ t licensed to maintain psychiatric hospital beds. However, in order to serve their clients in a humane and compassionate way they have creatively integrated provision of reclining chairs into their psychiatric urgent care centres with a “23:59”rule. These chairs allow homeless clients to nap / sleep after being assessed as needed for up to 23 hrs and 59 minutes while waiting for a 15
bed/refuge to be found. Another of the outstanding characteristics of Exodus has also been that it is a designated organisation. This means that they can receive patients who have been scheduled by police or referring physicians thus enhancing the urgent care centre’ s ability to divert patients away from local hospital emergency wards. Legislation can help - Director of clinical services at Exodus, Kathy Shoemaker, stated that legislation has been one of the keys to the development of Exodus. For example in 2004 the California state government passed legislation titled “Proposition 63”which imposed a 1% income tax on personal income in excess of $1 million. Statewide the act has since generated over $250 million annually since inception which has been dedicated to funding new mental health projects. 2. Centre for Vulnerable Population Research; UCLA The Center for Vulnerable Populations Research (CVPR) is a nurse led research centre based at the University of California Los Angeles (UCLA) which grew out of the work of a homeless health nursing clinic in Skid Row in Los Angeles in the 1980’ s. The project gained federal funding in 1999 focused on developing nursing which assists communities to reduce health disparities amongst vulnerable populations. I was privileged to meet two directors of the centre Inese Verzemnieks and Deborah KoniakGiffen. Inese was exceptionally helpful in assisting me to visit two services working with disadvantaged populations in downtown Los Angeles, “People Assisting the Homeless” (PATH) and “Homelessness Healthcare Los Angeles”(HHLA). 3. People Assisting The Homeless (PATH) On entering PATH I felt as if I had entered a first class “one stop shop”for people who are homeless. This wonderful service incorporates a facility with over 100 beds and more than 20 on-site social services including a clothes shop, case management centre, technology centre, mental health clinic, physical health clinic, and even a hairdressing/beauty salon. Linked to long term supported accommodation options for clients, the PATH model is an internationally acclaimed, comprehensive service helping people who are homeless to transition towards more stable, independent lives. 16
Emerging Themes Environment supportive of wide and advanced nursing roles - I met nurse practitioner Helen who works in the health clinic at PATH mall. Helen reported a satisfying career where she felt challenged and empowered to function autonomously and creatively amongst a challenging cohort of clients. CVPR project director Inese Versalikis stated PATH has also provided invaluable practice based learning experiences for nursing students through interactions with the homeless population. Innovative programs - A recent example of student involvement was a survey they conducted focusing on risky behaviour, condom usage and STDs among people using PATH's services. The students educated clients and staff providing information on sexual health and risk reduction, and implemented a sustainable method for providing condoms to clients. This sort of academic involvement in services amongst disadvantaged groups in the USA provides an example of high standard for counterpart Australian universities. 4. Homelessness Healthcare Los Angeles (HHLA) This busy dedicated organization employs a wide team of allied health professionals who provide a variety of services including, assessment, triage, case management, education for homeless service providers, mental health and substance abuse treatment, case management, counseling, physical health management and parenting programs. Emerging Themes Environment supportive of wide and advanced nursing roles - I met the executive director of HHLA, Mark Casanova. A vibrant, successful social entrepreneur Mark spoke in glowing terms about the role and potential of nurse practitioners in homelessness healthcare. He stated that nurse practitioners have been used in the mental and physical health services of the organization.
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Innovative programs - HHLA provides a needle exchange harm reduction center in the skid row area of Los Angeles. This successful program has been shown to decrease numbers of injecting drug users who share syringes and has cut the spread of associated health problems. The organization prides itself on principals of acceptance and making an effort to meet people who are homeless where they are at, respecting their right to choose goals and their own pace of recovery. HHLA is also a dedicated advocate for the needs of people with mental illness. Its leadership team is highly respected by professionals who work in the field of homelessness and they consult widely, advocating and lobbying government for improved services and rights for people who are homeless. 5. Dr Lorna Kendrick; Advanced Psychiatric Nurse in Private Practice I was lucky to be able to phone interview Dr Lorna Kendrick who has vast experience in private practice mental health nursing delivering psychotherapy, and comprehensive care to youth and families. Lorna has is a developed a niche researching and working with African communities in the USA and has a burgeoning academic career, currently employed through the Centre for Vulnerable Population Research at UCLA. Emerging Themes Importance of an environment supportive of private practice nursing –Dr Kendrick has faced many challenges through her career in mental health nursing and described the implications of organizational support and policy on private practice. She particularly identified the difficulty of negotiating varied registration requirements and policies of state governments in the USA. She also described the practical challenges of adapting her practice to available space. For example, she is currently utilizing an office on a university campus for her private practice work which allows her to save on overheads while she pursues research interests. Lorna’ s partnership with a university in this way presents a pertinent example for possible partnerships between private practice mental health nurses and the Australian tertiary sector.
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Advanced practice nursing adapts psychotherapy to client needs - Lorna differentiated her role from medical practitioners by her emphasis on empowering clients through teaching in therapy. She adopts an eclectic psychotherapeutic approach which may draw on theories such as gestalt, play or brief therapy etc. She emphasized one of the strengths of mental health nurses as being their ability to adapt psychotherapeutic theory to meet client’ s needs, rather than teaching a rigid theoretical approach. Lorna’ s emphasis on adaptation, creativity and working with patients embodied knowledge has direct implications for the Australian psychiatric nurse practitioner movement as it seeks to differentiate and promote the NP role as distinct from medicine and psychology. Location 2: Washington 1. Pamela Marcus; Advanced Psychiatric Nurse in Private Practice In Washington my main contact was a fantastic advanced practice psychiatric nurse Pamela Marcus who had a wide variety of links with local services. Pam has run her own private practice delivering psychotherapy, medication management and comprehensive care for adults and families for more than 20 years. She is highly regarded in her local community and has a national reputation as a teacher, often being invited to speak at conferences throughout the USA. Emerging Themes Importance of an environment supportive of private practice nursing –While she is nationally recognized as an expert in her field a significant challenge in Pam’ s practice over the years has been management of third-party reimbursement, payer mix and negotiating successive government policy changes. She is widely respected for delivering vital services in her community yet her practice is rebated at substantially lower rates than her local medical counterparts. This has meant she has had to cut back on services due to the challenges of the 2009 economic crisis. As policy is developed in Australia around re imbursement for nurse practitioners, Pam’ s example emphasizes the importance of accounting for private practice costs and overheads in the same way they are costed for medical practitioners and psychiatrists. 19
Relationships and infrastructure form a solid foundation - Pam emphasized relationships with local referring clinicians and services as a key to success in the business of running a private practice. She also spoke about the need for an evolving, creative marketing plan in and stressed the importance of a well-planned management information system for patient data collection, billing, and outcome measurement. The future development of mental health nurse specific data management systems hold great opportunity for Australia’ s growing tertiary nursing sector. 2. Prince Georges Urgent Response Team Pam arranged a visit for me with “Prince Georges Urgent Response Service,”one of a number of programs run by “Santé Group”a health promotion charity in Maryland Washington. The program operates 24 hrs, 7 days a week providing comprehensive community mental health crisis response services for people experiencing mental health crisis. It’ s funding is largely administered through Maryland Department of Health and the Developmental Disabilities Administration (DDA). Emerging Themes Innovative programs - I met with clinical director Joy who stated that the programs ability to assess and respond appropriately to clients experiencing mental health crisis has led to significant positive feedback from the community and local police. The police greatly appreciate the ability to concentrate on policing without having to blur roles. Significantly, the team leader (who may be a psychotherapist, psychologist, advanced mental health nurse or similar) on each shift of the Prince Georges urgent care team has been granted authority to commit patients for hospital based psychiatric assessment. Effective collaboration with police - As the service tries to compliment the work of local police it has been able to negotiate access to a number of police radios which enable its crisis response teams to respond to incidents which occur in the community at a moment’ s notice. Each shift has a team of clinicians equipped with a police radio which 20
assists them to effectively triage and respond to mental health crisis situations. Quick response has led to improved ability to relieve police from situations where they are best used elsewhere and has led to significant cost savings. The model’ s success has led to it being adopted by nearby counties. This collaboration between police and mental health non government organizations is virtually unheard of in Australia and provides a great example of creative service delivery options for people experiencing mental health crisis. 2. Prince George’ s Community College (PGCC) Prince George’ s Community College is one of more than 1,000 two year post-secondary colleges across the USA providing certificate degrees in arts, science and nursing. I visited Prince George’ s main campus located in Largo, Maryland. The college services a largely African American community with significant migrant populations from various parts of Africa and Asia. The average age of students in the college’ s nursing program is approximately 30 years and the faculty were an inspiring group who promoted a philosophy of practice based learning, focusing on the strengths of students and their local community. Emerging Themes Developing nurses the future of health care delivery: With more than 40 years advanced community nursing experience Diane Davis is the Assistant Professor of the Department of nursing at PGCC. She is regularly consulted and provides advice through boards at a state and national level regarding public health policy. Diane emphasized that economic principles require that health care be provided in a costeffective manner. This means that practice based training which produces graduating registered nurses through colleges like PGCC have the potential to contribute to the growing need for registered nurses in the modern USA health care system. Future production of nurse practitioners: Diane stated that with recent moves towards nationalized health insurance through policy laid out by the Obama administration the need and opportunity for advanced practice nurse led services provided by nurse 21
practitioners in the community will grow. She foresees that on completion of their two year associate degree through St Georges many graduating students move on to complete 4 year degrees and masters degrees through major universities, this has the potential to provide a wider cohort of registered nurses to produce the nurse practitioners the USA is going to need moving into the 21st century. 4. Minute Clinics The demand for affordable, accessible health care in the USA has led to the establishment of a modern version of nurse managed centres known as “Retail Health Care Clinics”(CCCs). Retail clinics are challenging existing models of primary care by shifting location of care provision to shop fronts in shopping malls, marketplaces and pharmacies. Retail clinics are cutting costs and making primary healthcare more competitive with average visits costing between $50 - $75. This is compared to a physician’ s office visit, which can cost from $100 - $250, meaning treatments provided at retail clinics offer considerable savings. When compared to the same treatments in a hospital emergency room, the savings are even greater. Emerging Themes Environment supportive of wide and advanced nursing roles - I met with Maria and Sheryl, two young nurse practitioners (NP’ s) working for one of the most successful chains of retail health clinics in the USA called “Minute Clinic.”Both NP’ s appreciated the positive working environment, pay and conditions afforded to them as they delivered affordable, well regulated treatment with no appointment needed in pharmacy based clinics. Typical conditions treated included strep throat, eye and ear infections, mononucleosis and vaccinations. The “Minute Clinic”chain is also paperless, having developed their own treatment protocols and computer management systems. Increasing accessibility and meeting need –Offering primary health care, retail clinics are based in high traffic retail outlets with often adjacent to pharmacy services. Since establishment at the turn of this century CCC’ s have provided more than 3.5 million patients with assistance related to common ailments, physicals, health screenings, 22
vaccinations and preventive care. Retail clinics have successfully contributed to meeting the need of the approximate 30-40 percent of the American population that does not have a primary care provider. They provide yet another example for Australia as we seek to meet the challenges of cost effective 21st century healthcare. Location 3: Philadelphia 1. The National Nursing Centers Consortium (NNCC); In Philadelphia I was privileged to have my visit coordinated by the National Nursing Centers Consortium (NNCC). The NNCC CEO Tine Hansen-Turton and her team are enthusiastic advocates for nurse managed centres, which are safety net healthcare providers generally located in disadvantaged rural, suburban, and urban communities throughout the country. Accountability is a hallmark of nurse-managed centers with most receiving federal funding which covers overheads such as building or rental and administrative costs with other sources of funding such as third-party reimbursement mechanisms, private donations and partnership contracts being utilized. 2. The Health Annex The Health Annex is one of three nurse managed centres which are part of the “Family Practice and Counseling Network.”This is a nurse led organization serving over 14,000 patients annually. I met with Health Annex clinical director Lorraine Thomas who gave me a tour of the facility which provides comprehensive primary care services, including dental, prenatal, gynecological and behavioural health care. A number of health promotion programs also operate out of the center, including: “Lead Safe Babies,”a childhood lead poisoning prevention program; “Southwest Breast Health Initiative,”a program that provides breast health education and screenings for women over 40 years old; “Go Red for Women,”a cardiovascular health education and awareness program for women and “Stay Quit, Get Fit,”a combined tobacco cessation and exercise program.
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Emerging Themes Environment supportive of wide and advanced nursing roles - The nurse practitioners who work at the Health Annex apply a holistic nursing model of care, establishing positive long-term relationships with patients which encourage greater use of the clinic and adherence to health teaching. This sort of health education is typically associated with the excellent patient outcomes of nurse managed centres right across the USA. According to managed care data, health center users report 30% fewer hospitalizations than patients receiving care at traditional primary care practices. Likewise, the rate of emergency department usage among nurse-managed health center users is 15% less than at traditional practices (NNCC, 2008). Targeted placement of nursing places - The strategic placement of “The Health Annex” in a community that lacks adequate health care services has helped reduce medical disparities and the unnecessary use of health care resources. This centre exemplifies the sort of health outcomes and cost savings that could be achieved through nurse managed centres in Australia. 3. Mary Howard Health Centre Also in Philadelphia, Mary Howard Health Center is a nurse managed center which has been providing primary healthcare for homeless adults since 1997. The center’ s philosophy includes provision of health care to homeless people at all points along the continuum: from the street to shelter to transitional housing and to self-sufficiency. Emerging Themes Environment supportive of wide and advanced nursing roles -: I met with psychiatric nurse practitioner Rhonda Fletcher who stated that engagement with homeless individuals with a mental disorder tends to take longer than usual. There is often a degree of mistrust and paranoia surrounding healthcare figures. For this reason Rhonda’ s reported her role often involved lengthy periods of involvement with clients, and she often needs to adapt a creative management plan. She described being a member of a nurse managed centre as being enormously empowering as she felt 24
supported to pursue and deliver the treatment required by individual client’ s wrather than feeling restricted by the pressures of a medicalised model of care. Innovative programs - Compliance with medical treatment, especially for mental illness, is generally poor. The reasons for this are similar to the reasons the individual becomes homeless in the first place. Poor motivation, poor self-esteem, lack of insight, lack of self-care and psychological regression all contribute. Side effects of anti-psychotic and antidepressant medication can be undesirable (including impotence and movement disorders such as tardive dyskinesia). Rhonda has adapted her role to meet this need by offering clinics to shelters in the local community. In this way she often tracks the care of clients who move from service to service, developing a better understanding of their needs and feeding back into her treatment plan. Location 4: New York 1. New York University (NYU) New York University College of nursing is one of the largest nurse training centres in the USA with an annual student cohort of approximately 1,500 students. Alongside undergraduate degrees NYU College of nursing offers a range of nurse practitioner programs. Emerging Themes National standards for nurse practitioner preparation - I met with Dr Madeline Naegle the director of NYU’ s behavioural health advanced nursing courses. Madeline informed me that the University’ s courses are seeking to work towards reflecting the Licensure, Accreditation, Certification & Education (LACE) guidelines adopted in 2008 by the American Association of Colleges of Nursing. LACE is a consolidated national policy approach to advanced practice nurse training. The policy seeks to consolidate nurse practitioner roles into Family, Geriatric, Peadiatric and Psychiatric specialties. This consolidation in preparation of nurse practitioners at a university level has significantly streamlined the Nurse Practitioner movement into simplified deliverables for public health policy. 25
The importance of matching university outputs with public health priorities- The LACE policy acknowledges the need for nurse practitioners to keep pace with the forecast rising demand in the aged care sector and stipulates that all advanced practice mental health training must include standardized training in geriatric care by 2015. With the recent introduction of national registration of nursing in Australia and the federal government’ s 2010 legislation giving NP’ s prescribing rights for the first time, the LACE model of academic preparation should be used as an example for academic institutions in Australia regarding the need to streamline the outputs of academic institutions to match the public health needs. 2. Henry Street Clinic It was an honour for me to visit Lorraine Ahto the Director of behavioural health at the “Henry Street Settlement.”This was the service established by public health nursing pioneer Lillian Wald serving the poor in New York City in 1893. Henry Street's core divisions include a multidisciplinary arts center; homeless shelter support services; behavioral and health services; senior services; home care services; a workforce development center; day care centers; and after school and summer programs for neighborhood youth. Emerging Themes Environment supportive of wide and advanced nursing roles -:Henry Street’ s community consultation centre employs advance practice mental health nurses as members of a wide allied health team providing outpatient mental health services, psychiatric day treatment, crisis services, HIV/AIDS counseling, vocational rehabilitation, housing, primary healthcare, parenting education and job training opportunities. Innovative programs: Historically distinguished by a profound connection to its community and use of innovative solutions, it was inspiring to see the settlement has maintained its innovation and deep connection with its community. This was demonstrated through clinics actively running in the basement of public housing estate buildings with the residents living in flats above. Lorraine emphasized that effective 26
healthcare can only be delivered when health care providers are willing to appreciate the environment of the populations they serve. This important point has implications for the development of effective nurse led mental health services in Australia which may meet a real need in Australian primary healthcare if they are willing to meet people in disadvantaged communities where they are live. Speaking the people’ s language - Henry Street has employed a pro bilingual staff employment policy in order to meet the needs of the immigrant populations it serves. Its multi-ethnic staff provide services in English, Spanish, three dialects of Chinese, Italian, Sicilian, and German. Lorraine made the innovative suggestion that university based mental health nurse and allied health training of the future should include study in language. This sought of creative thinking about healthcare and the way it is delivered alongside a willingness to adapt innovative modes of service to meet community needs made this service and its leadership team a stand out example of the sought of creative health models needed in Australia in the 21st century.
Location 5: Boston 1. Mclean Psychiatric Hospital It was an honor to visit Mclean psychiatric hospital, a major teaching facility of Harvard Medical School and the preeminent psychiatric hospital in the United States. The hospital has a significant place in nursing history having established the first school of nursing in a psychiatric hospital in 1882 and is the home of numerous internationally acclaimed innovations in psychiatry including the in the Basis 24 patient measurement outcomes scale which is used widely in Australia. I was lucky to make contact with Linda Faherty, Senior Vice President of Patient Care Services at Mclean who coordinated a round table discussion with several directors of 27
nursing from the hospital who described their programs and shared collective wisdom regarding psychiatric nursing in the USA. Emerging Themes Innovative programs - A strong theme from my discussions at Maclean was the hospitals provision of a wide range of psychiatric programs marked by constantly evolving innovation. It is widely acknowledged that a single model of care cannot cater to the variety of needs people with mental health disorders and their families need when experiencing the challenges of mental illness. It was evident that Maclean is making a significant effort to innovate and provide clients with access to a wide variety of choice of psychiatric treatment. This is rarely found in Australian hospitals where programs tend to be based on the risk associated with patients. For example, instead of a specialist program for people with schizophrenia or obsessive compulsive disorder, patients tend to be admitted to the “acute”or “sub acute”wards of hospitals where generic treatment programs are offered, often missing opportunity for targeted treatment of conditions. Matching innovation with cost effectiveness - It was a real privilege to meet with this team of nursing leaders who confirmed that cost effectiveness is a key determinant in the delivery of services in the 21st century. As such, they predicted that the growth of community based nurse led services (nurse practitioners, nurse managed centres, etc) which operate as alternative providers of primary healthcare, containing costs, integrating pathways of care and leading to shortened hospital stays will grow in importance in the future. 2. Boston Healthcare for the Homeless Boston Healthcare for the Homeless Program (BHCHP) is the largest and most comprehensive health care for the homeless service in the USA serving more than 10,000 people annually. I was privileged have my visit coordinated by Barbarra Cocci the director of behavioural program at BHCHP. She stated that this magnificent services
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success had been largely due to a talented and politically astute leadership team who has been able to match funding streams with innovative programs. Emerging Themes Environment supportive of wide and advanced nursing roles - I spent clinical time with Jennifer, an advanced mental health nurse at BHCHP who described her role as extremely satisfying. She emphasized taking into account her patient’ s milieu in delivery of care also noting the influence of culture on diagnoses, treatment and therapeutic compliance. She stated she felt supported and empowered in her role at BHCHP which she described as an organization supportive of advanced practice nursing roles. Innovative programs - With over one hundred beds, BHCHP in many ways resembled an Australian hospital, though staff I met were at pains to emphasize that it was a “respite health centre”and not a hospital. Admission to beds was targeted at people who required respite from homelessness due to their need for appropriate physical healthcare. While occupying a bed at the centre however, patients receive far more than just treatment for their medical condition. They receive comprehensive mental health and social assessments and are linked in to a host of programs all designed to assist transition out of homelessness. While this sort of integrated homeless service has been implemented on smaller scale in Australia the idea of using healthcare as a window through which other social services can be delivered stood out as a worthwhile model for application in Australia.
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Conclusions 1) A wide scope of practice for mental health nurse practitioners improves care. The fellowship revealed that advanced practice mental health nurses (nurse practitioners etc) have been well supported throughout the USA for many years. The roles of mental health nurse practitioners have also been widened in order to meet community needs. For example, in some states nurse practitioners have the ability to commit patients to hospital if required. This practice was working well, providing effective care for people experiencing mental health crisis and reducing police involvement. 2) Innovation means adaptation. Again and again throughout my fellowship I was inspired by innovative leaders who were adapting their models of care to the changing needs of the disadvantaged groups that they served. The implications of this conclusion for Australia is that effective healthcare amongst disadvantaged communities may often occur through “people and programs”rather than just through building service “places”. 3) Nurse managed health centres are very effective. The “nurse managed centre”model has been extremely effective amongst disadvantaged communities in the USA. An affordable and high-quality safety-net option, these centres deliver primary healthcare in an extremely cost effective way through nurse practitioners who are able to diagnose and treat illnesses, order and interpret laboratory tests, and prescribe medications to treat acute and chronic illnesses, 4) The role of legislation is important. It was clearly evident that government policy has an enormous impact on the way in which mental health nursing services are provided in the USA. For example, nurse led services in California cited “Proposition 63” a government bill passed in 2004, which imposed a 1% income tax on personal income in excess of $1 million redirecting money to new mental health services. This act has provided significant opportunity for nurse 30
led mental health centre to access increased funding, personnel and other resources to support new mental health projects. 5) University involvement is very effective. Several of the projects visited were funded by universities who saw it as part of their duty to the community to contribute to the needs of disadvantaged groups. The benefits for students through these programs is immense, with thousands of graduate and undergraduate nursing students participating in these clinical training sites each year. Nurse managed academic learning centres provide a wonderful example and opportunity in the Australian context. 6) Providing consumers with right to choose improves care and lowers cost. Many Americans are choosing to access health care services from nurse practitioners because of the alternative quality services they provide. The nurse practitioners I spoke with applied holistic nursing models of care, establishing positive long-term relationships with patients and encouraging greater adherence to health recommendations which is associated with excellent health outcomes. While the Australian government is to be applauded for its recent support through legislation of nurse practitioners we must acknowledge that the mental health care challenges of the 21st century cannot be solved by a medical model of health care alone, and that mental health nurse practitioners have a vital role to play in the future of primary care in Australia.
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Recommendations 1) People: Increase production of nurse practitioners. The unquestionable effectiveness of nurse practitioners as providers of cost effective, quality primary healthcare in the USA strongly suggests that the Australian federal government, the newly formed national nursing registration board and the tertiary sector should move to adopt a cohesive national plan to develop a nurse practitioner workforce for 21st century Australia. The American tertiary model which allows undergraduate nursing students to enroll in nurse practitioner Masters programs, thus producing nurse practitioners through a comprehensive 5 year Masters level course, provides a effective model to achieve this. 2) Programs: Widen roles of mental health nurse practitioners. “Dr does not always know best,”and for this reason it is imperative that Australian mental health policy stop the monopoly of the medical profession over mental health service delivery: Australian systems must begin to provide more choice to consumers by supporting and widening the role of mental health nurse practitioners. For example, in Australia people experiencing mental distress can only access bulk billed mental health nursing care if they are referred by a medical practitioner. This maintenance of the medical profession’ s monopoly over the Medicare re imbursement system diminishes patient’ s right to choose under the pretense of forcing “teamwork”between health professionals. This premise is void of meaning and will always be inefficient as effective teamwork only occurs when individuals, professional or otherwise, are treated as autonomous equals. Another example of the medical monopoly on mental health is the sad state of affairs which allows only police and medical doctors in the ability to commit patients for hospital based psychiatric assessment in Australia. The American experience suggests we can deliver better care to people experiencing mental health crisis by widening the practice roles of mental health nurse practitioners in order to reduce police involvement in
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mental health crisis. Promoting access to mental health nurse practitioners with these sort of measures will allow patients better choice and better care. 3) Places: Pilot “nurse managed psychiatric urgent care centres.” Given Australia’ s difficulty serving people with mental illness, shortage of general practitioners, shortage of nurses and our rapidly ageing population, we should move quickly to invest in piloting nurse managed psychiatric urgent care centres. These services could function as safety net healthcare providers in disadvantaged communities, substantially alleviate emergency hospital admissions and also serve as community based health workforce development sites in partnership with universities. Final Thanks I would like to repeat my first note of thanks by stating that this fellowship would not have been possible without the kind assistance of many people. In particular I would like to thank Kathy Shoemaker from Exodus Recovery INC; Inese Versalekis from UCLA; Pam Marcus and her wonderful colleagues at Prince Georges Community College in Washington; Tine Hansen Turton from the National Nursing Centres Consortium in Philadelphia; Madeline Nagle from New York University; Lorraine Ahto from the Henry Street Clinic in New York; Linda Faherty from Mclean Hospital and Barbarra Cocci from Boston Healthcare for the Homeless. All these exceptional people and services consistently treated me with great courtesy and enthusiasm and I only hope I can return the favor to some of these dear colleagues on visits to Australia in future. Finally I would like to sincerely thank the Winston Churchill Trust for what can only be described as a life changing experience. I will continue to advocate widely for reform of mental health nursing services in Australia through universities, submissions to governments; presentations to professional and community conferences; researching and lobbying. I also hope to implement these findings by applying lessons learnt to my own mental health nursing practice.
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