Access to psychiatric care can be an obstacle for both patients seeking care and the primary care providers who refer them. Of medical patients referred to mental health services, more than half do not follow through when referred to a mental health specialist due to perceived inconvenience, stigmatization, transportation issues and/or cost.1 In a study, two-thirds of physicians reported they were unable to obtain quality mental health services for their patients, more than double the rate for other common healthcare services.2
These obstacles, combined with a critical lack of psychiatric care providers, long waiting lists and a culture that often does not value mental health, prevent access to care.3 For these reasons, more patients seek treatment for psychiatric disorders from primary care providers as opposed to mental health specialists. Today, almost 50% of common psychiatric disorders are treated by primary care providers who lack mental health training.4
The availability of an NP or PA with expertise in mental health can provide significant benefits to patients in the primary care setting. The interventions of a mental health NP or PA in primary care can increase patient participation and improve adherence. Early detection and treatment of mental illness, along with evidence-based treatment approaches delivered by mental health NPs and PAs, can increase recovery rates, improve physical health, reduce overall healthcare costs and, in turn, improve patient care and satisfaction.
This article describes my evidence-based practice (EBP) change project, which sought to implement a strategy for increasing access to psychiatric care by integrating psychiatric services into a primary care setting.
A literature search identified three patterns that support the premise of this EBP change project: psychiatric care access improves with the presence of a mental health NP in the primary care setting;3,4 primary care providers are overwhelmed by the volume and acuity of the mental health care needs of their patients;3,4 and the stigma of mental illness is lessened when patients have timely access to a psychiatric professional in the primary care setting.5,6
These patterns formed the basis for the goals of the EBP change project: to improve access to psychiatric care; to decrease the primary care burden to treat psychiatric disorders; and to improve patient safety and satisfaction.
A cluster randomized control trial3 compared the effectiveness of treating patients with common psychiatric disorders in a collaborative care practice model with the effectiveness of treating such patients through traditional referral to mental health services. In the collaborative care practice model, a mental health professional was on site and available to provide evaluation and initial psychiatric treatment to patients referred (in house) by the general practitioner. In the traditional model, patients were referred out for mental health services.
Psychopathology and quality of life improved in both groups. The collaborative care practice model resulted in greater satisfaction among general practitioners; shorter referral delay; reduced time in treatment; and reduced cost. The number of psychiatric referrals to outside mental health specialists per primary care provider was substantially less than in the collaborative care practice model, which suggests an increase in access to psychiatric care with the collaborative care practice model.3
In a descriptive study outlining the success of existing partnerships between psychiatric-mental health NPs and primary care providers in Australia, Fisher stated that the collaboration of psychiatric-mental health NPs and primary care providers can improve psychiatric care access by 21%.7 The study concluded that this practice model improved access to mental health services by providing quality, cost effective mental health care in a timely manner and decreased the workload for both primary care providers and psychiatrists.7
In a study in Canada, Swenson and colleagues found that the availability of mental health NPs to provide comprehensive psychiatric services in a collaborative care practice model was highly valued by primary care providers.8 The researchers determined that the model would decrease the workload of the primary care provider, who no longer had to attempt to meet the complicated mental health needs of patients who presented with psychiatric symptoms, and eliminated the frustration of long waiting lists for referrals to mental health services.8
In a study designed to examine customer satisfaction with the care delivered by psychiatric-mental health NPs in the United States, patients reported high levels of satisfaction in the following areas: they received more information about their illness, including health teaching and written patient education materials; more laboratory and psychometric tests were ordered by the NP; and a greater number of follow-up appointments and longer consultations occurred with NPs.9
The design of this EBP change project was a collaborative care practice model that placed a psychiatric-mental health NP in the primary care setting. The NP accepted patient referrals from the primary care providers and provided psychiatric diagnostic evaluation and treatment planning, brief psychotherapy and medication management for a maximum of six visits. Patients requiring more intensive psychiatric care (greater than six sessions), were referred to Psychiatric Consultants of Central New York (PCCNY) for long-term psychiatric care.
The providers in each of the primary care practices had expressed frustration with the lack of services available for psychiatric referral. They identified a lack of skills essential to treating psychiatric conditions and a desire to improve continuity of care for their patients with psychiatric disorders. In anticipation of this project, each of the primary care practices was asked to estimate the percentage of patients referred for psychiatric evaluation and treatment who did not follow through. These estimates were determined by tracking referrals for follow-up during a 3-month timeframe. These estimates ranged from 50% to 75% (depending on the practice), and were consistent with the national norms.2
For the purposes of billing and record keeping, all psychiatric services were billed through PCCNY. All state regulations with regard to chart review and scope of practice were maintained by the NP and collaborating psychiatrist of PCCNY. Primary care providers made an in-house referral to the NP for patients they identified as requiring psychiatric evaluation and treatment. Once a patient was referred to the NP, the patient was scheduled for an appointment for initial psychiatric evaluation within 1 week. The patient was asked to sign a release of information for both the NP and primary care provider for the purpose of continuity of care. Copies of the release of information and the psychiatric evaluation and treatment plan were placed in the patient's primary care chart.
Setting and Population
This EBP change project took place in suburban Syracuse, N.Y. Three primary care practices agreed to collaborate with PCCNY in this project. Seven primary care providers and 12 office staff participated. Each practice agreed to provide a private space for the NP to interview patients. Patients seen by the NP were identified by their primary care provider and had to be 18 and older.
Efficacy of the EBP practice change was determined by outcomes. The national and local average of patients who do not follow through with psychiatric care exceeds 50%.2,4 Improved access to care was targeted at a reduction to 35% of patients referred for psychiatric care who do not follow through. This reduction represents an increase of 15% in patient participation in psychiatric care. Patient satisfaction was determined by perceived convenience. Primary care provider satisfaction was determined by decreased burden of treating psychiatric disorders, shorter referral delay, and improved continuity of care for patients with psychiatric disorders.
Forty-six patients were referred to the collaborative care practice model by the three participating primary care practices from January 2, 2012, through April 30, 2012. Of these, 36 patients (78%) followed through with psychiatric treatment. The percentage of patients who were referred but did not follow through dropped to 22%, representing a 28% improvement in the rate of patients who followed through with referral. Thus, the goal of improved access to psychiatric care was met.
Surveys showed that patients perceived greater convenience in the collaborative care practice model. The primary care providers highly valued the collaborative care practice model. The providers said they experienced relief at not having to treat the complex needs of their patients who present with psychiatric symptoms. They valued shorter referral delay and continuity of patient care provided by the collaborative care practice model.
Office staff members also reported a positive response to the collaborative care practice model, focusing on greater ease of the referral process as a primary benefit.
Limitations of this EBP change project included short time frame of implementation, limited number of primary care settings, and small number of patient referrals. The strength of the project lies in the fact that the goals were met and were reflected in the outcomes. The target goal of increasing access to psychiatric care by increasing patient participation by 15% was exceeded. Patients perceived greater convenience in the collaborative care practice model. Primary care providers indicated said they valued the collaborative care practice model. This EBP change suggests that the inclusion of a mental health NP or PA in a primary care practice opens a new portal to psychiatric care for patients.
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5. Parse RR. The Lived Experience of Suffering. In: Illuminations: The Human Becoming Theory in Practice and Research. New York, NY: National League for Nursing Press; 1995: 243-246.
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8. Swenson J, et al. Development and implementation of a collaborative mental health care program in a primary care setting: The Ottawa share program. Canad J Commun Mental Health. 2008;27(2):75-91.
9. Wortans J, et al. The role of the nurse practitioner in psychiatric/mental health nursing: Exploring consumer satisfaction. J Psychiatr Ment Health Nurs. 2006;13(1):78-84.
Bambi A. Carkey is an adult psychiatric-mental health nurse practitioner who is in private practice in Fayetteville, N.Y. She is a clinical assistant professor of nursing at SUNY Upstate Medical University in Syracuse.