AACP Positions on Access to Psychiatric and
Psychopharmacology Services in Underserved Areas
Overview:
The AACP, as a professional organization
committed to public service, believes that quality psychiatric care should be
available to all in need. We call on our profession and our allies in
this mission to make this a reality and to work vigorously toward the
elimination of the designation “underserved” for communities and
populations. Toward that end, we offer the following paper to spark further
actions.
AACP believes that the issue of access to
psychiatric services in underserved areas, particularly rural areas, is an
important priority for attention by psychiatry organizations. AACP supports the availability of competent
psychiatric services through a combination of direct access to psychiatrists
(in person and via telehealth linkages), to
psychiatric practice extenders who have access to consultation and/or
supervision, and to primary care providers in Federally
Creating service access within these
areas, particularly in rural and impoverished urban and suburban communities
most critically requires an organized PUBLIC HEALTH approach, which:
· defines the global needs of populations
(including children and adolescents) in underserved communities for various
categories of psychiatric services, and then develops a strategic plan for how
to best meet those needs.
· clearly delineates the role of the
psychiatrist as a specialist within
an array of service providers, and establishes which functions can be most
appropriately performed by other providers with psychiatric support (and with
what types of support), and which functions require the special knowledge and
skills of a psychiatrist (and through what mechanisms).
· includes strategies to attract adequate
numbers of primary health and behavioral health workers of all types to
underserved areas, as well as approaches to specifically attract and retain
psychiatrists.
The following outline incorporates bullet
point strategies for achieving this outcome.
OUTLINE
I. Define
the Needs of the Population and Available Resources:
a. Epidemiology/Prevalence of adult,
youth, and child behavioral health service needs.
b. Penetration of service in underserved
areas compared to average urban or suburban areas – measurement of gap.
c. Availability of behavioral healthcare
human resources, primary healthcare workforce resources, psychiatrists and
psychiatrist extenders, physicians and physician extenders.
d. Direct psychiatric services –
assessment, medication prescription, hospital management, emergency and crisis
care, forensic evaluations, and medical psychotherapy for both adult and
child/adolescent populations.
e. Indirect psychiatric services –
consultation and liaison with primary care physicians and physician extenders,
consultation to and supervision of psychiatric nurse clinical specialists or
nurse practitioners and physician assistants with prescribing privileges (both
adult and child/adolescent specialists), oversight and supervision of, as well
as consultation to non-medical front line behavioral health providers and
interdisciplinary teams; and specific medical direction to behavioral health programs,
agencies, and systems.*
f. Identification of Federally designated
Mental Health Manpower Shortage Areas and areas that might be eligible for such
designation.
g. Identification of existing projects for
creating or expanding psychiatric services in underserved areas: APA survey of
district branches, National Association of State Mental Mental
Health Program Directors (NASMHPD) Medical Directors survey, managed care
organization survey, Health Access Foundation Grants, National Rural Mental Health Association
(NARMHA)NARMHA.
h. Continued monitoring of “access” data
at the state and tribal level: e.g., by NASMHPD, the American Psychiatric
Association (APA) and its District Branches, AACP, and using this data to
organize continued improvement efforts.
i. Discuss
how some but not all of these functions can be offered through other
professionals under psychiatric supervision.
CORE POSITION
AACP supports the
availability of competent psychiatric and psychopharmacology prescribing
services through a combination of the following:
·
access
directly to psychiatrists (both in person and via telehealth
linkages)
·
access
to psychiatric practice extenders who have available consultation and/or supervision (both on site
and via telehealth),
·
access
to primary care providers (both those in FQHCs and
those in other settings) with adequate psychiatric consultation and support.
Each of these areas will be
discussed in the following recommendations.
II. Recommendations
to improve access to psychiatric services and access to competent
psychopharmacology prescribing providers in underserved areas.
A.
Improving availability of psychiatrists
in underserved areas
a. Proposed Remedies to improve numbers of
psychiatrists in rural and other underserved areas:
i. Economic
incentives:
1. Reimbursement rates on parity with
other medical specialists enhanced in rural areas and other federally
designated underserved areas.
2. An organized effort to identify and
create designations for mental health under-served areas in order to create
prioritization for J-1 status and other federal initiatives.
3. In addition to the above, initiate
extensive review to expand the current criteria for designation of underserved
rural areas. Many geographical areas
fail federal “underserved” criteria despite pockets of very poor access,
especially access to adult and child psychiatrists. The existence of homeless shelters within
otherwise non-designated areas is such an example and such facilities should be
designated as “underserved areas” for recruitment purposes.
4. Expansion of the definition of “primary
care specialty” to psychiatry
5. Access to appropriate formularies –
physicians are not attracted to work in environments where they cannot provide
acceptable treatments.
6. Tax and other incentives to attract
psychiatrists to underserved regions
7. Reimbursements for telehealth
and for non face-to-face consultations with PCPs, Physician Assistants (PAs), Nurse Practitioners (NPs) (see below).
8. Mechanisms for broadening the ability
of FQHCs to oversee a broad array of community based
mental health services under the auspice of their enhanced reimbursement
framework.
9. Similar mechanisms for health clinics
in Native American tribal settings with 100% federal match for Medicaid.
ii. Other Job Enhancements:
1. Involvement in a supportive
multidisciplinary team as an essential feature of job satisfaction and
attraction.
2. Standardized job descriptions that are
fair and meaningful and incorporate supports that compensate for professional
isolation – e.g. involvement in clinical supervision, teamwork, and program
development, as well as community consultation, not just direct service.
3. Organized professional support networks
for psychiatrists and psychiatry extenders in underserved and isolated areas.
4. Appropriate compensation and fringe
benefits.
5. Relocation expenses, compensatory time
off.
6. Increased student loan forgiveness
benefits.
7. Paid educational opportunities to
ensure professional growth.
8. Appropriate availability of support
staff.
9.
Access
to good quality telehealth linkages, with adequate
telecom and IT infrastructure.
10. Access to university faculty appointments
and telehealth-linkage to department supports.
11. Membership in AACP.
iii. Developing enforceable regulatory
standards
1. Federal and/or state guidelines
defining a role for psychiatrists in rural and other underserved areas as a
necessary component of a local system within the public health framework, and
creating expectations that local systems invest in the recruitment process.
This may involve setting minimum thresholds of psychiatrists (or sample ratios
for rural and other underserved areas) needed to be part of a comprehensive
delivery team that involves front line behavioral health providers, psychiatry
extenders and PCPs.
2. AACP/APA/American Public Health
Association/American
Consortium of Mental Health Administration (ACMHA)/ACMHA
playing a
central role in determining these standards, collaborating with other
organizations such as NASMHPD and the National Council of Community Behavioral
Health and professional associations for Psychiatric PAs
and NPs.
iv. Education re: benefits/need for
psychiatry:
1. Clinics and hospitals, human services
providers, government, and the public at large do not adequately appreciate the
value of good quality psychiatric care.
2. Join with other educational advocacy
initiatives to support increased awareness of value of psychiatric involvement.
v. Improved coordination of recruitment
efforts through organized collaborations and information exchange mechanisms
(e.g. available positions, work/pay
conditions, resources for hiring) regionally and nationally.
1. Local psychiatric societies and
university departments of psychiatry could be offered incentives to develop or
expand current efforts to promote access to underserved areas, and to maintain
regional job banks.
2. Partnering with Area Health Education Collaboratives and FQHCs in
recruiting mental health expertise, including psychiatry, as part of core
primary care responsiveness in rural and other underserved areas.
3. Organize local projects to facilitate
recruitment and retention of individuals with J-1 Visa status.
4. Development of rural community
psychiatry fellowships to attract residents and early career psychiatrists into
underserved areas.
5. Block grants and fellowships from other
sources – including pharmaceutical companies - to connect psychiatrists with
jobs in underserved areas.
6. APA could coordinate and underwrite a
recruitment service for underserved areas, given that APA - Psychiatry News classified advertisements and the APA Job
Bank listings are costly.
7. Many publicly-funded agencies do not
have adequate human resources departments for negotiating physician jobs. Their
efforts could be standardized and supported by APA.
8. Partnerships with
universities to promote community engaged scholarship and other
community-academic partnerships with a focus on creating mechanisms for
leadership training in public service psychiatry in underserved areas.
9. Create economic incentives for academic
departments of psychiatry to extend training to these areas through federal
funding enhancements and expansion of the J-1/H-1 visa programs.
B.
Improving access to psychiatric
extenders in underserved areas - Other
non-MD health professionals are qualified to fill many psychiatric functions
(NPs, and physician assistants [PAs]):
i. Define
which categories of medically trained non-MDs are already involved in meeting
some functions defined above.
a. Define their current level of skill and
training
b. Describe the scope and limitations of
their practice (this varies from state to state, but APA could provide useful
general guidelines for local societies to advocate).
c. Provide model(s) of successful
collaboration between NPs/PAs and MDs.
d. Define mechanisms for psychiatry
supervision, training, support (including organized mechanisms for telehealth consultation support by university departments
of psychiatry) that enhance the capacity and functioning of physician
extenders. This should include access to
subspecialty consultation (child & adolescent, addictions, geriatrics).
e. Expand access to training opportunities
for NPs and PAs in underserved areas.
f. Consider each incentive item above
(see Section IIAa) for psychiatrist recruitment
and retention, and apply the same items to the training, recruitment, and
retention of psychiatrist extenders (including those with pediatric
sub-specialization).
g. Identify APA as committing a
substantial investment to the development of this workforce in order to be
perceived as sincerely concerned about quality and not merely guild issues.
1. Helpful will be data analysis comparing
the development and training of non-medical mental health professionals
concerning to the cost of developing a larger contingent of adult and child
psychiatrically trained physician extenders.
2. Take a position re: APA/AACP support for maximizing the availability of
medically trained psychiatric extenders , versus being against using non-medical mental health professionals to solve the
problem (e.g. psychology prescribing issue).
3. A
“Call to Arms” to other stakeholders to join with us to improve access to
psychiatrists and psychiatric services.
a. APA
b. Consumer
and other groups, for example: National Alliance on Mental Illness,National
Mental Health Association NMHA, National Rural Mental Health Associationlliance, NARMHA,
NASMHPD, NCCBH, and Association of Clinicians for the Underserved.
C.
Improving access to competent and
well-supported primary care physicians and nurse practitioners, physician
assistants, and Pharm.Ds in underserved areas who
can provide psychopharmacologic services.
1. Major investment in PCP training and
organizing availability of consultation by psychiatric societies or university
psychiatry departments of psychiatry in each state (the New Mexico Rural Health
Initiative coordinated by AACP member Chris Pedersen is an example of a
systematic approach by a university Department of Psychiatry to build
behavioral health competency in rural primary care settings).
2. Teleconsultation
methods.
3. Review of reimbursement for
consultation.
4. Build on the Health Resources Services
Administration’s encouragement of behavioral health services development in FQHCs.
5. Delineation by APA of recommended scope
of psychiatric practice for PCPs, PAs, and NPs in
both routine settings and in underserved settings. It is important that APA take a position
recognizing the value of PCPs in providing integrated behavioral health
services in all practice settings.
6. Behavioral health integration into
primary care in rural areas, with non-medical professionals to do assessments,
PCPs to prescribe, and telepsychiatric consultations.
7. Definition of non-prescribing PCP
interventions, such as brief interventions for alcohol misuse.
D.
Improving methods for organizing teams
of direct care adult and child behavioral health caregivers with primary health
care providers and psychiatrist extenders, and with psychiatrists providing
support to the whole team.
1. APA can take a position on the fact
that good team development both attracts psychiatrist into underserved areas
and enhances the ability of psychiatrists to provide competent access to care.
2. Further, APA can invest in supporting
and encouraging the development of such efforts by local psychiatric societies
and by local departments of psychiatry.
3. APA can partner with other professional
organizations who would value more organized availability of interdisciplinary
teamwork and consultation to create an advocacy base for this effort in both
adult and child systems of care.
* Also see AACP Position Papers: “Interface and Integration with Primary Care Providers” and, “AACP Guidelines for Psychiatric Leadership in Organized Delivery Systems for Treatment of Psychiatric and Substance Disorders.” Available at http://www.comm.psych.pitt.edu/finds/leadership.html