Introduction by the column editors: We are pleased to present this overview of various community psychiatry fellowship training programs across the country. We have a special interest in such training partnerships: both of us have been affiliated with the long-standing public-academic collaboration between the Maryland Mental Hygiene Administration and the Department of Psychiatry at the University of Maryland. The so-called Maryland Plan has been described in a number of articles in this journal over the years, and it continues to train community psychiatrists for the mental health system in Maryland and adjoining jurisdictions.
Early- and mid-career psychiatrists spend more time in publicly funded organizations than in private practice (1). Provisions of the Affordable Care Act will require an even greater number of psychiatrists to work in these publicly funded settings. These settings provide services to the poor and to individuals with disabling behavioral conditions. Psychiatrists who lead and work in these organizations need to understand and be able to implement systems-based practices to deal with the myriad requirements that must be addressed when an organization accepts public funds (2).
To better prepare psychiatrists to meet these challenges, the number of public-community psychiatry fellowships has increased dramatically in the past six years, from two to 15. Almost all of these programs pair a public behavioral health agency with an academic institution in formal and ongoing collaborations that take a variety of forms. This column describes five types of public-academic collaboration on which the fellowships are based.
Several fellowship programs have been created through structural and fiscal collaborations between public behavioral health agencies and academic institutions, in which the former provide the main source of fellowship funding. The public agencies may be state or county behavioral authorities, municipal hospitals, or nonprofit organizations with public mandates. The oldest existing fellowship—the Columbia University Public Psychiatry Fellowship—was created in 1981. Its faculty and fellows are employees of the New York State Office of Mental Health (NYS OMH).
In 2007, the State of Pennsylvania Department of Welfare provided funds to create three Centers of Excellence in Public Psychiatry at the University of Pennsylvania, Western Psychiatric Institute, and Lake Erie College of Medicine. Each center operates a postgraduate fellowship for psychiatrists interested in public-sector work, helping them develop skills for leadership and recovery-oriented care.
To assist in the conceptual development of these centers, in 2005 the Pennsylvania Office of Mental Health and Substance Abuse Services created the Pennsylvania Psychiatric Leadership Council (PPLC), a consortium of more than 70 service users, advocacy groups, administrators, government officials, and clinicians (including psychiatrists). Funds are channeled to the centers through the PPLC's fiduciary, the Family Training and Advocacy Center, which is contracted by the state to provide administrative support to the centers.
In 2004, California passed a statewide referendum, the Mental Health Services Act (MHSA), which provides funds dedicated to enhancing behavioral health services that are collected via a 1% state surcharge tax on persons with annual incomes of over $1 million (“millionaire's tax”). Revenue is earmarked for counties to provide behavioral health services and new education programs to remedy the shortage of qualified clinicians to serve individuals with severe mental illnesses. In 2011, the San Francisco County Behavioral Health Services (CBHS) agreed to use a portion of allocated MHSA funds to create the University of California San Francisco/San Francisco General Hospital (UCSF/SFGH) Public Psychiatry Fellowship for a trial of two years. Fellows are placed in CBHS- or SFGH-affiliated clinics.
Similarly, the San Diego County Health and Human Services Agency was able to obtain MHSA funds to start a fellowship in 2012 in partnership with the University of California, San Diego (UCSD). In addition to funding the fellowship, the county and UCSD have agreed to provide a community psychiatry track within the general residency program and community psychiatry teaching within the standard medical school psychiatry curriculum.
In the following three fellowships, which are collaborations between public behavioral health service organizations and academic institutions, the public behavioral health organization serves as the main training site for fellows.
In 2007, Yale University and the State of Connecticut collaborated to form a fellowship at the Connecticut Mental Health Center, which serves as the placement site. As of June 2012, each of the six graduates has taken a position in the public sector and half have assumed medical director roles in their agencies. The Connecticut Department of Mental Health and Addiction Services, which funds the fellowship, is now interested in expanding the number of fellowship positions and developing clinical training sites for fellows at the state hospital in Connecticut.
In 2008, New York University (NYU) created a fellowship funded by Bellevue Hospital. Fellows are recruited from among new junior faculty hired at Bellevue. Some fellows work at another municipal hospital and a forensic psychiatric hospital. The hospitals provide the funding that supports fellows and allows them time for didactic training and supervision. In return, the hospitals have been able to recruit psychiatrists who are better trained in the dynamics of public systems and who are open to participating in quality improvement initiatives and development of best practices.
In 2009, Metrocare Services, a nonprofit agency that effectively serves as the Dallas County Community Mental Health Center and provides the bulk of public behavioral health services in the area, funded a fellowship collaboration with the University of Texas Southwestern Medical Center(UTSW). The fellowship director is employed by UTSW and contracted to work full-time at Metrocare, giving Metrocare the benefit of an academic psychiatrist who is involved in introducing other academic activities (education and research) to the public institution and encouraging the use of evidence-based practices.
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For recruitment and retention
The primary goal of a public-community psychiatry fellowship is to recruit and retain high-quality psychiatrists for public agencies. Several programs have created collaborations between service agencies and academic institutions that permit fellows to choose among multiple training sites. The explicit goal of these collaborations is to place and retain high-quality psychiatrists at these agencies after their fellowship. Toward this goal, the service agencies provide partial or complete funding for individual fellows. Because fellows carry out leadership and evaluation activities in addition to providing direct clinical service, the available reimbursement does not always meet the expenses of the fellows' salaries. The agencies, however, see this as a way to recruit high-quality psychiatrists and to provide an academic affiliation for several psychiatrists who work at the agency. Case Western Reserve University (CWRU) has also actively recruited psychiatric nurse practitioners to participate in its fellowship, and a number of programs recruit child psychiatrists.
In the Columbia University fellowship, service agencies provide two-thirds of the funding for each fellow, with the other third coming from NYS OMH. Because the fellow is an employee of the agency and the agency provides protected training time for the fellow, both the agency and the fellow benefit from the collaboration. Ongoing surveys have demonstrated that more than half of the fellows stay at their placement agencies at the end of the fellowship year, and 95% of the graduates devote their careers to the public sector (3).
The Pennsylvania PPLC's mission is to address difficulties in training, recruitment, and retention of psychiatrists willing to work in the public sector, particularly in rural and impoverished urban areas of the state. Fourteen psychiatrists have been trained in the three Pennsylvania fellowships since 2008, the first year of operation, and 13 of the fellows have continued in public service, with 12 remaining in the state. The strategy of placing a fellow at a public behavioral health agency to enhance recruitment to the agency is one of the seven core elements of the Columbia fellowship (4) and is also described in the American Association of Community Psychiatrists (AACP) guidelines (5). This strategy has been adopted by most of the fellowships. At CWRU, fellows can choose from multiple sites. At the University of Florida, each fellow works at two specific public agencies over one year. The University of Alabama, which serves a rural population, has a funding collaboration with a local U.S. Department of Veterans Affairs medical center to provide services through a mobile care program. In addition, all the programs described above in the first group of collaborations—UCSF, UCSD, Yale, NYU, and UTSW—were created in the hope of recruiting fellows into the single-service agency that provides fiscal and structural support to the fellowship.
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To facilitate program evaluation, research, and policy
Most of the fellowships offer opportunities for program evaluation and research or policy development. Early in the development of the Columbia University fellowship, fellows were required to carry out program evaluations at their field sites. This requirement was conceived of as a management strategy—the use of research methods to support management goals. This strategy is also identified as one of the core elements of the Columbia fellowship (4) and is described in the AACP guidelines (5). It has been incorporated into the didactic curricula of most of the new programs. At NYU-Bellevue, fellows conduct program evaluation projects that have been presented at clinical staff conferences and whose recommendations have been incorporated into clinical policies, committee guidelines, or quality improvement programs.
UCSF and the University of Alabama include a services research component with the expectation that the research results will be submitted for publication. Other programs encourage fellows to submit the findings from their program evaluation projects for publication. UCSF has followed a more robust research strategy, providing a clinical leadership training program with an explicit health services research component. In addition to performing clinical work in community mental health clinics four days a week, fellows are expected to implement a mental health services research project at that clinic and submit the results for presentation or publication during the academic year. San Francisco CBHS provides dedicated funding to support this research effort, including a half-time research assistant. The projects are designed and carried out in collaboration with the clinic leadership to ensure that the quality improvement component meets the needs of the service agency.
All fellows trained at Emory University are simultaneously enrolled in a master's of public health program (6), with the goal of training psychiatrists as policy leaders. The programs at Columbia University, the University of North Carolina, and Western Psychiatric Institute and Clinic offer limited opportunities for fellows to simultaneously enroll in MPH programs.
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With primary care physicians to foster integrated care
A number of programs have developed integrated care strategies through collaborations with public-sector primary care providers and programs. The University of Alabama fellowship runs in conjunction with a primary care-behavioral medicine fellowship. The primary care fellow is integrated into a psychiatric setting and receives consultation from the psychiatry fellow. The UCSD program plans to have fellows spend part of their time in primary care settings. At UCSF, one fellow each year works on an integration health services research project. Many of the other programs offer the options of placements in primary care settings.
Many of the fellowships have created opportunities for ongoing collaboration with fellowship alumni to enhance and support their public-sector career development. Columbia University encourages its fellows to consider placements where they will be supervised by fellowship alumni. The resulting supervision creates a tighter integration with the aims of the fellowship. In addition Columbia University invites approximately 25 alumni to make annual presentations to the fellows, during which the alumni describe their current work, focusing on a management problem. The resulting discussion provides alumni with valuable feedback from faculty and allows fellows to actively participate in the consultation.
This strategy is also identified as one of the core elements of the Columbia fellowship (4) and is described in the AACP guidelines (5), and most of the newer fellowships have pursued this model to the extent that they have developed their own alumni networks. Faculty of the CWRU fellowship mentor fellowship graduates to assist them in writing and submitting articles for publication, as well as in program development and evaluation
In Pennsylvania, the PPLC continues to be actively involved with the three centers to support academic activities and network development. It organizes three face-to-face meetings each year, which bring together public service clinicians and fellows in a forum for problem solving in regard to challenging issues for service providers. Administrators from relevant state agencies frequently attend these meetings, which allows attendees to have direct access to policy makers and engage them in a dialogue.
In addition, Western Psychiatric Institute provides continuing medical education for psychiatrists working in community settings through a biweekly video seminar series, “Community Psychiatry Forum.” The institute also provides consultation to psychiatrists and the agencies where they work—or where they may one day work—to create satisfying career opportunities.
Public-community psychiatry fellowships offer unique opportunities for collaborations between public behavioral health agencies and academic institutions. These collaborations serve the primary goal of recruiting and retaining high-quality psychiatrists to function as clinical and research leaders in the public sector. A long-term strategy includes fostering ongoing collaborations with alumni to support their public-sector work throughout their careers. Another long-term strategy is to prepare psychiatric residents for these fellowships through enhanced public-community psychiatry training during residency. Most of the fellowships are actively engaged in promoting public-community psychiatry in their affiliated residency programs. Since 2008, an annual meeting of the network of public-community psychiatry fellowship directors has been held to discuss strategies for maintaining ongoing collaborations and developing new ones. Through their Listservs, the networks of the Columbia University fellowship alumni and AACP members are facilitating a national collaboration between academic centers, public-community psychiatrists, and the behavioral health agencies where they work. This national collaborative discussion will ensure that psychiatrists play a key role in the rapidly evolving health care system.