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Open ForumFull Access

A Community Psychiatry Nurse Practitioner Fellowship: Preparing Nurse Practitioners for Mental Health Workforce Expansion

Published Online:https://doi.org/10.1176/appi.ps.201900420

Abstract

The increasing need for psychiatry services in medically underserved communities has proven to be challenging for health care systems. Caring for this population is complex and can be overwhelming for the inexperienced provider. Proper utilization of psychiatric and mental health nurse practitioners in this setting can expedite meeting the mental health needs of the community. A postgraduate fellowship program that provides supervision and additional training specific to community psychiatry facilitates the transition from novice provider to experienced clinician while aiming to improve retention rates. In this Open Forum, the authors outline the structure of a federally qualified health center’s Community Psychiatry Nurse Practitioner Fellowship.

The increasing demand for psychiatric services is projected to overtake the supply of psychiatrists by 12%–25% in 2025 (1). The American Psychiatric Nurses Association (2) released a report indicating a projected shortage of 250,000 mental health professionals by 2025. This decline is attributable to aging of the current workforce, high expected retirement rate (3), and a national shortage of psychiatry residency slots (4) in addition to the increased demand for services. The shortage of mental health services is especially concerning in medically underserved areas, such as rural populations, urban neighborhoods, and community health care centers, and is expected to have a disproportionate impact on racial-ethnic minority groups with higher levels of unmet mental health needs (2).

Psychiatric and mental health nurse practitioners (PMHNPs) are beginning to address the nation’s shortage of mental health providers. According to a 2017 report by the National Council for Behavioral Health, 13,815 PMHNPs were practicing in the United States, and this number is projected to grow to 17,900 by the year 2025 (1). Although this workforce expansion will not be sufficient to meet the needs of the nation’s communities, several states have demonstrated that PMHNPs are effectively stepping forward to fill gaps in care (2). However, working in federally qualified health centers (FQHCs) and community health centers is often associated with challenges related to high staff turnover while serving patients with complex medical, behavioral, and psychosocial needs (5). These challenges can be especially difficult for the new clinician. The adjustment into practice from academia can influence the development of the practitioner’s role, the practitioner’s confidence, and whether the practitioner chooses to remain in the position—and even in the profession—within the first year of practice (6). Community health organizations can address these challenges by implementing formal mentorship to new nurse practitioners (NPs) entering the workforce. Mentorship during the first year of practice can provide additional guidance and support to facilitate the transition from novice NP to experienced clinician (7).

FQHCs are nonprofit, community health centers that deliver comprehensive health care and social services in underserved areas to patients regardless of insurance or ability to pay. Approximately 91% of patients who receive care at FQHCs are at or below the 200% of the federal poverty level, about two-thirds of patients belong to racial-ethnic minority groups, and nearly one-fourth are best served in a language other than English (8). At a minimum, all health centers that receive grant funding from the Health Resources and Services Administration under Section 330 of the Public Health Service Act are required to provide referrals to substance abuse and mental health providers. Nearly three-quarters of health centers had onsite mental health or substance abuse treatment staff in 2010, and they provided more than 5.2 million encounters (8). Additionally, in 2010, patient encounters for depression were the third most frequent encounters, following hypertension and diabetes (8).

The community mental health setting highlights the advantages of utilizing interdisciplinary teams in delivery of care (9). PMHNPS are an invaluable source for designing and providing mental health care and leading and working within interprofessional teams within the rapidly changing field (10). PMHNPs hold master’s or doctoral degrees and provide a full range of mental health and psychiatric services. They assess and diagnose, prescribe medications, provide psychotherapy, provide consultation and liaison services, and participate in policy and research development (2). All 50 states grant PMHNPs prescriptive authority to some level. In New York State, NPs may prescribe independently after completing 3,600 hours of practice with a collaborating physician and written protocols.

The PMHNP certification granted by the American Nurses Credentialing Center requires 2,000 hours of clinical practice during academic training. However, the placements and experiences of clinical practicums can vary widely by setting, experience of preceptor, and population of patients in regard to demographic characteristics, diagnoses, and symptomatology. The Institute of Medicine’s Future of Nursing report (11) makes the recommendation to implement residency programs for both undergraduate and advanced practice nurses to support the transition into practice. Delaney and Vanderhoef (10) also recognized the value in postgraduate training programs and suggested that these programs will support and expand the PMHNP workforce with a specialty focus given the complexity of the population and their mental health needs.

The Community Psychiatry Nurse Practitioner Fellowship

The Community Healthcare Network (CHN) Community Psychiatry Nurse Practitioner Fellowship began in 2016, following the initiation of the Family Nurse Practitioner Fellowship in 2015. The fellowship enhances clinical skills and prepares the psychiatric NP to work in a systems-based practice within the FQHC, increasing awareness of the larger context and system of health care. The fellowship creates a positive transition for NPs from student to a community psychiatry provider under the guidance and mentorship of both experienced NPs and community psychiatrists and aims to increase retention rates while improving patient outcomes. Current fellows and graduates of two local public psychiatry fellowships, as well as the former director of a public psychiatry fellowship, are involved in the development of the curriculum and the training and evaluation of the fellows. Rooted in a systems-based practices approach, weekly case conferences and didactics focus on enhancing clinical skills necessary to treat the special needs of patients served by this and other community-based organizations, as described later.

In the full-time, 12-month program, the fellows are expected to further hone their clinical skills as they provide direct patient care at the FQHC and external community mental health care agencies. CHN has partnered with other community health organizations to house fellows for specialty rotations in emergency and inpatient psychiatry, homelessness psychiatry, substance use treatment, serious mental illness treatment, geriatric psychiatry, and neurology. Additionally, fellows have internal specialty rotations at CHN’s integrated care centers, school-based health centers, and telepsychiatry programs. The time spent in each rotation is tailored to meet the individual needs of the fellow, depending on experience and special interests.

In its third year, through grant funding, CHN partnered with the Institute for Community Living (ICL), adding another track for the fellowship. This track provides an opportunity for early career PMHNPs employed by ICL to participate in the fellowship. Furthermore, other community mental health organizations have partnered with the fellowship without external grant support. Now in its fifth year, the cohort includes fellows working at five community health organizations, including CHN where the fellowship is housed. The fellows of the outside organizations participate in weekly case conferences and didactics while providing patient care at the clinical sites of their respective employers. The addition of these fellows necessitated a major modification in the curriculum to cover care for adults with serious mental illness and co-occurring disorders. Although the core financial support for the program comes from CHN, these partnering organizations provide the financial support to the fellows to attend the half-day of classes.

Functioning within an integrated care model, CHN recognizes the importance of interdisciplinary collaboration and the integration of primary care and behavioral health services. To that end the fellowship has monthly combined classes and case conferences that bring the family NPs and PMHNPs into the classroom together. This provides an opportunity for interdisciplinary training as well as a space for the PMHNP and family NPs to conduct direct consultation and collaboration on clinical cases and issues.

Outcome Evaluation

In the first four completed fellowship years, all graduates (except two who left the state) have taken permanent jobs within their respective organizations after completion of the fellowship. The two graduates who left the state accepted positions in community settings. These outcomes support previous studies indicating the improved retention of providers within the setting where they receive training. Leadership is currently developing a tool for self-evaluation based on Benner’s (12) From Novice to Expert model and will begin surveying all alumni at the end of this fellowship year. Components of evaluations will include systems-based practice, patient relationship, clinical performance, and professionalism.

Weekly online surveys of individual classes generally reveal positive evaluations of speakers, and introduction of new speakers is informed by these surveys. In addition, current fellows are offered the opportunity to recommend new speakers or topics over the course of the year. Annual focus groups serve to inform the ongoing development of both the clinical and didactic components of the fellowship and take place during the last quarter of the program. A representative not affiliated with the fellowship facilitates these groups in efforts to decrease bias and promote honest and candid feedback. The fellows are asked various questions pertaining to the different components of the fellowship and are encouraged to think critically about what worked well and what did not. This feedback is then reviewed by the fellowship leadership and integrated into the planning of the program as appropriate. Fellows use the monthly mentoring sessions to develop leadership skills that will enhance their job satisfaction and performance in their careers (13).

Feedback collected from fellows requested more psychopharmacology lectures. When possible, leadership implemented feedback into the program during the same year. Such was the case with the psychopharmacology lectures as well as feedback pertaining to homework assignments. One fellow suggested that they present these assignments to each other during class time to share their research and findings with their peers. The leadership agreed this practice would be beneficial and made time for these presentations in the course schedule.

Discussion and Conclusions

Because CHN’s Community Psychiatry Nurse Practitioner Fellowship is the only one of its kind in New York City, it is serving a crucial need to prepare PMHNPs to function in community settings. As evidence of this need, other community agencies (in addition to those mentioned earlier) have expressed interest in affording their early career psychiatric NPs this specialized training program, and the 2020–2021 class has significantly expanded from three to eight fellows since its inception in 2016. The fellowship hopes to continue to expand in coming years.

CHN thus has the potential to serve as the hub of specialized community psychiatry training for PMHNPs in New York City. In this regard, the organization is following the lead forged by the Columbia University Public Psychiatry Fellowship that has been training community psychiatrists for almost 40 years. The alumni and faculty from that fellowship are playing an integral role in the development and implementation of this fellowship.

Although the number of PMHNP fellowships and residencies across the country has been increasing, and there is a handful of community psychiatry fellowships that recruit PMHNPs (9) alongside psychiatrists, whether there are any other community PMHNP fellowships in the country is not clear. It is hoped that the success of this fellowship will encourage the development of similar PMHNP fellowships, just as the success of the public psychiatry fellowship mentioned earlier has spawned an increasing network (currently 24) of similar fellowships throughout the country. CHN’s Community Psychiatry Nurse Practitioner Fellowship leadership plans to increase efforts to identify other community PMHNP fellowship programs to form a network for future collaboration and program development.

Community Psychiatry Nurse Practitioner Fellowship Program, Community Healthcare Network, New York (Frissora, Ranz); Department of Psychiatry, Columbia University Medical Center, New York (Ranz).
Send correspondence to Dr. Frissora ().

The authors report no financial relationships with commercial interests.

The authors thank Robert Hayes, chief executive officer of Community Healthcare Network (CHN), for supporting the creation and development of CHN’s Community Psychiatry Nurse Practitioner Fellowship, as well as Elizabeth DuBois, D.N.P., F.N.P., for providing the original inspiration and launching of the fellowship.

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