Presented by:

Cynthia Harrison, BSN, MS, RN Rowena Gillo, LCSW Mission College Pacific Clinics

September 17, 2013

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California is one of the most racially and ethnically diverse states in the country, and is projected to become even more so in the coming decades

Population projections suggest that by the year 2030, 66% of the state’s population will be non-White

Over the next 25 years the state’s population is projected to grow by roughly 12 million people. Over 90% of this population growth is projected to occur among California’s Latino (75%) and Asian (17%) populations.

These dramatic changes underscore the need to address the lack of racial and ethnic diversity among key mental health professions in the state

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Source: Lok, V. and Chapman, S., UCSF Center for the Health Professions, The Mental Health Workforce in California: Trends in Employment, Education, and Diversity

A prolonged shortage of psychiatrists. Nearly 30 percent of physicians are over 60 years old - a higher percentage than any other state*

Increased demand for integrated services that are Multi-Culturally Responsive. Specifically, a need for more culturally responsive and competent provider practices to engage underserved populations+

Increased demand for services that are Affordable and Accessible to the Community

An educational system that lacks capacity to provide the Behavioral Health workforce needed to meet future demands

Healthcare nursing professionals are not adequately prepared to work in community-based MH/Behavioral Health settings

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Source: * California Health Care Foundation, CA Health Care Almanac Regional Markets http://www.chcf.org/almanac/regional-markets +CIMH, Jarvis and Freeman Briefing Paper 4: Workforce Issues Today and in the Future Workforce Implications of Increased Demand for Mental Health and Substance Use Service, June 2012

The shortage of Registered Nurses (RNs) experienced in California is well documented

According to the “United States Registered Nurse Workforce Report Card and Shortage Forecast” published in the January 2012 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country between 2009 and 2030. In this state-by-state analysis, the authors forecast the RN shortage to be most intense in the South and the West.*

There has been aggressive effort to expand the state’s capacity to train new RNs

Since 2000 the number of new licenses issued each year has approximately doubled

The California Board of Registered Nursing continues to offer a certificate to practice as a certified psychiatric/mental health nurse

As of May 2012, there are 330,943 RNs with active licenses in California+

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Sources: *American Association of Colleges of Nursing , Nursing Shortage Facts Sheet http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage +OSHPD Healthcare Workforce Clearinghouse, Registered Nurses, June 2012

Advanced practice registered nurses (APRNs) :◦ Are nurses who have received education beyond their initial registered nurse (RN) education to work in a

specialized role in the delivery of health care services, preparing him/her for one of the four recognized APRN roles

◦ Are prepared in master’s-degree programs that often carry a credit load equivalent to doctoral degrees in the other health professions.

◦ Has acquired advanced clinical knowledge and skills preparing him/her to provide direct care to patients, as well as a component of indirect care

◦ Has clinical experience of sufficient depth and breadth to reflect the intended license

Four types of APRNs in the United States: ◦ Certified Nurse Midwives (CNM)◦ Certified Registered Nurse Anesthetists (CRNA)◦ Clinical Nurse Specialists (CNS): bring specialized knowledge about the patient population, the

environment, and disease management◦ Nurse Practitioners (NP): focus on primary care activities

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Sources: California Board of Registered Nursing http://www.rn.ca.gov/pdfs/forms/survey2010cns.pdf National Council for State Boards of APRN Advisory Committee, APRN Joint Dialogue Group Report, July 7, 2008

Certification requires 500 hours of specified clinical experience and a master’s degree

Certified psychiatric/mental health nurse requirements include education at the master’s level (the degree must be directly related to mental health) and two years of supervised clinical experience providing mental health counseling services

Certification for Psychiatric-Mental Health Nursing and is not required for practice in the state

As of February 2011:◦ there were 2,865 CNS and they are not widely distributed across the state◦ there were 14,623 NP ◦ there were 334 certified psychiatric/mental health nurses

NPs tend to work in counties that have low health care provider per population ratios

Northern California has higher NP certifications per population ratios compared to Southern California

The annual number of certifications issued has declined steadily since 1985

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CNS certification focuses on areas of clinical specialization in nursing practice, and provides direct patient care. The most commonly reported areas of primary focus are adult/gerontology (22.4%), and acute/critical care (20.4%)

CNSs influence care outcomes by providing expert consultation for nursing staffs and by implementing improvements in health care delivery systems

CNS education focuses on how clinical care is affected by the patient’s personal and family characteristics, the environment, the nursing personnel who provide care, and the health system organization

While the CNS certification began as a mental health specialization, only 16.3 percent of CNSs reported psychiatrics/mental health as one of their clinical areas of specialization

CNSs can not furnish or order medications

The CNS certification has been discontinued in California primarily due to low student enrollment rates in CNS programs. The Clinical Nurse Leader (CNL) has replaced the CNS.

The CNL is an advanced clinician with education at the master's degree level, but not prepared as an advanced practice registered nurse as the APRN is currently defined. The CNL is a Generalist that oversees the lateral integration of care for a distinct group of patients and may actively provide direct patient care in complex situations *

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Source: California Board of Registered Nursing http://www.rn.ca.gov/pdfs/forms/survey2010cns.pdf *American Association of Colleges of Nursing http://www.aacn.nche.edu/cnl/frequently-asked-questions

The Psychiatric-Mental Health Nurse Practitioner (PMHNP) is:*o An advanced practice registered nurse who focuses clinical practice on individuals, families, or populations across the

life span at risk for developing and/or having a diagnosis of psychiatric disorders or mental health problems

o A specialist who provides primary mental health care to patients seeking mental health services in a wide range of settings

o Primary mental health care provided by the psychiatric-mental health nurse practitioner involves the continuous and comprehensive services necessary for the promotion of optimal mental health, prevention and treatment of psychiatric disorders and health maintenance. This includes the assessment, diagnosis, and management of mental health problems and psychiatric disorders.

o The psychiatric-mental health nurse practitioner is a provider of direct mental health care services

The scope of practice of NPs in California is regulated by the state. California requires that NPs work under standardized procedures developed through collaboration among administrators and health professionals, including physicians and surgeons and nurses.+

NPs may obtain additional certification from the BRN to furnish or order drugs or devices under standardized procedures developed with the supervising physician and surgeon.

In October 2010, the Institute of Medicine recommended full independent practice for Nurse Practitioners: “Nurses should practice to the full extent of their education and training”.+

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Source:* American Association of Colleges of Nursing http://www.aacn.nche.edu/leading-initiatives/education-resources/PMHNP.pdf +Institute of Medicine, The Future of Nursing http://www.iom.edu/nursing

FEBRUARY 2013: SENATE BILL 491 WAS INTRODUCED TO THE CALIFORNIA LEGISLATURE

Section 1, Senate Bill 491 California Legislature found and declared the following: (b) Nurse practitioners will play an especially important part in the implementation of the federal Patient Protection and Affordable Care

Act, which will bring an estimated five million more Californians into the health care delivery system, because they will provide for greater access to primary care services in all areas of the state. This is particularly true for patients in medically underserved urban and rural communities.

(d) Nurse practitioners will assist in addressing the primary care provider shortage by removing delays in the provision of care that are created when dated regulations require a physician’s signature or protocol before a patient can initiate treatment or obtain diagnostic tests that are ordered by a nurse practitioner.

Proposed Law: SB 491 would expand the scope of practice for nurse practitioners, by deleting the requirement that nurse practitioners provide certain services only under the supervision of a physician or surgeon .

Specifically, the bill would expand the scope of practice of a nurse practitioner by authorizing a nurse practitioner to provide the following services independently:

- Order durable medical equipment - Certify disability claims - Manage patients’ health status

- Make changes to a plan of treatment for certain home health patients

- Assess patients, synthesize data, and apply the principals of health care;

- Analyze data to identify the nature of a health problem and implement appropriate treatment

- Examine a patient and establish a medical diagnosis

- Order prescription drugs - Refer patients to other health care providers

- Delegate duties to medical assistants - Order hospice care - Maintain malpractice insurance.

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Source: California Legislative Information, SB 491 http://leginfo.legislature.ca.gov/faces/billVersionsCompareClient.xhtml

AUGUST 2013: SENATE 491 AMENDED AS FOLLOWS:

Existing law, the Nursing Practice Act, provides for the licensure and regulation of nurse practitioners by the Board of Registered Nursing. Existing law authorizes the implementation of standardized procedures that authorize a nurse practitioner to perform certain acts, including, among others, ordering durable medical equipment, and, in consultation with a physician and surgeon, approving, signing, modifying, or adding to a plan of treatment or plan for an individual receiving home health services or personal care services. A violation of those provisions is a crime.

SB 491 Supporters withdrew their support. Supporters believed SB 491 would increase Californians' access to care, reduce paperwork burdens, and promote high-quality primary health care.

SB 491 Opposition believed this bill compromised patient safety. The physician groups emphasize collaborative care provided by a physician-led team is ideal. They indicate requirements for standardized protocols and physician review are in place to ensure that patient care includes the involvement and oversight of a physician who is substantially more qualified and experienced to oversee patient care, both in depth and in years of education and training, than a nurse practitioner practicing alone.

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Source: California Legislative Information, SB 491 http://leginfo.legislature.ca.gov/faces/billVersionsCompareClient.xhtml

According to the 2012 Technical Assistance Collaborative (TAC) and the Human Services Research Institute (HSRI) California Mental Health and Substance Use System Needs Assessment : o Approximately 4.3 million Californians currently without health coverage will now be eligible for health insurance in 2014. Many

of these newly insured will need mental health and substance use services.

o Estimated 200,000 persons in increased demand for mental health services. Estimated 115,000 persons in increased demand for substance use services.

o New enrollees can be expected to be more disabled and more expensive to serve than the Medi-Cal non-disabled population, but substantially less disabled and less expensive than the current Medi-Cal disabled population

o Much of the heavy lifting for healthcare reform implementation will occur at the state and even county level

While experts interviewed indicated that it was “difficult” to estimate specific numbers of PNPs and CNSs needed upon the Patient Protection and Affordable Care Act (PPACA) implementation, the changing demands of this nation's complex healthcare environment require the highest level of scientific knowledge and practice expertise to assure quality patient outcomes*

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Source: *California Institute for Mental Health, Jarvis Brief Papers http://www.cimh.org/LinkClick.aspx?fileticket=qYRw198CQAo%3D&tabid=36

According to the National Association of Community Health Centers report Building a Primary Workforce for the 21st Century:

Health centers are increasingly challenged to meet their primary care workforce need. Health centers currently need 1,843 primary care providers, inclusive of physicians, nurse practitioners, physician assistants, and certified nurse midwives. On top of this need, they are 1,384 nurses short

To reach 30 million patients by 2015, health centers need at least an additional 15,585 primary care providers, just over one third of whom are non-physician primary health care providers. Health centers also will need another 11,553 to 14,397 nurses

To reach 69 million patients, health centers will need at least 51,299 more primary care providers over the current number, as well as an additional 37,981 to 44,522 nurses

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Source: *National Association of Community Health Centers http://www.nachc.com/client/documents/ACCESS%20Transformed%20full%20report.PDF

California’s RN workforce is growing, but aging as the average age of working RNs is 47.2, and nearly half of the workforce is over 50 years old

Over 40 percent of RNs are non-White, but the Latino population remains underrepresented

Men continue to be underrepresented, making up only 14 % of California’s RN workforce

Despite the large increase in nursing school enrollments, demand for education still far exceeds the supply

DRAFT 13

Patient Protection and Affordable Care Act (PPACA) is expected to both increase demand for health care services resulting from expanded insurance coverage

Potential for NPs to become needed providers, but barriers included the scarcity of post-graduate specialty programs and the prevailing culture of physician specialty practices

The role of NPs has been somewhat limited due to the lack of legislation expanding their scope beyond the traditional scope of practice for RNs

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Experts recommend focusing attention on the educational requirements, career ladders, and professional recognition of CNAs, HHAs, and MAs

Lack of qualified faculty to train new nurses and the key barrier is lower compensation for academic teaching than positions in clinical areas

LPTs and LVNs could potentially be a large source of future RNs

Investing in LPT/LVN-to-RN education programs offers an opportunity to increase the diversity of the RN workforce as the LVN workforce is more diverse than the RN workforce

DRAFT15

According to data from the 2008 National Sample Survey of Registered Nurses (NSSRN): Nurses from minority backgrounds represented 16.8% of the registered nurse (RN) workforce. Considering

racial/ethnic backgrounds, the RN population is comprised of 5.4% African American; 3.6% Hispanic; 5.8% Asian/Native Hawaiian; 0.3% American Indian/Alaskan Native; and 1.7% multi-racial nurses.

Though men only comprise 6.2% of the nation’s nursing workforce, this percentage has climbed steadily since the NSSRN was first conducted in 1980. The number of men in nursing has increased from 45,060 nurses in 1980 to 189,916 nurses in 2008.

The ability of California Registered Nurses (RNs) to provide culturally competent care to Californians is associated with the language skills and diversity of the RN workforce. Diversity in the RN profession reflects progress in providing opportunities for young people to obtain postsecondary education and enter the health professions. +

California’s Nursing Workforce also includes: Psychiatric Technicians Vocational Nurses

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Sources: *American Association of Colleges of Nursing http://www.aacn.nche.edu/media-relations/fact-sheets/enhancing-diversity +CA Board of Registered Nursing, UCSF The Diversity of California’s Registered Nursing Workforce http://www.rn.ca.gov/pdfs/schools/diversity.pdf

Psychiatric Technicians (PTs) and Vocational Nurses (VNs) are licensed by the California Board of Vocational Nurses and Psychiatric Technicians (BVNPT)

PTs:◦ Entry-level practitioners who provide care for mentally disordered or developmentally disabled clients under the director of

services◦ Limited number of PT educational programs in California (11 Community Colleges; 5 Private Universities)◦ No pathway for PTs to advance to RN

As of September 2012, there were 9,855 PTs with active licenses in California

VNs:◦ Vocational nursing is an entry-level practitioner responsible for basic nursing care under the direction of a physician or

registered nurse◦ Vocational nurses programs, colleges and universities

(42 Community Colleges; 123 Private Universities; 27 Adult Educational Programs; 5 Regional Occupational Programs)◦ Has increased dramatically, more than tripling between 2000 and 2010+

As of August 2012, there were 87,514 VNs with active licenses in California

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Sources: California Department of Consumer Affairs Board of Vocational Nurses and Psychiatric Technicians Public Master File, September 2012 Revision 2/26/2013 via OSHPD Healthcare Workforce Clearinghouse, Psychiatric Technicians, November 2012 / Vocational Nurses, September 2012

In 2011, Pacific Clinics created its Nursing Bridge Program, a community-based collaborative model*

Pacific Clinics Nursing Bridge Program is a multi-tiered non-sequential community based collaborative model, that creates a seamless higher education & career pathways for Licensed Psychiatric Technicians (LPTs) and Licensed Vocational Nurses (LVNs); builds learning opportunities for RN and APRN students within community-based MH/BH settings; and educates, trains, and advances the behavioral health competencies of the nursing students and faculty.

(1) Higher education and career pathway for LPTs and LVNs to become Advanced Practice Nurses (e.g., Nurse Practitioner), beginning with the completion of their RN/ADN degree.

LPT/LVN RN/ADN BSN MSN/FNP DNP

An additional pathway is a fast-track into advanced practice nursing non-nursing Bachelor-level persons, including MH professionals (LCSW, LMFT, LPCC, Psychologists), bypassing the BSN degree.

BA/BS ELM/FNP DNP

(2) Clinical and Transition-to-Practice Residency rotations for newly grad RN’s, master and doctoral-prepared nursing students specifically placed within various community-based mental/behavioral health organizations.

(3) Advance the behavioral health competencies of the nursing profession via community education and training, including faculty leadership development

and student simulation lab learning.

Pacific Clinics Nursing Bridge Program: Provides a creative and collaborative solution to the critical shortage of Psychiatry Increases nursing workforce diversity Increases community accessibility Creates a skilled and advanced practice nursing workforce trained to provide multi-culturally responsive community-based integrated BH services Cost-effective Time efficient Staff Recruitment and Retention: “Growing our Own” Duplicatable Model

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*All rights, title and interest to this Nursing Bridge Program Community-Based Collaborative Model belongs to Pacific Clinics and shall not be duplicated in any manner whatsoever without the expressed written consent of Pacific Clinics.

Experts interviewed believe SB 491 will re-surface once California experiences the full impact of PPACA implementation

Use of terminology in SB 491 may have added to Opposition’s concerns: “Prescribing” vs. “Furnishing”; “Consultation” vs. “Supervision

Collaborative consulting relationship between NPs and Psychiatrists can amicably co-exist to benefit both parties: Develop formal relationship between NPs and Psychiatrists that imbeds a set of Protocols where NPs can

practice independently to the extent of their education and training Both parties agree at what point in treatment is beyond the NP’s scope & training, whereby the NP refers

the treatment to the Consulting Psychiatrist NP pays psychiatrist to serve as a Consulting Physician (e.g., Glide Health Services in San Francisco)

DRAFT 19

Psychiatrists are traditionally educated and trained in the Medical Model: Disease-oriented and Disease Management

Nurse Practitioners are educated and trained in a Holistic Wellness and Recovery Model: Prevention-oriented, and Strategies to teach in educating the consumer/client within a holistic approach – easier for NPs to embrace the concept of integrated mental health and healthcare delivery

Build practice models that include community-based MH/Behavioral Healthcare organizations as Primary Care Providers

NPs can supervise/preceptor bachelor, master and doctoral-level nursing students during internship & residency rotations at community-based MH/BH clinics (e.g., Pacific Clinics Nursing Bridge model)

NPs can oversee triage functions within Peer Health Navigation programs

Develop collaborative partnerships between Community-based MH/BH and HMOs to serve new PPACA enrollees. NPs can expand access in providing services to new enrollees, especially those residing in underserved communities

Increase Nurse-managed community-based MH/BH clinics with Psychiatrist as paid Consultants (e.g., Glide Health Services in San Francisco)

DRAFT 20

In a 2005 report titled Advancing the Nation's Health Needs: NIH Research Training Programs, the National Academy of Sciences called for nursing to develop a non-research clinical doctorate to prepare expert practitioners who can also serve as clinical faculty

The Doctor of Nursing Practice is designed for nurses seeking a terminal degree in nursing practice and offers an alternative to research-focused doctoral programs. DNP-prepared nurses are well-equipped to fully implement the science developed by nurse researchers prepared in PhD, DNSc, and other research-focused nursing doctorates.

DNP curricula build on traditional master's programs by providing education in evidence-based practice, quality improvement, and systems leadership, among other key areas

Schools nationwide that have initiated the DNP are reporting sizable and competitive student enrollment. Employers are quickly recognizing the unique contribution these expert nurses are making in the practice arena, and the demand for DNP-prepared nurses continues to grow.

DNPs can contribute to the increase of direct practice nursing personnel, and nursing faculty with additional preparation that adds pedagogical skills to their base of clinical practice

Within an integrated model of MH/Behavioral Healthcare delivery system, DNPs can be wisely utilized to practice, to teach, and to provide Executive Practice Leadership in various behavioral health and healthcare arenas

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Source: American Association of Colleges of Nursing, The Doctor of Nursing Practice Facts Sheet http://www.aacn.nche.edu/media-relations/fact-sheets/dnp

Bachelor-Level non-nursing health professionals (Psychologists, LCSWs, LMFTs, LPCCs)

Middle School, High School, Community College Students, Undergraduates, and Graduate students

Incumbent Workers Career Changers Displaced Workers Immigrant Health Professionals Licensed Psychiatric Technicians Licensed Vocational Nurses Underserved ethnic groups Under-represented groups People with lived experiences Veterans

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BRANDMAN UNIVERSITY CALIFORNIA INSTITUTE OF NURSING AND HEALTHCARE (CINHC)Kathleen McCoy, DNSc APRN-BC FAANP Judith Berg, RN, MS, CHE Carolyn Orlowski, MSN, RNDirector of Psychiatric & MH DNP Program President/Executive Director Southern California Regional Coordinator

Deloras Jones, RN, MS(Retired) Executive Director

NATIONAL UNIVERSITY CALIFORNIA STATE UNIVERSITY, LOS ANGELESGloria McNeal, Ph.D., MSN Beatrice Yorker, J.D., R.N., M.S., F.A.A.N. Lori Judson, PhD, RN, NP, Professor

Dean, School of Health & Human Services Dean, College of Health and Human Services Associate Director, School of NursingJovita Ezrihim, Clinical Assistant Professor Cythnia Hughes, Ed.D., PNP, Professor Nnenna Weathers, Ph.D., RN, FNPSchool of Health & Human Services Director, School of Nursing Assistant Professor, School of Nursing

SADDLEBACK COLLEGE PACIFIC CLINICSDonna Rane-Szostak, EdD, MSN, CNE Susan Mandel, Ph.D. Peter Lopez, LPT Viola Gaffaney, LMFT, RN Dean, Health Sciences & Human Services President/CEO Division Director Division DirectorTamera Rice, MSN, RN, CNE Wendy Wang, MPA Sharon Duris, LPT Samantha James-Perez, LPT Assist. Dean, Health Science & Human Svc Corp. Director, Public Policy Division Director Victoria Broussard, LPT

Brian Gomez, LPTUNIVERSITY OF CALIFORNIA, SAN FRANCISCO Bethany Phoenix, RN, Ph.D., CNS, FAANVice Chair, and HS Clinical Professor, School of Nursing

American River College Butte College College of the Canyons Golden West College Grossmont CollegeMission College Solano Community College Rio Hondo College San Jose State University

UCSF Center For The Health Professions

 

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American Association of Colleges of Nursing http://www.aacn.nche.edu American Nurses Association, Nursing World: Advanced Practice Nurses http://www.nursingworld.org/EspeciallyForYou/AdvancedPracticeNurses

California Action Coalition http://www.CAactioncoalition.org California Association for Nurse Practitioners http://www.canpweb.org California Board of Behavioral Sciences http://www.bbs.ca.gov/pdf/mhsa/resource/workforce/mhsa_workforce_information.pdf California Board of Registered Nursing http://www.rn.ca.gov California Institute for Nursing & Health Care (CINHC) http://www.cinhc.org California Health Care Foundation, CA Health Care Almanac Regional Markets http://www.chcf.org/almanac/regional-markets California Institute for Mental Health, Jarvis Brief Papers http://www.cimh.org/LinkClick.aspx?fileticket=qYRw198CQAo%3D&tabid=36

Institute of Medicine, The Future of Nursing http://www.iom.edu/nursing Legislative Analyst’s Office, Streamlining Nursing Education Pathways http://www.lao.ca.gov/reports/2011/edu/nursing_ed/Streamlining_Nursing_Ed_Pathways.pdf Lok, V. and Chapman, S., UCSF Center for the Health Professions, The Mental Health Workforce in California: Trends in Employment, Education, and Diversity (2009)

http://www.futurehealth.ucsf.edu/Content/29/2009-03_The_Mental_Health_Workforce_in_California_Trends_in_Employment_Education_and_Diversity.pdf

Lok, V. , Christian, S. and Chapman, S., UCSF Center for the Health Professions, Restructuring California’s Mental Health Workforce: Interviews with Key Stakeholders (2009) http://www.thecenter.ucsf.edu/Content/29/2009-

03_Restructuring_Californias_Mental_Health_Workforce_Interviews_With_Key_Stakeholders.pdf

National Association of Community Health Centers, Building a Primary Workforce for the 21st Century http://www.nachc.com/client/documents/ACCESS%20Transformed%20full%20report.PDF

National Council for State Boards of APRN Advisory Committee, APRN Joint Dialogue Group Report, July 7, 2008 https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf OSHPD Healthcare Workforce Clearinghouse, Psychiatric Technicians, November 2012 http://www.oshpd.ca.gov/HWDD/HWC/FactSheets/PsychiatricTechnicians.pdf

Vocational Nurses, September 2012 http://www.oshpd.ca.gov/HWDD/HWC/FactSheets/VocationalNurses.pdf

Raines, F. and Taglaireni, E. , “Career Pathways in Nursing: Entry Points and Academic Progression”, The Online Journal of Issues in Nursing, Vol 13 No 3 Manuscript 1

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No3Sept08/CareerEntryPoints.aspx

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Barrier Recommendation

-NPs not able to practice independently to the full extent of their education and training

May critically affect California’s ability to expand MH/BH service access to the estimated 200,000 persons in increased demand for mental health services, estimated 115,000 persons in increased demand for substance use services

- Lobby/campaign to allow APRNs to practice independently to the full extent of their training and education. Enact SB 291 in its original intent.

- Develop formal collaborative Consulting relationship between NPs and Psychiatrists, with clear and established set of protocols that allows the NPs to practice independently to the full extent of their education and training

- Increase nurse-managed clinics. NPs to pay for Consulting Psychiatrist’s servicesEX: Glide Health Services in San Francisco

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Barrier Recommendation- Limited nursing school clinical practicum sites and internships available within community-based MH/BH settings

- Limited NP clinical internship sites and competition with MD and PA students as well as required 500 clinical hours need to be across the lifespan which requires more than one preceptor

- Issues/concerns with licensing agency regarding curriculum and clinical practicum sites for mental health/behavioral health

-Increase internship sites for nursing students through the use of alternative community based sites and underrepresented multicultural specific facilities EX: Pacific Clinics Nursing Bridge model

-Increase internship sites through the use of simulation center around mental/behavioral health

- Develop clinical internship and transition-to-practice residency for APRNs and DNPs EX: Pacific Clinics Nursing Bridge model

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Barrier Recommendation- Lack of career pathway from psychiatric technician (PT) to registered nurse (RN) arena

-Lack curricula components in PT training programs that are required for a seamless transition into RN/ADN and BSN programs

- Limited mental health/behavioral health and community based curriculum components integrated into nursing programs

-Curricula differences regarding rigor of programs above the licensing agency standards

- Impacted nursing schools, specifically RN/ADN and BSN programs. LPTs low priority candidates

- Develop higher education/career pipeline from PT to RN/ADN-BSN EX: Pacific Clinics Nursing Bridge Model

-Match PT school training with transfer school curricula

- Offer college/university credit for MH/BH work-related experience to LPTs with experience of 6+ years

- Integrate community-based practice in didactic and clinical curricula components at the college and/or program level

-Address didactic and clinical curriculum components at the college and/or program level

-Develop standardized PT to ADN curriculum using innovative models

-Lobby/campaign for recognition of standardized bridge curriculum for PT to RN

-Engage nursing schools and nurses in practice to increase awareness of PT roles and service delivery functions within community-based MH/BH settings

-Enhance collaboration between BRN and BVNPT

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Barrier RecommendationCost of education:-Financial hardship for nurses who want to pursue APRN or DNP may still have previous loan payments-Nursing education costs may not be affordable to those interested in a nursing career, or those with child/family responsibilities.May negatively impact recruitment of qualified and culturally diverse workforce into PMHNP career pathway

- Lack of awareness of Scholarships, stipends, loan repayment, and loan forgiveness programs

- Cost of additional faculty due to increased student enrollment may be a hardship for nursing institutions. May affect school’s ability to recruit and hire qualified and diverse nursing faculty.

- Develop financial incentive programs for nursing students, such as scholarships, stipends, and loan forgiveness/repayment programsEX: MHSA WET funds to be used to pay previous nursing education loans in exchange for commitment to employment in MH/BH field, upon successful completion of APRN certification or DNP degree

-Increase awareness of scholarships, stipends, loan repayment and loan forgiveness programs through listserv and marketing strategies

- Develop and offer scholarship workshops

- Increase incentives for faculty recruitment and retentionEX: Engage DNPs to assist with faculty recruitment- Provide continuing education and training in leadership development and mentorship

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Barrier Recommendation- Lack of awareness of faculty development for mental health/behavioral health

- Lack of nursing faculty to precept/supervise students in community-based MH/BH settings

- Lack of APRNs working within the community-based MH/BH arenas to lend experience as nursing faculty

- Collaboration between Health Workforce Centers , DMH, CBOs and other organizations to develop, market, and offer faculty development opportunities

- Create post-certification residency with stipends to extern at a community-based MH/BH settings working with underserved communities

- Provide faculty leadership development/training to APRNs within community-based MH/Behavioral Health sectors

- Develop financial incentive programs such as loan forgiveness and stipends combined with commitment to employment in MH/BH settings

Limited number of psychiatrists’ to provide supervision to NPs which limits client/consumer service access and efficiency within the community

- Enact SB 491 in its original intent: allow NPs to practice independently to the full extent of their education and training

- Modify supervisory relationship to formal collaborative consulting relationship between NPs and Psychiatrists, which will allow for more independence in practice for NPs with little reliance on Psychiatrists – will enhance service access to consumers/clients

-Develop and provide a supervisory/preceptor training program for psychiatrists

- Recruit psychiatrists

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Barrier Recommendation- Lack of awareness about mental health/behavioral health/substance use careers and higher educational/certificate programs in MH/BH

- Limited MH/BH and substance use careers exploration outreach opportunities for middle school and high school students

- Reduced number of career guidance counselors to provide awareness of mental health/behavioral health and substance use careers and to develop appropriate educational plans

-Campaign to educate schools and communities about mental/behavioral health and substance use careers and higher educational/certificate programs in MH/BH

- Enhance collaboration between middle-high schools, DMH, CBOs, and local community colleges/universities to develop strategies to recruit and mentor middle-high students toward mental/behavioral health-related careers. Recruit/mentor students from underserved groups (e.g., deaf and hard of hearing communities).

- Develop shadowing and volunteer field experiences for middle-high school students at community-based MH/BH organizations

-Increase number of MH/BH and substance use careers exploration outreach opportunities for students

-Increase the number of career development programs geared towards MH/BH careers

-Provide financial support to schools to hire more guidance counselors through grant funds- Develop immersion trainings for guidance counselors within DMH and CBO sites to increase understanding of the MH/BH system and diverse occupations within the MH/BH field

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Barrier RecommendationReduction of stigma around mental health/behavioral health and substance use to increase entry in mental health/behavioral health and substance use careers

Increase mental health/behavioral health and substance use stigma reduction and wellness and recovery information programs and workshops for students, faculty, hiring organizations

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Barriers Recommendations Supports MHSA Core Values* and WET Goals**

(Sources: *CA BBS and **OSHPD)

(1) NPs not able to practice independently to the full extent of their education and training

-Lobby/campaign to allow APRNs to practice independently to the full extent of their training and education. Enact SB 291 in its original intent.

- Develop formal collaborative Consulting relationship between NPs and Psychiatrists, with clear and established set of protocols that allows the NPs to practice independently to the full extent of their education and training

MHSA CORE VALUES: (1) Develop a diverse, culturally sensitive and competent workforce in order to increase the availability and quality of mental health services and supports for individuals from every cultural group. (2) Outreach to underserved and unserved populationsWET GOALS: 1) Develop sufficient qualified individuals for the public mental health workforce (2) Increase the partnership and collaboration of all entities involved in public mental health workforce education and training

(2) Limited nursing school clinical practicum sites and internships available within community-based MH/BH settings

Increase internship sites for nursing students and develop transition-to-practice residency for APRNs/DNPs within community based sites and underrepresented multicultural specific for APRNs and DNPs EX: Pacific Clinics Nursing Bridge model

MHSA CORE VALUES: Develop a diverse, culturally sensitive and competent workforce in order to increase the availability and quality of mental health services and supports for individuals from every cultural group. WET GOALS: (1) Increase the quality and success of educating and training the public mental health workforce in the expressed values of the Act (2) Increase the partnership and collaboration of all entities involved in public mental health workforce education and training(3) Develop sufficient qualified individuals for the public mental health workforce

(3) Lack of career pathway from psychiatric technician (PT) to registered nurse (RN) arena

-Develop higher education/career pipeline from PT to RN/ADN-BSN EX: Pacific Clinics Nursing Bridge Model

-Enhance collaboration between BRN and BVNPT , and nursing schools to develop standardized PT to ADN curriculum

MHSA CORE VALUES: Develop a diverse, culturally sensitive and competent workforce in order to increase the availability and quality of mental health services and supports for individuals from every cultural group. WET GOALS: (1) Increase the quality and success of educating and training the public mental health workforce in the expressed values of the Act (2) Increase the partnership and collaboration of all entities involved in public mental health workforce education and training(3) Develop sufficient qualified individuals for the public mental health workforce

(4) Cost of education not affordable to potential nursing students, and a financial hardship to nurses who have previous education loans

-Develop financial incentive programs for nursing students, such as scholarships, stipends, and loan forgiveness/repayment programs

MHSA CORE VALUES: Develop a diverse, culturally sensitive and competent workforce in order to increase the availability and quality of mental health services and supports for individuals from every cultural group. WET GOALS: (1) Develop sufficient qualified individuals for the public mental health workforce(2) Increase the quality and success of educating and training the public mental health workforce in the expressed values of the Act

Target Groups: Bachelor-Level non-nursing health professionals (Psychologists, LCSWs, LMFTs, LPCCs)Middle School, High School, Community College Students, Undergraduates, and Graduate students Incumbent Workers Career Changers Displaced Workers Immigrant Health Professionals Licensed Psychiatric TechniciansLicensed Vocational NursesUnderserved ethnic groupsUnder-represented groupsPeople with lived experiences Veterans

Target Groups: Bachelor-Level non-nursing health professionals (Psychologists, LCSWs, LMFTs, LPCCs)Middle School, High School, Community College Students, Undergraduates, and Graduate students Incumbent Workers Career Changers Displaced Workers Immigrant Health Professionals Licensed Psychiatric TechniciansLicensed Vocational NursesUnderserved ethnic groupsUnder-represented groupsPeople with lived experiences Veterans

Quality, Diverse Health Workforce

Pre-Training Health Professions Education Workforce

Career Awareness

AssessmentAcademic

Preparation & Entry Support

Financial & Logistic

Feasibility

Health Professions

Training Program Access

Training Program Retention

Internships Hiring & Orientation

K-12 Education

Cultural Sensitivity and Responsiveness

Retention & Advancement

Financing & Support Systems

Lack of clear employment opportunities for mental

health/behavioral health NP and CNS Lack of clear employment

opportunities for mental health/behavioral health NP and

CNS

Limited residency practicum

sites in community-

based settingsAdapted from the coordinated health career pathway developed by Jeff Oxendine.

Lack of awareness about mental health/ behavioral health and substance use careers and access to different educational programs

Cost of education a

financial hardship; not

affordable

Lack of financial

incentives

Impacted nursing school programs

RN/ADN and BSN. LPTs low

priority

Stigma about mental illness

and substance use

Lack of faculty

Reduced number of

career counselors

Lack of career pathway for

LPTs

Lack of faculty development

DRAFT 34

Questions ???