Integrating behavioral health care into primary care increases the likelihood that patients and their families receive holistic care in a familiar, accessible setting. Increasing the availability of mental health services is especially important in Nebraska because most counties are designated as mental health service shortage areas. Only three counties, located in eastern Nebraska, are considered mental health non-shortage (Sarpy and Cass) or partial shortage (Douglas) areas (Rural Health Information Hub, 2022).
In 2020, the UNMC College of Nursing received a three-year, $1.5-million federal HRSA (Health Resources Services Administration) Grant, Increasing Access to Integrated Behavioral and Primary Care Services through APRN-Led Teams.
Project director Therese Mathews, PhD, APRN-NP, and her team (Margaret Emerson, DNP, APRN-NP; Stephanie Burge, DNP, APNR-NP; Jill Reed, PhD, APRN-NP; Leigh Cook, MSN, APRN-NP; and Marissa Davala, PhD, UNK Counseling) partnered with Heartland Federally-Qualified Health Care Clinic (Heartland FQHC) in Grand Island, Nebraska, and Nebraska Medicine (NEMed) to implement the project in two settings:
- A newly-established satellite clinic for Heartland FQHC in Ravenna, Nebraska. The Ravenna Clinic, located in northeast Buffalo County, draws patients from surrounding communities/counties; and
- The Nebraska Medicine Durham Internal Medicine Clinic in Omaha. The Durham Clinic serves a diverse urban population, including patients and families experiencing economic and other barriers that impact accessing mental health services.
In both clinics, the interdisciplinary team provides behavioral health care based on the University of Washington Collaborative Care Model (CoCM) (aims.uw.edu). This evidence-based model facilitates quality and efficient behavioral health care by considering the patient population served, promoting patient engagement in care, and providing support for primary care providers in care delivery.
In both clinics, the interdisciplinary team consists of family practice APRNs, who are the team leaders; a licensed behavioral health provider; psychiatric APRN-NP consultant(s), and registered nurses.
The Ravenna team consists of Dr. Burge, Michelle Clark, MSN, APRN-NP; James Mitchell, MA, PLMPH, and Abby Obermiller, RN; Leigh Cook and Dr. Mathews are the psychiatric NP consultants.
The Durham Clinic team consists of Melanie Huber, APRN-NP; Laura Boon, APRN-NP, Michael Walsh, MA, PLMPH, and Vanessa Warneking, BSN, RN, clinic manager; Dr. Emerson is the psychiatric NP consultant. Debbie Kibbe serves as the grant’s project coordinator and Kevin Kupzyk, PhD, is the statistician. Joseph Evans, PhD, and Julia Houfek, PhD, APRN-CNS, are consultants. Participating administrators are Tami Smith (Heartland FQHC) and Stephen Mohring, MD (Nebraska Medicine Durham Clinic).
The grant has five aims:
- develop an integrated behavioral health nurse-led primary care team at the Ravenna Clinic;
- increase access to an APRN-led, integrated behavioral health care clinic in the Durham Internal Medicine Clinic;
- provide interdisciplinary leaning and clinical experiences to educate the current and future nursing and behavioral health workforce to improve evidence-based, integrated behavioral health in primary care;
- develop community-based partnerships to improve access and delivery of integrated behavioral health care by addressing social determinants of health, and
- support the development of community and school-based partnerships to improve screening and delivery of evidence-based school interventions for high-risk children and adolescents in Ravenna, Nebraska.
During Year 1, grant personnel focused on training for the interprofessional teams and beginning clinic services. The unique organization and needs of the two clinics and their communities were considered by teams as they began to integrate behavioral health services. For example, based on a needs assessment, behavioral health for children and adolescents was a significant need in Ravenna.
HRSA grant personnel and school psychologist consultants Brandy Clarke, PhD, and Erica Franta, PhD, from the Mid-America Mental Health Technology Transfer Center (MHTTC), are collaborating to provide mental health consultation in the Ravenna School System. MHTTC is funded by the Substance Abuse and Mental Health Services Administration (SAMSHA) and is located at the UNMC Munroe-Meyer Institute. Mental health care for children/adolescents and their families is provided by Ravenna clinic’s behavioral health provider. The Ravenna team also participated in various open-house and community activities to promote the new clinic, its providers and services, including behavioral health.
At the Nebraska Medicine Durham Clinic, the interdisciplinary team worked to provide mental health services across the various medical provider teams. The presence of a full-time behavioral health provider, a feature of the HRSA grant, improved same-day mental health care access for patients who are experiencing a crisis or who have difficulty making multiple clinic trips. Having accessible behavioral health services within primary care clinics can reduce stigma associated with seeking mental health care and improve communication between primary care and behavioral health providers (Miller-Matero, Khan,Thiem,DeHondt, Dubaybo, & Moore, 2018).
In the academic realm, the grant has improved teaching and evidence-based practice scholarship. In Spring 2021 and 2022, over 110 UNMC advanced practice nursing students and UNK-graduate counseling students participated in a primary care integrated behavioral health simulation experience. This experience is taught by grant personnel and volunteer nursing and counseling faculty. The simulation is designed to increase students’ integrated behavioral health knowledge and skills. Finally, to document evidence-based outcomes, grant personnel have developed an innovative data collection tool using REDCap (Research Electronic Data Capture) that is specific to the behavioral health assessments and treatments provided by the interdisciplinary teams.
In 2021, the clinics provided integrated behavioral health care for 67 and 107 patients/families at the Ravenna and Durham clinics, respectively. Evaluation of the grant’s services by patients and the providers have been positive.
In summary, the grant and its team have increased access to mental health care and student training in both rural and urban mental health shortage areas. A long-term goal of the grant is to explore ways to sustain evidence-based integration of behavioral health care in primary care.
References:
Rural Health Information Hub, Mental Health Shortage Areas, Nebraska (2022). https://www.ruralhealthinfo.org/charts/7?state=NE Accessed 04/06/2022.
University of Washington AIMS (Advancing Integrated Mental Health Solutions) Center. https://aims.uw.edu. Accessed 04/06/2022.
Miller-Matero LR, Khan S, Thiem R, DeHondt T, Dubaybo H, Moore D. (2018) Integrated primary care: patient perceptions and the role of mental health stigma. Primary Health Care Research & Development, 20 (e48): 1-4. doi: 10.1017/ S1463423618000403.