Acad Psychiatry DOI 10.1007/s40596-015-0331-z

COLUMN: EDUCATIONAL CASE REPORT

The Benefits of a Physician Assistant and/or Nurse Practitioner Psychiatric Postgraduate Training Program Tracy B. Keizer 1 & Michael A. Trangle 1

Received: 25 August 2014 / Accepted: 12 March 2015 # Academic Psychiatry 2015

In 2008, Regions Hospital in Saint Paul, Minnesota, began an advanced practice psychiatric provider fellowship program. Our mental health department offers a 1-year postgraduate psychiatric training program for physician assistants (PAs) and nurse practitioners (NPs) interested in obtaining further expertise in psychiatry. This is one of three current programs in the USA that offers postgraduate training for PAs and was the first postgraduate program for NPs in the field of psychiatry. The students participate in a 12month program where the primary areas of focus are adult inpatient, crisis, and outpatient mental health services. Additionally, the fellows receive training in the management of substance abuse disorders as well as comorbid acute and chronic medical conditions. The motivation for developing this program was to increase access and expertise in treating psychiatric illness in the community, on inpatient psychiatric units, and outpatient clinics. The mission is to graduate PAs and NPs who demonstrate clinical expertise, ethical behavior, leadership skills, cultural awareness, professionalism, and ongoing commitment to learning.

Benefits to Trainees Our postgraduate training program provides multiple opportunities for advanced practice providers. One of the benefits to students is the opportunity for supervised clinical and didactic

* Tracy B. Keizer [email protected] 1

Regions Hospital, St Paul, MN, USA

formalized training that could traditionally take many years of on-the-job training [1]. A concentrated psychiatric training program that embeds a student in multiple mental health settings, provides a fast-paced learning experience, and puts them ahead of other new graduates. Whereas many advanced practice graduate programs provide a broad overview of multiple topics and specialties, our in-depth specialty-specific postgraduate program will provide indepth experience, which will improve judgment, technical skills, and confidence. The postgraduate participants at Regions Hospital receive clinical as well as didactic instruction that emphasizes differential diagnosis using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5); psychopharmacology; neuroscience; psychotherapy; emergency psychiatry; addiction psychiatry; toxicology; and forensic psychiatry. The students are given didactic experiences alongside psychiatric medical residents in addition to medical and psychiatric grand rounds and other hospital-issued educational experiences. A postgraduate-trained advanced practice provider typically receives preferential employment opportunities and initially higher pay in comparison to an advanced practice provider who has not completed a postgraduate training program. Dehn [2] found that surgical PAs who completed postgraduate training received a 15 % higher salary than those who did not complete a similar program. In addition to higher salaries, advanced practice providers with postgraduate training often experience a higher level of autonomy postgraduation than their colleagues with less experience. Physicians and other administrative leaders who have hired the Regions psychiatric trained advanced practice providers have noticed and appreciate the level of training and experience the graduates have learned in their program. There is an increase in confidence because the graduates have had a wide variety of patient contacts and have seen multiple cases.

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Benefits to the Institution A postgraduate training program adds prestige to the institution and becomes a magnet for advanced practice providers seeking additional education. Postgraduate training programs also attract employers seeking highly trained and specifically trained individuals. It can also improve the quality of patient care, decrease recruitment costs, ensure quality of new hires, and help cover gaps left by new resident duty-hour rules. Training institutions have improved performance and patient care quality due to teaching and clinical review among peers [3]. Training programs can provide educational programs for institutional staff members, including continuing medical education in seminars, grand rounds, and other learning programs. The Regions Hospital postgraduate program requires the students to teach medical students, and they are invited to present at grand rounds and journal clubs. Incorporating postgraduate students into a health care model brings a focus on innovation, frequent use of current medical knowledge, electronic medical records, and use of evidence-based medicine and brings attention to details that may not have been seen without the supervision used in training programs [3]. Training programs also provide opportunities to test out new models of collaboration and partnership between students and attendings—such as collaborative documentation and billing practices. There are direct financial benefits to developing a PA/NP training program. When the PA/NP are fully credentialed and licensed, these clinicians are eligible to bill for services they deliver for the institution. Therefore, postgraduate students are not merely learning and using resources but bring in revenue for the institution. At the Regions Hospital Psychiatric training program, the students bill for house officer duties and medical consults using their individual NPI number. On average, the PA/NPs in the training programmed were able to bill independently and be reimbursed $15,000 in revenue for the institution. In addition, the PA/NP may conduct shared services with their attending, therefore improving the production of the team. One of the most prominent benefits of postgraduate training is the advantage of recruitment. Many programs have come to appreciate the capacity to retain graduates within their health care system and can substantially reduce recruitment costs for the facility. A Regions Hospital human resources recruiting specialist commented that the typical cost to turnover and replace an advanced practice provider is half the annual salary for the position. This translates to roughly $45, 000, but it is difficult to translate this to annual savings because our turnover is low. “Growing your own” is much less expensive and time consuming than starting from scratch. Retaining postgraduate students also cuts down on orientation time because these individuals are familiar with the health care system facilities, resources, procedures, and protocols.

As hospital and medical communities seek to hire providers in the wake of the Affordable Care Act and to meet the need of newly insured members, it will be very important to hire quality and well-trained providers. Hiring a graduate from an in-house specialty training program also ensures a high-quality workforce after graduation. There is certainly a benefit of being familiar with candidates’ strengths and weaknesses before hiring them. In addition to the financial and recruiting benefits of a PA/ NP training program, postgraduates are also able to aid in resolving a serious health care dilemma. Postgraduate PA/NP programs can meet the needs resulting from recent residency hour and funding changes. In July 2011, Accreditation Council for Graduate Medical Education (ACGME) hours were implemented, which highlighted direct supervision in postgraduate year 1 and shortened duty hours [4]. Due to the limitation of residents’ hours, there is a shortage of health care providers who are qualified to take their place. At Regions Hospital, where psychiatric medical residents had been completing the majority of house officer call before 2011, the postgraduate PA/ NPs are now providing a substantial portion of this coverage. They work weekday evening swing shifts and weekend and overnight shifts that were once covered by resident interns. Besides changes in duty hours, funding for traditional graduate medical education programs has decreased. In response, many hospitals and institutions have hired and relied on the work of advanced practice providers to fill this gap. At Regions Hospital, the postgraduate PA and NP clinician each completes over 350 h of house officer call as part of the program. This has saved Regions Hospital about $33,000 per trainee in additional moonlighting call coverage. During the psychiatric training program, postgraduate students also can provide additional medical coverage needed in inpatient and emergent care for acute and chronic health problem management. A typical scope of practice by most advanced practice providers includes performing physical exams, writing prescriptions and ordering diagnostic tests, diagnosing and treating conditions such as diabetes or high blood pressure, and educating patients on health and lifestyle choices. Both NPs and PAs hold prescriptive abilities in all 50 states, although stipulations regarding controlled substances and the need for physician supervision vary by state. Using postgraduate students to complete this crossover role during their training reduces the need for out-of-department medical consultants. There are also benefits to inpatient attending and outpatient mental health providers. The postgraduate psychiatric students work along staff psychiatrists in a similar way to medical residents and can assist in multiple ways. Using shared clinical documentation notes and billing in the inpatient setting with a postgraduate student, a staff physician can increase their billings between 8 and 13 work relative value units (wRVUs) per day. According to the Regions Hospital compensation model—developed from the 2012 Medical Group Management Association (MGMA) survey—the medial

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compensation to wRVU ratio is $46. With this increase in wRVUs, a provider’s compensation is increased between $368 and $598 per day or roughly $82,000 per year. The PA/NPs extend the services of the staff providers by being part of the treatment team carrying out documentation, conducting family meetings, gathering collateral, and conducting important medication checks.

Benefits to the Community Although hospital cost centers often focus on tangible benefits to the institution, many intangible benefits to the greater community are often overlooked. In the minority of instances where the trainees are not recruited by the training institution but, rather, by the other institutions in the local community, the community benefits by receiving a well-trained provider and improved quality and access to care. Regions Hospital has graduated PA/NP mental health providers to work primary care clinics, outpatient psychiatric clinics, psychiatric emergency rooms, mental health consult-liaison practices, and medical-psychiatric units in our greater community. These postgraduate providers have increased the access to care to quality mental health care. The American Association of Medical Colleges has estimated that the USA will face a physician shortage of over 90, 000 physicians by 2020, a figure that is expected to reach over 130,000 by 2025 [5]. This shortage is propelling NPs and PAs into an increasingly important role in all areas of medicine. Staffing requests for advanced practice providers have grown rapidly in the last several years. One of the highest needs for providers is in the mental health field. Between the years 2000 and 2008, the number of psychiatrists in the USA dropped 14 % according to study author Dr. Tara F. Bishop, an assistant professor of public health and medicine at Weill Cornell Medical College. This drop is poised to continue or worsen, as fewer medical students are opting for psychiatry as a specialty. Fifty-five percent of psychiatrists in Minnesota are age 55 years or older. Many psychiatrists who are expected to retire soon will not be replaced [6]. According to the Health Resources and Services Administration, 30 % of Americans live in areas with a shortage of mental health providers. Nearly 18 % of counties nationwide have unmet needs for mental health nonprescribers (such as therapists and mental health case management), and nearly 96 % of all US counties have unmet needs for mental health prescribers and therefore some level of unmet need overall. Rural counties and those with low per capita income had higher levels of unmet need [5]. Graduating high-quality advanced practice providers (APPs) from a training program and providing APPs who are working at the top of their license are ways that Regions Hospital is actively meeting the needs of the mental health community.

Discussion Although there are multiple benefits and genuine advantages of developing a training program for postgraduate APP students, there have been obstacles to overcome and continued challenges to solve. During the early stages of the training program, many psychiatry and nursing staff expressed unease as regards to accepting the role of the PA/NP in their postgraduate training. Over the last 7 years, however, the treatment teams have truly come to accept and now rely on the genuine skill sets and capabilities of these clinicians. The principal obstacle that the program continues to navigate is the financial justification of trainees’ salaries in the context of maintaining the revenue and workload of attending psychiatrists. We currently justify the salaries of the PA/NP students by accounting for after-hour house officer call that is part of their training program, independent billing, and recruitment and turnover savings. We have learned that it is important that the program hires only licensed and fully credentialed clinicians to ensure full privileges and billing potential the first day they start the program. Billing for after-hour admissions and medical cross-cover evaluation and management have been vital to defraying the cost of training. A further obstacle is balancing the ratio of trainees per attending faculty. The Regions Hospital psychiatric department has multiple trainees including medical students and PA and NP students in addition to psychiatric medial residents and PA/ NP postgraduate students. The education directors at Regions work hard to organize and schedule trainees far in advance in order to maintain a sustainable trainee/attending staff ratio. As a hospital, Regions psychiatric department must also predict further recruiting needs years in advance. As the department grows and ages, it is important to assess the current and future hiring needs. The Regions psychiatric department is presently recruiting and looking to train PA/NPs for inpatient psychiatric units, acute psychiatric emergency department, and psychiatric consult positions. In the changes that lie ahead, it will be important to prioritize training programs and an ongoing commitment to learning. Implications for Academic Leaders • In order to work at the top of their license in a specialty area, advanced practice providers may want to consider completing a postgraduate training program. • Training advanced practice providers in a postgraduate psychiatry program can help recruit onboard clinicians faster and more efficiently. • Advanced practice providers are important members of the psychiatric treatment team and can fill the gap in patient coverage.

Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest.

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Accreditation Council for Graduate Medical Education. Resident duty hours in the learning and working environment—comparison of 2003 and 2011 standards. Available at h t t p : / / w w w. a c g m e . o rg / a c g m e w e b / P o r t a l s / 0 / P D F s / d h ComparisonTable2003v2011.pdf Association of American Medical Colleges. GME funding: how to fix the doctor shortage. Available at https://www.aamc.org/ advocacy/campaigns_and_coalitions/budgetcuts/ Bekiempis V. This lack of psychiatric care is madness. Newsweek. 12/11/2013. Available at http://mag.newsweek.com/2013/12/13/ psychiatric-health-insurance.html

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