Promoting emotional well-being is a fundamental role of the Psychiatric Mental Health Nurse Practitioner (PMHNP). A PMHNP ensures the overall mental health of the patient is taken into consideration and built into the patient's plan of care. The PMHNP equally manages a patient's physical condition along with their mental and behavioral health, leading to evaluation, diagnosis and treatment planning including medication implementation when necessary. Although most PMHNPs work in mental health care settings, they are starting to promote emotional well-being in all health care settings.
Recent studies show that psychosocial issues can be the cause of up to 70% of primary care visits. Busy primary care clinics are addressing complicated behavioral and mental health disorders more frequently. Although there is strong evidence that integrating behavioral and mental health into primary care improves access and outcomes, clinics still struggle to put this evidence into practice due to lack of providers on staff that specialize in mental health.
Sometimes, patients are diagnosed by their Primary Care Physician (PCP) with depression after a positive screening and evaluation. However, most clinics do not have psychotherapy interventions in place. Clinics are hiring PMHNPs to help manage these patients from their initial diagnosis. PMHNPs serve as clinical instructors, project managers and psychiatric consultants to primary care clinicians using the collaborative care model as a framework.
As a Mental Health NP, the dedication to patients and their outcomes is an ongoing process. Using integrated methods to heal the entire person has proven to be the most effective means for success. Integrative behavioral health encompasses the delivery of primary, mental and behavioral health care to individuals with the goal of healing the whole person in one setting.
Nurse Practitioners (NPs) have become integral to collaborating with different interdisciplinary teams to treat and heal each person holistically. The Integrative Behavioral Health Model includes a high level of collaboration and communication among health professionals.
Creating a working relationship with your patient and other health professionals to create an integrative approach has been proven effective in treating a patient’s overall health. A collaboration involving different specialties should comprise the patient’s needs, priorities and preferences to ensure success. Professionals should include needs-based and evidence-based methods and treatments in the care plan.
Integration of behavioral health and primary care is not “one size fits all.” There are several models and differing levels of integration. Depending which model of integration is implemented, factors such as the health care delivery systems in place, reimbursement policies and available personnel need to be considered.
A vital role of the PMHNP is consulting with the patient. A detailed protocol should be established to evaluate their needs. Conducting a comprehensive history and physical with the patient is a logical starting point to get a good picture of one’s overall health. This step will include their overall physical health, current medications, labs and imaging and mental and behavioral well-being. The history should cover their immediate biological family to determine if there are familial issues to consider.
A list of questions for the patient to determine their mental and behavioral health might include the following:
- What are your stress levels?
- Have you been eating and sleeping regularly?
- When were you most happy? How did you express this happiness?
- What was the best experience that happened to you this year? How and with whom did you celebrate?
- Have you argued with friends, family or coworkers this year? How did that situation evolve and resolve? Who were the key players? How did you feel afterwards?
After a PMHNP completes the comprehensive consultation of their patient’s physical, mental and behavioral well-being, coordinating care for that patient is the logical next step in the plan. The plan can include counseling sessions, journaling, medications and working with a specialist in a specific medical, mental or behavioral health field.
As the PMHNP, it is essential to facilitate introductions and create relationships between the patient and a variety of specialists. This way, you can build an integrative healing approach tailored to that patient's needs. The specialists work together to achieve a common goal for the patient while delivering care separately. The plan will include the correct timing and order of behavioral practices, the appropriate environment for the treatment and ensure proper documentation to measure results, whether they indicate success or failure.
Here are a few reasons care coordination is important:
- Much of the current health care system frequently lacks coordination, and procedures differ between primary care and specialized clinics.
- Patients often have questions about the rationale behind their primary care provider referring them to a specialist, how to schedule an appointment and what to do after seeing a specialist.
- Specialists frequently do not get appropriate information on previously performed tests or clear justifications for the recommendation. Rarely do primary care doctors get information about what happened at a referral visit.
- Care for the patient is less effective due to the missing communication between the primary care doctor and the mental health specialist.
Follow Up and Reassess
At different predetermined intervals throughout the patient's treatment, the PMHNP will follow up with the patient and the interdisciplinary team to complete a thorough reassessment of the care plan and the patient’s current status. Identifying continuing or additional needs ensures success in their healing journey. Assessing the patient's progress is a clear indicator of the quality of the care plan.
If the patient is not progressing as predicted, the PMHNP would then update the care plan to reflect new and continuing goals by working directly with the patient and other members of the interdisciplinary team to review goals on the integrated health care plan. The team will then establish new plans and schedule the implementation for all involved.
When the PMHNP reassesses their current plan, the following is taken into account:
- When the PMHNP focuses on problems, they want to focus on a problem that can be measured. They pay attention to important areas that are neglected.
- The PMHNP evaluates what is working and values transparency in the data.
- The PMHNP is aware that everyone’s time is valuable.
- The PMHNP takes into account any discomfort the patient is having and evaluates if this is providing value or just pain for no reasonable outcome.
Case Study: Adolescent Outpatient Program (ADOL)
A 13-year-old male came into the clinic with a diagnosis of social anxiety disorder and general anxiety disorder. He has no other comorbidities. The PMHNP completed an extensive medical and social history.
When the boy was in the seventh grade, his best friend moved away. He then began to get bullied by his peers both online and in person. Halfway through his seventh-grade year, he refused to go to school, resulting in an incomplete for that grade. He began to self-harm and attempted suicide after a fight with his mother. He was assessed and released after his mother brought him to the emergency room.
After unsuccessful treatment with individual counseling at a community-based youth service, residential services were recommended, which was refused by his mother. The boy's anxiety symptoms and panic attacks returned at the thought of going back to school.
A PMHNP met with the boy and referred him to a School Day Program that combined academics along with mental health programming. At this school, he received individual Cognitive Behavioral Therapy (CBT) with a social worker. He also continued to work with the PMHNP during this time to ensure he stayed on track with his mental health progress, as well as with his sleep, nutrition and physical activity.
The boy's family doctor initiated psychotropic medications, working with the NP to titrate them to therapeutic doses. Because of the entire disciplinary team of the doctor, NP, social worker, psychiatrist and psychologists, the boy showed significant clinical improvement and was discharged from the ADOL program.
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