View as pdf
A later version of this article appeared in Nurse Leader, Volume 21, Issue 6, December 2023.
Nurse leaders have repeatedly called for an expansion of nursing education, research, and clinical practice to identify and meet the social and healthcare needs of diverse and vulnerable populations. The National Institute of Nursing Research’s mission calls for optimizing health and advancing health equity through five lenses, as reflected in their new strategic plan: Health Equity, Social Determinants of Health, Population and Community Health, Prevention and Health Promotion, and Systems and Models of Care.1 Further, the National Academy of Medicine’s (formerly the Institute of Medicine) reports on the Future of Nursing specifically call for nurses to provide care and to lead or contribute to solutions for vulnerable populations. These national nursing priorities build upon a foundation established by Berwick and colleagues4 which advanced our understanding that access to culturally- based care should be provided where people live and be available when they need it.
Programs preparing nurse practitioners are ideally suited to respond to these calls to action. Important innovations are emerging in Doctor of Nursing Practice (DNP) programs. These changes are due to three main factors: First, growing market demands, especially the dearth of psychiatric providers; second, an increasing number of registered nurses entering DNP programs who wish to pursue dual certification; and finally, more current nurse practitioners (NPs) are returning to earn post-master’s degree certification in a second specialty.5,6 Dual certification DNP curricula are comprehensive and challenging. Successful graduates have the knowledge, expertise, and skills to positively impact patient outcomes within the increasingly complex healthcare infrastructure. Although there are many plans of study for dual certification, of particular interest for this article are NPs with dual certification in primary care and psychiatry (PC/PMHNP). These NPs are exceptionally well qualified to provide and lead care for patients across the lifespan and with varying levels of acuity as well as high needs/high-cost patients7 in institutional and community-based settings. Primary care settings and rural communities with compromised accessibility to specialty care such as psychiatry stand to benefit from incorporating a dually certified PC/PMHNP. The purpose of this paper is to inform nurse leaders about this emerging role and provide tangible ways on how nurse leaders can support implementation.
Introducing the Dually Certified Practitioner Role
Nationally, approximately 20% of Americans experience a mental illness yearly, but only half are treated8 Lack of care is a consequence of many factors including costs/coverage, too few care providers, and the stigma of receiving psychiatric care. The consequences of having a mental illness are high and include increased comorbidity risks for cardiovascular and metabolic diseases, substance use disorders, and other illnesses adversely affecting quality of life. Moreover, the COVID-19 pandemic amplified preexisting psychiatric disorders and increased anxiety and depression in the general public.
Access to mental health care is particularly challenging due to limited available mental health facilities. Dual PC/PMHNP providers in primary care settings increase access to mental health services by reducing the stigma attached to seeking services in a psychiatric setting, reducing wait times associated with referrals, and decreasing the need for persons seeking mental health care to negotiate additional schedules and relationships. National data indicate a decrease in primary care physicians’ growth by approximately 7% while nurse practitioner growth is expected to increase by 40% over the next decade, particularly amongst the care of rural and underserved populations.9 Consequently, NPs have unique opportunities to address common challenges for practicing in rural settings in the care of patients with complex chronic physical and mental health conditions.
NPs are a source of affordable, quality, and trustworthy healthcare and are recognized for their expertise in preventive care. They are also highly effective at optimizing the patient experience, improving patient outcomes, and minimizing costs for the care of complex patients. Dual-track NP programs that combine primary care and psychiatric mental health care by advanced practice nurses were first developed in 1997.10 The combination of primary care and psychiatric mental health NP preparation enables the integration of medical and behavioral health care promotion, prevention, and management. The integration of primary and mental health care also facilitates holistic care, allowing providers to evaluate the effectiveness of medical and psychiatric therapies on the whole patient.11
NP academic program curricula follow closely the National Organization of Nurse Practitioner Faculty (NONPF) Core Competencies that provide a foundation for NP role expectations and are aligned with the American Association of College of Nursing (AACN) Essentials for graduate nursing education.12,13 Population-specific competencies (e.g., FNP, PMHNP) are also provided by NONPF to ensure clinical expertise preparation required for certification and entry into practice.14 Curriculum design for dual NP programs has not been standardized, allowing academic institution flexibility in program design. Moreover, there is a lack of consensus amongst nursing academicians about the structure and makeup of a dual NP program. Many regulatory bodies (state boards of nursing and certification bodies) do not track whether individuals have more than one NP certification, or if they do, make it publicly available.
The University of Iowa College of Nursing has offered dual-track NP programming amongst the 8 specialty tracks since 2015 with 18 BSN-DNP dual graduates and specifically 13 PC/PMHNP graduates at the time of this publication. Evaluations from graduates reveal high satisfaction with dual-track preparation with few disadvantages that included additional rigor and tuition requirements.6 A pilot program, supported by funding from a Telligen Community grant in 2022, developed and implemented additional coursework and practicum experiences with a focus on integrative care for PC/PMHNP dual program students.
The remainder of the paper focuses on benefits, barriers, and implementation of the dually certified PC/PMHNP role. Content is based on the literature and authors’ clinical experiences in the role. We include illustrative examples that reflect our practice observations and leadership in developing and implementing the role.
Benefits Associated with the Dual Practitioner Role
Systems that employ dually certified nurse practitioners receive many benefits. These include a holistic approach, decreased stigma, patient empowerment through education and relationships, cross-system care across the care trajectory, and consultant expertise, as described next.
Holistic approach
Many patients with physical conditions have co-occurring psychiatric conditions which impact both hospitalization and cost.15, 16 The PC/PMHNP can address both the psychiatric and physical conditions yielding less fragmentation.
The visit becomes holistic when the patient is empowered to think, “What do I need today?” For example, the visit might be for psychiatric medication management follow-up, but the patient says, “My meds are doing well, but my throat is sore and my knee is bothering me.” The NP can shift and let the patient drive the visit. This is particularly important for people with serious mental illness (SMI) and substance use disorder whose most frequent contact is with psychiatry. If I were working only in a psychiatry office, I could only address psychiatric concerns, whereas in an integrated practice, I can address the whole person. We know physical health concerns are often underreported and under-addressed in people with SMI, so having the capacity for patients to bring up other health concerns is helpful. It reduces visits, builds trust and I can pick up on what might be a small issue before it becomes something bigger.
Streamlined care fosters efficiency, safety, and cost-effectiveness
Patients with co-occurring physical and psychiatric symptoms have higher healthcare utilization and thus are more costly to treat.17 Further, they may be unaware of the connection between mental health symptoms and somatic expressions, or of how mental health symptoms can worsen medical conditions and vice versa. As a result, they are at risk for duplication of services and polypharmacy.
Consider the case of a woman with post-traumatic stress disorder (PTSD) and major depressive disorder who was seen after a negative workup in the ER for chest discomfort. The NP and the woman worked together to process the episode, evaluating a recent trigger attributed to her PTSD. Moving forward the NP and the patient have a new way of talking about physical symptoms and PTSD-related anxiety. The NP can investigate any future somatic concerns and conduct a physical exam and, as appropriate, link somatic symptoms, (e.g., headache, chest pain) to increased anxiety. This reduces duplication of services, multiple visits and decreases the risk of inappropriate polypharmacy.
Streamlined care can also benefit the larger system. Mergers are happening between hospital systems and community mental health. NPs can seamlessly move between community systems (e.g., residential care facilities, group homes, family settings) and institutionally based settings such as hospitals and nursing homes. Further, they can advocate and communicate with many disciplines as patients move across care settings. Additionally, dually certified NPs can serve as consultants, provide case reviews and collaborate with other health professionals within the health care system.
A more streamlined approach to care means patients do not work as hard to get what they need.17 Having only one healthcare provider can minimize confusion, increase trust, and promote appropriate engagement in healthcare which may diminish ER visits and hospitalizations. This has the potential to lower costs, but rigorous cost evaluation studies are needed.
Stigma reduction
Persons with mental illness are particularly vulnerable to the adverse effects of stigma such as shame, isolation, hopelessness, and discrimination. 18
People are embarrassed to bring up their psychiatric concerns but when they know that I am also a psychiatric provider, they are relieved. I see the mental health concerns and can normalize symptoms and come up with a plan. Further, they are seeing me in a primary care office and don’t have to go to the psychiatry office, which is destigmatizing.
Dually certified PC/PMHNP are “empowerment enablers”
Patient empowerment19 can be enhanced through working with a dually certified PC/PMHNP. As described below, the NP’s holistic lens contributed to efficiency, patient empowerment, and enhanced job satisfaction.
I have seen growth in patient self-awareness and understanding of their own health. Nursing excels at taking time to provide patient education and promote self-management, but when we approach this through dual role/holistic services, patients gain an understanding of how their symptoms or day-to-day health is not an isolated representation of one problem, but rather a whole-body expression of what is going on. For example, if a patient living with diabetes and depression presents with an increase in average blood sugar readings they have a better understanding of how the two are interconnected --it sets us up to have a very different conversation as provider and patient than if I was only treating one condition and not the other. It is very rewarding to see patients empowered by understanding their own body/health.
Barriers to Implementing the Role
Several issues arise as barriers in the implementation of the dual cert role. These include constraints in the practice environment, practice logistics, and issues with full practice authority.
Practice environment
Because many healthcare administrators are unaware of this emerging role, it takes creativity and vision to inform them of the benefits of hiring a dually certified NP. One effective means to eliminate/minimize this barrier is to engage a physician or medical director champion.
The medical director quickly realized my vision for the dual role. If he hadn’t embraced the full capacity of the dual-prepared NP provider, I could have been reduced to primarily serving as either an FNP or PMHNP rather than the opportunity to use both at the same time.
Practice logistics
Issues with scheduling, appointment times, electronic health records, billing, and reimbursement may impede dually certified NP in maximizing their role. The NP often sees complex patients who require longer than a 15-minute appointment, especially when there is a need for collaboration with other disciplines. Further, some electronic health records may have automatic access restrictions on psychiatric notes which poses a barrier to communication for enacting full team-based care.
Another barrier that dual-certified NPs face is changing the paradigm from volume-based to quality and value-based reimbursement. Billing and coding professionals based in primary care may not be prepared to support the added coding capacities that the dual cert NP possesses such as the counseling codes available to the psychiatric provider.
Full practice authority
Lack of full practice authority is a barrier to implementation of the dual cert role. In states where NPs require collaborative practice agreements, the NP with dual certification would require two physicians of varied specialties to practice.
Facilitating Role Awareness and Adoption
Although there are many benefits to this role, it is still not well recognized nor understood. Before this role can be widely adopted, an evidence base of improved clinical outcomes and cost-effectiveness must be provided to healthcare system leaders. None of the currently published manuscripts on the dually certified role address cost nor systematically evaluate outcomes of the role.
The dually certified NP must be able to confidently articulate their emerging role to health system administrators, medical leadership, members of the healthcare team, and patients.
It’s about owning the role and educating. When I am meeting with a patient for the first time, I introduce myself stating, “I am fully certified for family practice and psychiatric mental health. I have some patients I see for one or the other and some patients I see for both.” Often the patient is coming to me for one or the other because they don’t even know that such a thing exists. So, taking 20-30 seconds to explain my role to patients in this way has grown my dual/holistic practice. They often respond, “Oh, I didn’t know you could do that.” And typically, by the end of the visit they have decided to establish care with me for both services.
Dually prepared nurse practitioners have an obligation to enhance awareness through the dissemination of information about the role. Dissemination can be by presentations, discussions, and publications in arenas where nurse executives and hospital administrators are likely to read and convene.
NPs must also collect data on their own practice. Data on patient outcomes and satisfaction and cost savings will help validate the effectiveness of their role. NPs can also collect data on their insurance reimbursements using psychiatric counseling codes (e.g., 90833) to demonstrate the value of allowing extended appointment times and the financial benefits of quality over quantity. Partnering with health system administration leadership, schools of nursing and health services researchers is essential to foster role adoption and needed policy changes.
Future Directions
This is a new role that requires a vision of non-fragmented care for high-cost, complex patients with co-occurring mental health and physical health care needs. Nurse leaders can impact implementation of the role through a variety of means. These include advocating to Medicaid for dual-certified NP-led demonstration projects for high-cost patients, such as people with schizophrenia; expansion of dual cert programs at colleges of nursing nationwide; and promoting presentations/ posters related to dual cert roles and outcome studies at professional conferences. Nursing regulatory leaders in state and national boards of nursing, certification centers, and credentialing bodies play a particularly important role in assisting with gathering data on those NPs who maintain dual certification. Nurse leaders must also spearhead efforts to establish full practice authority through working in collaboration with their state and national boards of nursing, professional nursing organizations, and legislators. In states where there is already full scope of practice, they must remain vigilant for encroachments into full scope of practice.
Conclusion
As noted, national reports such as the Future of Nursing, encouraged the provision of care by nurses especially to vulnerable populations. Dually certified NPs are ideally prepared to provide care to high-needs/high-cost patients.
This article is a beginning step to elucidating the dual certification role. Much more is needed to expand educational programs and the full practice of dually certified NPs. Most particularly we lack an evidence base on cost-effectiveness and patient outcomes. This is where nursing leaders in academic, regulation, and healthcare systems can collaborate to pave the way and expand program offerings, enhance awareness, and promote employment of dual certified NPs.
Acknowledgment
The authors wish to acknowledge Christopher Sang for his support in editing the manuscript.
References
- The National Institute of Nursing Research 2022–2026 Strategic Plan (2022). https://www.ninr.nih.gov/aboutninr/ninr-mission-and-strategic-plan
- Medicine IoM. The Future of Nursing: Leading Change, Advancing Health. 2011.
National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030, Flaubert JL, Le Menestrel S, Williams DR, Wakefield MK, eds. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); May 11, 2021.
Berwick DM, Beckman AL, Gondi S. The Triple Aim applied to correctional health systems. JAMA. Mar 9 2021;325(10):935-936. doi:10.1001/jama.2021.0263
Conley V, Judge-Ellis T. Disrupting the system: An innovative model of comprehensive care. J Nurse Pract. 2020;17(1):32-36. doi:10.1016/j.nurpra.2020.09.012
Wesemann D, Dirks M, Van Cleve S. Dual track education for nurse practitioners: Current and future directions. J Nurse Pract. 2021;17(6):732-736. doi:10.1016/j.nurpra.2021.01.024
Long P, Abrams M, Milstein A, Anderson G, Apton K, Dahlberg M, Whicher, D. (Eds). Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. National Academy of Medicine. 2017. https://nam.edu/wp-content/uploads/2017/06/Effective-Care-for-High-Need-Patients.pdf
Key substance use and mental health indicators in the United States: Results from the 2021 National Survey on Drug Use and Health (Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration) (2022). https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report
Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners (U.S. Department of Labor) (2023). https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm
Dyer JG, Hammill K, Regan-Kubinski MJ, Yurick A, Kobert S. The psychiatric-primary care nurse practitioner: a futuristic model for advanced practice psychiatric-mental health nursing. Arch Psychiatr Nurs. Feb 1997;11(1):2-12. doi:10.1016/s0883-9417(97)80044-1
Blount A. Introduction to integrated primary care. In: Blount A, ed. Integrated Primary Care: The Future of Medical and Mental Health Collaboration. 1st ed. Norton; 1998:1-43.
Faculties NOoNP. NONPF’s Nurse Practitioner Role Core Competencies. 2022. https://www.nonpf.org/general/custom.asp?page=NP_Role_Core_CompetenciesAmerican
Nursing AoCo. The Essentials: Core Competencies for Professional Nursing Education. 2021. https://www.aacnnursing.org/essentials
Faculties NOoNP. NONPF’s Population-Focused Nurse Practitioner Competencies. 2013. www.nonpf.org/resource/resmgr/np_competencies_&_ntf_standards/compilation_pop_focus_comps.pdf
Figueroa JF, Phelan J, Orav EJ, Patel V, Jha AK. Association of mental health disorders with health care spending in the medicare population. JAMA Netw Open. Mar 2 2020;3(3):e201210. doi:10.1001/jamanetworkopen.2020.1210
Launders N, Dotsikas K, Marston L, Price G, Osborn DPJ, Hayes JF. The impact of comorbid severe mental illness and common chronic physical health conditions on hospitalisation: A systematic review and meta-analysis. PLoS One. 2022;17(8):e0272498. doi:10.1371/journal.pone.0272498
Ezell JM, Cabassa LJ, Siantz E. Contours of usual care: meeting the medical needs of diverse people with serious mental illness. J Health Care Poor Underserved. Nov 2013;24(4):1552-73. doi:10.1353/hpu.2013.0158
Pescosolido BA, Halpern-Manners A, Luo L, Perry B. Trends in public stigma of mental illness in the US, 1996-2018. JAMA Netw Open. Dec 1 2021;4(12):e2140202. doi:10.1001/jamanetworkopen.2021.40202
Bailo L, Guiddi P, Vergani L, Marton G, Pravettoni G. The patient perspective: investigating patient empowerment enablers and barriers within the oncological care process. Ecancermedicalscience. 2019;13:912. Published 2019 Mar 28. doi:10.3332/ecancer.2019.912