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Psychiatric Mental Health Advanced Practice Regist ...
Presentation Q&A
Presentation Q&A
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Video Transcription
So let's go straight into the questions. So Donna, for the first one, we have someone who wrote in, why would you have both PMH CNSs and PMHNP credentials? How could you end up with both? They're tongue twisters, aren't they? They are. Yes, I can breathe again after all those initials that I've been saying over and over. So someone like myself has both of these credentials, and I have a good explanation for it. So I started out in the program, I went to the University of Pennsylvania, and it was right in the midst of this whole LACE situation, if you will. I graduated in 2002, and it was right at that time when all of the things were changing. So I was able to get prescriptive authority as a psych PMH CNS, but I was the first wave of PMH CNS students or graduates to be able to do that. And again, the CNS rule, you had to choose between adult or child adolescent, and I chose adult. So I didn't have that lifespan, ability to see patients across the lifespan. And even if I only wanted to see adults, depending on the state that I'm working in, a lot of states do not allow CNS to prescribe medications. So I lived in Pennsylvania at the time, they did not allow prescribing for CNS. So I had a license in New Jersey at that time, and I could prescribe there. And so later on, I got the PMH NP with the lifespan ability to see patients across the lifespan, in addition. So I have that super long trajectory, A, B, C, D, E, F, G, after my name. But in the post or midst of LACE period, that will no longer be the case, that we've essentially transitioned out of all the CNSs, and now it would just be NPs. Right. Except that people that still have a CNS that's active, that they maintain their certification, they can continue to work under that license. Correct. But they may also have additional licenses, depending on where they're working and who they want to provide care for. And do you feel like at this point, we've reached a steady state of transition? It seems like much of this had to do with the evolution of the field and the evolution of credentials to keep pace with the changes in the field and the change of scope. Do you feel like we've reached a steady state where this is the way it's going to be for some time? Or what do you see on the horizon in terms of the next wave of changes that may add or subtract letters from people's names? It doesn't seem like there is any impetus to change the PMHNP credential or the lifespan part of that. However, the master's level programs are said to be transitioning into DNP level programs. So the NOMP, the National Organization of Nurse Practitioner Faculties, I know there are a lot of these acronyms that I keep repeating, has put out a mandate that all programs must be DNP entry level by 2025. So all of the MSN programs are said to be transitioning now to meet this mandate. So you can either have a PhD or a DNP at that point, it seems. It seems for now. Right. Tell me a little bit about clinical hours and training. How do PMHNPs get their clinical hours? That's a good question. In many different ways. So it depends on the program. So PMHNPs must have, and programs can divide this up in various different ways so that students get a good varied experience, but the ANCC certifying body requires that they have two psychotherapeutic modalities. They don't really specify what that means, exposure to two, but then they are required to have lifespan exposure to psychiatric management. So they can get that by training with a psych EP or a psych CNS or a psychiatrist. And then now since 2014, they also have to have some basic management in medical conditions that are related to psychiatric conditions. And so in our program, the students are training with family nurse practitioners, family practice physicians, internal medicine physicians for a short amount of hours to get that accomplished in that. That may happen in different ways in different programs. And for the therapy hours, they can train with a psych EP, a psychologist and master's level therapist or psychiatrist if they're doing therapy. So, I mean, you talked a little bit about the training, but how, and you, I previously mentioned that the PMH CNSs, you had to choose between adult and child and you were kind of locked in. For the PMHNPs, let's imagine that they train predominantly inpatient, for example. How much flexibility do they have in their scope in terms of being able to change work settings and practice down the road once they have their credential? As long as they have had training, let's say, in a lifespan program and they've trained with child, adolescent and adult and geriatric, we also have geriatric hours, which I failed to mention, and they've done the therapy and checked all the boxes and all the areas, they can pretty much change jobs, you know, with some on the job training later on. I've had many different clinical jobs since I've gotten out of school a few times. And is there still the heterogeneity in terms of what they can do in each state at this point? I mean, you mentioned back in the CNS days, kind of the Pennsylvania, New Jersey difference that driving across the state line gave you a whole different scope of practice. I mean, nationally, how does the picture look? Well, that is not limited to the CNS versus NP. If you look back at the map, the green states, I could be functioning independently as if independently like a physician would function. Of course, we're going to collaborate with people as needed and make referrals and that sort of thing. In the yellow states, I would need to have a collaborative agreement with a physician to some extent. An example in New York, 2015, they passed the NP Modernization Act, I believe is what it's called. And after 3,600 practice hours, there no longer needs to be a written collaborative agreement with a physician. They can go from yellow to green, essentially. Sort of, yes. Yellowish green, like a lime. There are a few stipulations that don't make them completely green after 3,600, but almost green. And so there's some changes happening in some states. But in a red state, such as Texas, where I live, I am completely tied to a physician. I could write for medications like benzodiazepines, but I can't write my own Schedule 2 prescriptions. But if I went back to New York, I could write all of the potential substances by myself. So extend that for us and for the audience a little bit, thinking about how that might impact the different kinds of roles that those caring for SMI might play. So how does that influence somebody in Texas caring for someone with SMI versus somebody in a green state, like Rhode Island or even here in DC? What kinds of, how does that play out in terms of the differences in roles? Well, it depends on the setting that you're in. So if you're in a really rural place, it's going to benefit you to have a lot more independence. Texas is a rural state, as you know, and there is a huge shortage of child adolescent providers. And as you know, that controlled substance is a Schedule 2, is a commonly prescribed drug for stimulants for children and adolescents. So that puts a few extra steps and a lot of logistics in handling medications for adolescents. But for SMI, it really depends if you're talking about inpatient, it may not be as big a deal. And in an outpatient clinic, it's just going to depend on how many providers you have there. But it really does limit access in some settings and some states. And what do you think about, oh, we actually just got a comment that just came in, which was right what I was thinking on. How does that extend to the world of telepsychiatry? I know for physicians, for example, it gets really complicated as soon as your patient steps across the state line and you're videoconferencing with them, as opposed to if they were just down the street. But how is the world of telepsychiatry evolving in the context of advanced practice nurses? So there's a lot of telepsychiatry happening. And of course, if you're providing telepsychiatry to patients that live in another state, you have to have a license of that state as well. But you could get a license in a state that's less restrictive and work in that state, but then there are complications with controlled substances in prescribing via telepsych. There are some limitations with that as well, but less logistics with the collaborative agreements and such. So one thing is loosened and other things are more complicated. And within the physician world, there's talk of this. There's been a lot of fits and starts around what they're calling the interstate compact, which doesn't allow for immediate reciprocity of one medical license into another state, but it makes it much easier for physicians to rapidly get licensed in other states. Is there something similar for the nurses, or are there national efforts around trying to align some of the licensing and expediting it, or is it still pretty much state to state? It's tricky with the MPs because the scopes of practice are so different in every state. There is a nursing licensure compact for registered nurses. And I believe, last I checked, there is something in development in certain states are trying to do that for the advanced practice level nurses, but I don't know the current status of that. Great. That sounds like we're all kind of, all of medicine is trying to figure out what these geographic borders really mean in terms of the practice of medicine, particularly with all this technology we now have. Well, thank you for participating today and for sharing your expertise. We're really looking forward to learning a lot more about the world of nursing and advanced practice nursing and the care of patients with SMI in the coming years. And so, Dr. Roland, thank you for being here with us today, and we will hear a lot more from you in the coming months.
Video Summary
In this video, Donna discusses the credentials and training requirements for PMH CNSs and PMHNPs. She explains that she obtained both credentials due to changes in the field during her time in the program. She discusses the different scopes of practice for CNSs and NPs, and the ability to prescribe medication varies by state. She also mentions the transition of master's level programs to DNP level programs and the importance of clinical hours and training for PMHNPs. Donna discusses the variability in scope of practice for PMHNPs across states and how this impacts care for individuals with severe mental illness. She also touches on telepsychiatry and the challenges it poses for prescribing medications across state lines. The conversation concludes with a discussion on efforts to align licensing and enhance mobility across states for advanced practice nurses.<br />Credits to Donna, Dr. Roland for her expertise in the video.
Keywords
PMH CNSs
PMHNPs
scope of practice
state regulations
telepsychiatry
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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