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Joan King

Senior Integrated Health Consultant, National Council for Mental Wellbeing

Beyond the Bedside: Nurses In Integrated Care

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This article originally appeared in National Council Magazine

As integrated care continues to advance, questions around workforce are a cause for much discussion and concern. These questions include supply, competencies, workforce makeup, scope of practice questions, and changing roles for all professional disciplines in these settings. As a nurse and integrated health consultant, I often get asked about the role of nurses in the new integrated care workforce.

Historically, nurses have always been present in community mental healthcare. But over the last 15 – 20 years, their roles were reduced to giving injectable medications or performing task oriented and/or billable functions. In an integrated care environment, what we’re moving toward is really taking advantage of the full skills of a registered nurse.

By the virtue of their training, nurses work holistically with patients. There are more roles for registered nurses and advanced practiced nurses within the mental health organization than ever before. But, there are three main areas in which nurses today help with mental healthcare:

Prescriber Partner: A registered nurse must be able to help those prescribing medication. Here, the nurse is essential in helping patients understand the effects and side effects of their medication. In addition to monitoring vital signs, the nurse is a critical component to helping to remove the barriers to medication adherence and in helping patients advocate for themselves in a complex system. Telephone triage and follow up, coordinating care across multiple specialties and creating an environment of compassion are all roles that nurses fill in integrated care settings.

Consultative: As case management moves to care management, and the entire care team begins to look at people in terms of their whole health, the registered nurse can be used as a consultant to case management teams and to other staff within the organization. In this role, the nurse attends team meetings and listens for issues where mind and body connect. This might be the person with diabetes and depression or the person with acute anxiety and asthma. The nurse explores with the staff whether the appropriate screening has been done, whether mental health interventions are keeping the potential physical health issues in mind, and is available to see the person in complex situations.

In addition, the nurse can identify population-based education needs for the team. A team might have a high percentage of people with diabetes and so the nurse could provide some targeted education on different aspects of the management of diabetes. The nurse can also support the coordination of physical and behavioral healthcare by providing strategies to work with primary care and when necessary, stepping in to support the development of the relationship.

Direct Care: Because of their training across multiple scientific and psychosocial areas and because of competitive market forces, nurses are expensive to hire and maintain and there is a shortage of nurses available to work in community settings. This scarcity and cost of the resource makes it imperative that they function largely in the roles outlined above. But there are situations where the direct care services of the nurse are invaluable.

For instance, let’s say that you’re serving someone who really doesn’t have any family and now has been diagnosed with cancer, and they need to see multiple specialists and then they need to make treatment decisions. For a period of time, the nurse could step into the direct care role and help that person navigate the healthcare system. They can be the listening ear for the treatment options, as well as advocate for that person in the system. They can ensure the patient is having their needs met. Once the treatment protocol is established and the person is beginning to move forward, then the nurse can transition the direct care back to the case/care manager and return to the consultative role.

Population Health: Registered nurses can also have a role within the population health arena. They can help a team of case managers take a look the pressing physical health issues of the population being served. In this role, the nurse looks at the needs of a whole group or a community and evaluates the way the community is impacting the health of people. They then offer ways to help to mitigate that impact.

While these roles are effective and necessary, there are factors that inhibit registered nurses from filling these roles in mental healthcare. One of the reasons is that mental health providers often cannot compensate nurses properly. Behavioral health providers must make the effort to compensate nurses at the market rate, and then they can track the impact the nurse has on productivity and outcomes.

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