what is the level of evidence in this article? Mental Health Access to Care: Nurse

what is the level of evidence in this article? Mental Health Access to Care: Nurse PractitionereLed Telehealth Practice Ashley Fenton, Katherine G. Humphrey, Colleen King Goode, Lourdes Celius, Amanda Rohde Keywords: access to care mental health nurse practitioner telehealth abstract Expansion of full practice authority for nurse practitioners (NPs), coupled with the evolving use of telemedicine, can improve access to care. This project sought to gain a better understanding of how an NP-led integrated telemedicine practice provides access to mental health care in Maryland. Two hundred seventyfive patient zip codes were compared with Health Resources and Services Administration mental health shortage areas. Results showed the reach of the practice extends to 67% of all counties in the state, providing care to 69% of counties with the highest mental health needs. NP-led telemedicine practices can expand statewide access to care, and findings will help target high-need areas not currently served. © 2024 Elsevier Inc. All rights reserved. Background and Significance Expansion of full practice authority for nurse practitioners (NPs), coupled with the evolving use of telemedicine, can improve access to care. We sought to gain a better understanding of how an NP-led integrated telemedicine practice provides access to mental health care in Maryland. The United States has many health care professional shortage areas (HPSA) as defined by the US Department of Health and Human Services and Health Resources and Services Administration (HRSA). Nationwide, there were 6,464 identified HPSAs,1 with more than 165 million people living in workforce shortage areas in 2022.2 Rural Americans are the most affected by workforce shortage areas with 60% of all HSPAs in the rural United States. The US Government tracks these HPSAs related to primary care, dental, and mental health care professionals. In 2023, only 27.19% of the mental health care needs were met.2 To overcome this, the HRSA estimated that more than 8,000 additional mental health care providers are needed in the United States. Maryland has more than 6 million residents, with more than 85% of the total population living in urban or partially urban areas.3 The state has 64 federally designated mental health professional shortage areas, including 16 entire counties.4 Approximately 1.8 million people reside in the 64 HPSAs. According to the HRSA, Maryland residents have only 22.46% of their mental health care needs met and will require 105 more behavioral health providers to help close the gap.2 State strategies to address the shortage included increasing reimbursement rates, reducing administrative burden on providers, extending workforce, and incentivizing participation in Medicaid.5 These strategies had varying levels of success to increase the health care professional shortage and increase access to care. Another consideration to decrease this shortage is telehealth. In 2022, more than 75% of states reported that psychiatric mental health (PMH) services had the highest utilization on telehealth.1 PMH telemedicine increased to 88.1% in 2022 compared with 39.4% in 2019.5 The reach of telehealth to improve access to care, however, is not fully realized. NPs, especially psychiatric mental health NPs (PMHNPs) may be a solution to the workforce shortage. The HRSA projected PMHNP workforce to grow 62% from 2017 to 2030.2 Many states have eased restrictions on NPs for providing care during the pandemic, especially PMHNPs.5 These changes include decreased need for supervising providers, increased prescribing authority via telehealth, and increased participation in multistate compact license agreements allowing NPs to practice across state lines.5 NPs have the opportunity to use telehealth to help overcome barriers and reach patients in underserved areas. It is also important to consider improving access through telehealth for populations identified as having a higher need for services. It has been reported that facilities located in counties with higher proportions of Black residents (>20% of population) were 42% less likely to offer telehealth services.5 Conversely, practices located in rural areas were most likely to offer such services. This shows the potential for telehealth expansion in areas with a higher proportion of Black residents to increase access to mental health care.5 Despite the rapid shift to support telehealth mental health services, no national longitudinal studies have examined the impact of virtual mental health services in an NP-led integrated primary care mental health telemedicine practice. Although this study did not aim to address the effectiveness of telehealth services, evaluating the impact of an NP led telehealth platform for integrated health services on the coverage of care in Maryland Contents lists available at ScienceDirect The Journal for Nurse Practitioners journal homepage: www.npjournal.org https://doi.org/10.1016/j.nurpra.2024.104965 1555-4155/© 2024 Elsevier Inc. All rights reserved. The Journal for Nurse Practitioners 20 (2024) 104965 offers insight into the real-world impact of this modality of service delivery. Although there has been a rapid expansion of telehealth services since the pandemic, limited studies have evaluated the relationship between telehealth and access to care, particularly among high-need health care professional shortage areas. Methods This project was developed to gain a better understanding of how an NP-led integrated primary care mental health telemedicine practice provides access to mental health care. For the purposes of this project, mental health access was the primary focus given the largest number of patients. Because one of the overall goals of the practice is to expand access to care in areas of high need, the results from this project will be used to offer more services in identified areas. The setting for this project was an NP-led integrated mental health primary care telehealth practice in Maryland. The practice consists of 4 part-time psychiatric NPs and 2 primary care NPs. The primary care services are being newly integrated into the existing practice. All 4 psychiatric NPs see patients in Maryland, and 2 have multistate licensure for District of Columbia and Virginia. At the time of this project, data were collected only from Maryland because this was the largest number of patients served within the practice. Before data collection, the project was reviewed by the institutional review board and deemed exempt given use of a deidentified limited data set. A chart review was completed to determine the residence of all active clinic patients served through collection of zip codes. Data collection was completed by 2 clinic NPs. Patient identifiers were removed and only zip codes were included in the data collection. Data were saved on an encrypted password protected computer. The zip codes were reviewed and categorized by county and entered a protected data file. The counties were then compared with identified mental health shortage areas from the HRSA and categorized by location as a metro or nonmetropolitan area and portion of the county identified as a shortage area. The shortage areas were categorized in accordance with the HRSA as none of the county, part of the county, or the whole county. Data were then analyzed using statistical software using descriptive statistics. Data analysis was completed by 1 author and reviewed by coauthors. To assess mental health coverage visually, several maps were also created. Zip codes and shortage areas were mapped by area and sorted by color based on category. The zip codes were also entered into geo-mapping software to visualize the geographic reach of services. The geo-map was then overlayed on a state map from the HRSA depicting health professional shortage areas by county for mental health. Results A total of 275 patient zip codes from 4 part-time psychiatric NPs were reviewed for analysis. All zip codes from Maryland were included in the analysis. Most patients were in counties where the NPs reside (Anne Arundel County and Montgomery County). Breakdown of patient distribution is shown in Table 1 and Figure 1. The majority (98.9%) of the patients served by this practice were in metropolitan areas, as depicted in Table 2, which is consistent with Maryland’s demographics (85% of Maryland considered urban). Findings showed that 81.1% of the patients served fall within a partial shortage county, 16% are within a whole shortage county, and 2.9% are in a county with no mental health shortages (Table 3). Figure 2 provides a map showing a visual depiction of patients throughout the region. Of the 24 counties in Maryland, patients were identified in 16 (66.7%) of all counties. There are currently 16 counties in Maryland in which the whole county has a shortage of mental health providers (HRSA); the practice was found to have patients in 11 (68.7%) of these high need areas. These findings are shown in Table 4. As mentioned earlier, it is known that facilities located in counties with higher portions of Black residents were less likely to offer telehealth services; data were also analyzed to determine the percentage of patients in counties with >20% Black/African American population. Findings indicated that 38.5% of the current patients served fall into this category as shown in Table 5. Discussion Telehealth has been recognized as an effective modality for screening, assessment, behavioral therapy, medication management, case management, and crisis services for patients in need of mental health care and those with serious mental illness.6 Benefits of telehealth care include a decrease in costs for patients. Receiving care by telehealth reduces travel costs, increases access to timely care with less time away from employment through expanded flexible hours for appointments, and reduces in burden of childcare needs for family caregivers.6 In addition to this convenience for patients, the option for telehealth mental health care has potential to improve patient outcomes and reduce health disparities because it is know that specialty clinic practices are 3 times more likely to be in higher income versus lower income communities.7 Telehealth addresses geographic barriers for patients, offering access to appropriate, high-quality specialty care. The project results highlight scalability and potential for expanded patient reach with the use of a telehealth care model. This project demonstrates how 1 practice was able to connect patients residing in 66.7% of all Maryland counties to mental health care. As emphasized here, the NP-led integrated primary care mental health telemedicine practice extended care to 68.7% of those Maryland counties where the whole county was lacking mental health care services. Future studies on the percentage of patients within these counties in need of mental health care will be valuable for better understanding the impact of practice services in meeting community needs. Several studies reported success and limitations to increasing access using various interventions. Talarico reported an increase in access to care for follow-up appointments following the addition of telehealth services to a PMHNP practice, specifically with rural patients.8 Telehealth improved health care providers’ ability to Table 1 Location of Patients by County in Maryland Location Frequency Percent Anne Arundel County 127 46.2 Baltimore City 18 6.5 Baltimore County 8 2.9 Calvert County 10 3.6 Caroline County 2 .7 Carroll County 5 1.8 Cecil County 1 .4 Charles County 2 .7 Fredrick County 6 2.2 Harford County 4 1.5 Howard County 8 2.9 Montgomery County 51 18.5 Prince Georges County 19 6.9 Queen Annes County 6 2.2 Saint Mary’s County 7 2.5 Talbot County 1 .4 Total 275 100 2 A. Fenton et al. / The Journal for Nurse Practitioners 20 (2024) 104965 check on patient progress, provide supplementary materials, online assessments, and recommend mental health apps or online programs.9 The Veterans Health Administration has reported success in increasing access to mental health services and follow-up for veterans provided with a tablet to use with telehealth visits.10 Integrated care practices that offer primary care and mental health services in one practice, including telehealth options, provide opportunities to reduce disparities among patients with mental health conditions.11 Timely screening and assessment through telehealth provides early identification and intervention for mental health treatment, improving crisis response time for patients.6 While the project focused on counties identified by the HRSA as mental health care professional shortage areas, the data highlight the benefits of a collaborative care model. The integrated primary care mental health telemedicine practice included NPs licensed in psychiatric mental health (caring for pediatric, adolescents, and adults), primary family care, and adult gerontology care. The practice connected with patients who live in areas with the highest need for health care providers and offered team-based care to provide individualized coordinated care plans, with primary care support in addition to mental health care. Telehealth collaborative care increases the community’s access to evidence-based practice and trained specialties that may otherwise be unavailable within a feasible distance from home, fills a gap for necessary treatment, and has outcomes that are comparable to in-person care.6 Further practice outreach and partnerships will help expand patient care presence in all 16 Maryland counties designated as whole-county mental health shortage areas. When considering access to care and utilization of services, the results of this project demonstrate the critical importance of identifying and prioritizing ways to reach patients living in all areas of greatest need for mental health care services. Increasing access to care improves patient outcomes. The results reveal various implications for practice in both the primary care and psychiatric mental health settings. The addition of telehealth mental health care support for patients can expand clinic specialty care to underserved areas within the state, addressing geographic barriers and health care shortage areas. This model also supports opportunities to improve the continuum of care for patients in need of outpatient follow-up appointments after receiving acute inpatient treatment. Patients with a history of mental health conditions coupled with prior visits to the emergency department are at increased risk for both moderate and frequent hospitalizations for any medical condition.12 Providers can collaborate with the integrated primary care mental health telemedicine practice to help patients establish care for mental health services. Same-day mental health care appointments, flexible hours, and more frequent check-ins through telehealth may prevent loss to followup for patients during a vulnerable time after hospital discharge; this is especially critical for areas in the state that have limited mental health care providers. Waite et al evaluated patient satisfaction, quality of care, and treatment outcomes with results showing an increased preference for telehealth after exposure to virtual appointments.13 Table 2 Metropolitan Versus Nonmetropolitan Population Frequency Percent Metropolitan 272 98.9 Nonmetropolitan 3 1.1 Total 275 100 Table 3 Designated Mental Health Shortage Areas Maryland Frequency Percentage None of the county is a shortage area 8 2.9 Part of the county is a shortage area 223 81.1 Whole county is a shortage area 44 16 Total 275 100 Figure 1. Patient distribution by county. A. Fenton et al. / The Journal for Nurse Practitioners 20 (2024) 104965 3 Additionally, patient utilization of telehealth care was significant. Higher appointment attendance rates, higher frequency of health visits, and higher rates of treatment completion were reported for patients engaged in telehealth mental health programs.13 The practice currently serves patients in 11 of the 16 Maryland counties (68.7%) reporting the highest need for mental health care services due to a shortage of providers, and the data reveal gaps in care that can be addressed with targeted expansion to reach remaining 31.3% of counties in need according to HRSA. To better support these health care shortage areas, partnerships with local community organizations should be prioritized to increase awareness of available telehealth mental health services for the patients within the communities. Limitations There were several limitations to the project. First, our sample was limited to only 1 practice within 1 state. Additional data collection and analysis should include other practices as well as additional states serviced within the same practice. Therefore, findings are not generalizable to the entire population. Second, because the focus of this project was on location of services, other demographics such as insurance, ethnicity, and socioeconomic status were not included in the analysis. Future research may be needed to Figure 2. Patients Within Health Care Professional Shortage Areas Regions Image adapted from data.HRSA.gov, 2023 (https://www.ruralhealthinfo.org/charts/7?state¼MD). Table 4 Reach of Clinic Services in Maryland Counties Serviced by Clinic Percentage Total number of counties 24 16 66.7 Whole MH shortage county 16 11 68.7 MH ¼ mental health. Table 5 Patients in counties with >20% Black/African American population Location Frequency % Black/African American (US Census Bureau, 2022a ) Anne Arundel County 127 19.8% Baltimore City 18 61.6% Baltimore County 8 31.9% Calvert County 10 14.2% Caroline County 2 13.8% Carroll County 5 4.4% Cecil County 1 8.4% Charles County 2 53.3% Fredrick County 6 12.1% Harford County 4 16% Howard County 8 21% Montgomery County 51 20% Prince Georges County 19 64.1% Queen Annes County 6 6.2% Saint Mary.¼’s County 7 15.6% Talbot County 1 12.8% Total in Maryland 106 38.5% a https://www.ruralhealthinfo.org/charts/22?state¼MD. 4 A. Fenton et al. / The Journal for Nurse Practitioners 20 (2024) 104965 explore the relationship between telehealth, insurance, and access to care. Third, the focus of this project was limited to mental health telemedicine visits. Because primary care is also provided at this practice, it would be prudent also to evaluate the access to statewide care provided through the clinic’s telehealth platform. Conclusions The findings of this project show opportunities to help address health disparities by improving accessibility to trained mental health care providers, reducing barriers to critical health treatment services, and improving health outcomes. An NP-led integrated mental health telemedicine practice can increase access to statewide care through telehealth, compared with in-person only visits. Outpatient health care services are optimized with decreased burden and cost of transportation for patients, improved patient experience, and opportunities to improve population health with efficient connections to telehealth mental health care. Additional evaluation of practice quality improvements and prioritization of care in areas of high need will be beneficial. Health equity considerations to address include availability of Internet access and technology in the communities served and identification of affordable and accessible resources for patients who would benefit from mental health telehealth services. Community-based partnerships, practice incentives to increase access in shortage areas, and provider cross-training will help address gaps in care. Through increased access to high-quality mental health care, this model of care can help advance health equity and improve health outcomes. CRediT Author Statement Ashley Fenton: Writing e review & editing, Writing e original draft, Supervision, Methodology, Formal analysis, Data curation, Conceptualization. Katherine G. Humphrey: Writing e review & editing, Writing e original draft, Formal analysis, Conceptualization. Colleen King Goode: Writing e review & editing, Formal analysis. Lourdes Celius: Writing e review & editing, Writing e original draft, Conceptualization. Amanda Rohde: Writing e review & editing, Writing e original draft, Conceptualization. Declaration of Competing Interest In compliance with standard ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. Funding No external or internal funding was provided. References 1. Kaiser Family Foundation. Mental healthcare professional shortage areas (HPSAs) 2022. https://www.kff.org/other/state-indicator/mental-health-care-healthprofessional-shortage-areas-hpsas/?currentTimeframe¼0&selectedRows¼% 7B%22states%22:%7B%22maryland%22:%7B%7D,%22virginia%22:%7B%7 D%7D%7D&sortModel¼%7B%22colId%22:%22Location%22,%22sort%22:% 22asc%22%7D 2. Bureau of Health Workforce. Behavioral health workforce projections 2017. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/ bh-workforce-projections-fact-sheet.pdf 3. Maryland State Data Center. Urban and rural areas 2020. https://planning. maryland.gov/MSDC/Pages/census/Census2020/2020-Census-urban_rural. aspx 4. Health Resources and Services Administration. Health workforce shortage areas 2023. https://data.hrsa.gov/topics/health-workforce/shortage-areas 5. McBain RK, Schuler MS, Qureshi N, et al. Expansion of telehealth availability for mental health care after state-level policy changes from 2019 to 2022. JAMA Network Open. 2023;6(6):e2318045. https://doi.org/10.1001/jamanetwork open.2023.18045 6. Substance Abuse and Mental Health Services Administration. Telehealth for the treatment of serious mental illness and substance use disorders. SAMHSA Publication No. PEP21-06-02-001. Rockville, MD: National Mental Health and Substance Use Policy Laboratory; 2021. 7. Cummings JR, Allen L, Clennon J, Ji X, Druss BG. Geographic access to specialty mental health care across high- and low-income us communities. JAMA Psychiatry. 2017;74(5):476-484. https://doi.org/10.1001/jamapsychiatry.2017. 0303 8. Talarico I. The use of telehealth to increase mental health services access and promote medication adherence in rural locations. J Am Assoc Nurse Pract. 2021;33(11):1074-1079. https://doi.org/10.1097/JXX.0000000000000495 9. Reay RE, Looi JC, Keightley P. Telehealth mental health services during COVID19: summary of evidence and clinical practice. Australasian Psychiatry. 2020;28(5):514-516. 10. Jacobs JC, Blonigen DM, Kimerling R, et al. Increasing mental health care access, continuity, and efficiency for veterans through telehealth with video tablets. Psychiatr Serv. 2019;70(11):976-982. https://doi.org/10.1176/appi.ps .201900104 11. Fenton A, Humphrey KG, Celius L, et al. Integration of primary care services into a nurse practitioner telemental health practice: review of literature to guide best practices. J Nurse Pract. 2023;19(8):104719. 12. Penzenstadler L, Gentil L, Grenier G, Khazaal Y, Fleury M. Risk factors of hospitalization for any medical condition among patients with prior emergency department visits for mental health conditions. BMC Psychiatry. 2000;20:431. https://doi.org/10.1186/s12888-020-02835-2 13. Waite MR, Diab S, Adefisoye J. Virtual behavioral health treatment satisfaction and outcomes across time. J Patient Cent Res Rev. 2022;9(3):158-165. https:// doi.org/10.17294/2330-0698.1918 Ashley Fenton, DNP, PMHNP-BC, FNP-BC, LCSW-C, is an assistant professor at Johns Hopkins University School of Nursing, Baltimore, MD, and is affiliated with the The Collective NP Clinic, Gambrills, MD; she can be contacted at contacted at a..2@jhu. edu. Katherine G. Humphrey, DNP, FNP-BC, is faculty, Colleen King Goode, DNP, FNPBC, is an assistant professor, and Lourdes Celius, DNP, FNP-C, is clinical faculty at Johns Hopkins University School of Nursing, Baltimore, MD; they are also affiliated with The Collective NP Clinic, Gambrills, MD. Amanda Rohde, DNP, AGPCNP-BC, CNE, TCP-BC, is an assistant professor at Johns Hopkins University School of Nursing, Baltimore, MD

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