The increasing need for psychiatry services in medically underserved communities has proven to be challenging for health care systems. Caring for this population is complex and can be overwhelming for the inexperienced provider. Proper utilization of psychiatric and mental health nurse practitioners in this setting can expedite meeting the mental health needs of the community. A postgraduate fellowship program that provides supervision and additional training specific to community psychiatry facilitates the transition from novice provider to experienced clinician while aiming to improve retention rates. In this Open Forum, the authors outline the structure of a federally qualified health center's Community Psychiatry Nurse Practitioner Fellowship.

Back to table of contents Previous article Next article From the ExpertsFull AccessPsychiatrists Can Take Steps to Enhance Value of ServicesWesley Sowers, M.D., Jules M. Ranz, M.D.Wesley SowersSearch for more papers by this author, M.D., Jules M. RanzSearch for more papers by this author, M.D.Published Online:14 Oct 2020https://doi.org/10.1176/appi.pn.2020.10b25As consumers of goods and services, we would like to get the highest quality product at the lowest possible price. We commonly think of this as getting a good bargain or getting the “biggest bang for our buck.” Another way to express the quotient of quality/cost is value. Well-run businesses attempt to produce products that will satisfy customers at an affordable price. In competitive markets, where there is moderate demand, this will generally assure success. However, if the demand for a product is much greater than the supply, prices will likely increase, and quality may be diminished. Such is the case in the U.S. health care system.The United States has the largest economy in the world and also spends more of its gross domestic product on health care (now nearly 20%) than any other developed nation, by at least a factor of two. If our results were twice as good as these other countries, then we might consider the spending worthwhile. Similarly, we would likely feel justified in buying an expensive luxury car if that car performed very well. But if that car performed poorly and required frequent repairs, we would feel deceived and betrayed. In almost all respects, the U.S. system (which is really a fragmented conglomerate of systems) performs much worse than the systems of other developed countries. What created this system that clearly lacks good value and what sustains it? How can we fix it?Unfortunately, American medicine has paid insufficient attention to value, as medical practice has become more complex and expensive. As an example, it is only recently that greater attention has been paid to the interaction of physical and emotional health. While American medicine has excelled in delivering high-technology life sustaining procedures and devices, it has failed to promote a healthy population, which requires a strong emphasis on emotional health. The shape of the American system is sculpted primarily by free-enterprise market forces rather than any centralized or unifying planning. As a result, the quality of services is quite variable, and we are ill equipped to respond to public health emergencies, as the current pandemic has clearly illustrated.We can do better. Over the course of time, many factors have led to fragmentation, waste, and unnecessary expense. Many attempts have been made to circumvent these problems, but they have not amounted to much more than Band-Aids on gaping wounds. There is a glaring need to think about real solutions as we confront the major challenges that lie ahead. Our dysfunctional and costly systems of care will not be sufficient to meet them. Systems must change to provide more appropriate incentives for efficiency, reduction of administrative waste, an emphasis on prevention and population health, and the incorporation of technology. There are other unique opportunities to increase the overall value of services, such as harm-reduction strategies, correctional reform, workplace health, end-of-life care, and even working with individuals and communities to alleviate the corrosive effects of climate change.While system change would deliver the most significant and uniform results, such outcomes are also the most difficult to achieve. There are significant ways that individual psychiatrists and the profession can alter their practices to enhance the value of services provided. Changes in psychiatrists’ scope of practice, including their relationship with other professionals, can have a positive impact. An expansion of the workforce, and psychiatrists’ capacity to provide consultations and supervision that are appropriately reimbursed, are required. Improving the diagnostic system, prescribing practices, and the psychiatrist’s role in advocacy and leadership are items that will potentially contribute to enhancing the value of services.A vision for a comprehensive and effective health system that prioritizes emotional and population health is sorely needed but is only the first step toward change. Short- and longer-term strategies for incremental transformation have to be part of the plan. These strategies must recognize that meaningful change will be accomplished only through collaboration with varied stakeholders at all levels of society. For readers who are interested in delving deeper into these issues, a new book produced by the Mental Health Services Committee of the Group for the Advancement of Psychiatry (GAP) titled Seeking Value: Balancing Cost and Quality in Psychiatric Care is now available from APA Publishing. The book provides an analysis of the factors that have helped shape the current system and prevent it from meeting acceptable standards for community health. In addition, it explores the relationship of emotional health to overall population health. Looking beyond the current quagmire of American medicine, a roadmap for change, which will achieve the high value health care system that Americans need, is an urgent priority. This volume will be a compelling and practical read for anyone interested in actively seeking value in American health care. ■Wesley Sowers, M.D., is the director of the Center for Public Service Psychiatry and its Fellowship Program at Western Psychiatric Hospital. He is a past president of the American Association of Community Psychiatrists and has served as co-chair of the Mental Health Services Committee of the Group for the Advancement of Psychiatry (GAP) since 2009.Jules M. Ranz, M.D., is a clinical professor of psychiatry at Columbia University Medical Center and former long-time director of the Public Psychiatry Fellowship of New York State Psychiatric Institute/Columbia University. He has been co-chair of GAP’s Mental Health Services Committee since 2006. They are the co-editors of Seeking Value: Balancing Cost and Quality in Psychiatric Care from APA Publishing. APA members may purchase the book at a discount here. ISSUES NewArchived

OBJECTIVE:This paper aimed to develop a model for understanding the various dimensions of system-based practice (SBP) and determine the extent to which psychiatry residents perform behaviors along these dimensions.METHODS:Sixty-one supervisors from seven psychiatry programs rated resident performance of SBP behaviors using a 60-item instrument. Multi-dimensional scaling and cluster analysis were conducted to determine how the instrument items related to one another and the larger concept of SBP. Average supervisor ratings between clusters were compared to determine resident performance along the identified SBP dimensions.RESULTS:The data supports a model of SBP defined along two dimensions: (1) from micro (patient) to macro (population-based) interventions and (2) from low to high system complexity. Residents were more likely to perform behaviors at the patient level compared to those at the population-based level.CONCLUSIONS:Training in SBP remains predominately focused on the doctor-patient level and not the greater system of health-care delivery.

The goal of this study was to investigate residency training in the four roles of systems-based practice: patient care advocate, team member, information integrator, and resource manager.

During yearly meetings of the recently developed network of 15 public/community psychiatry fellowships, it has been noted that programs are having varying degrees of success with regard to recruitment. To understand factors that impact recruitment, a quality improvement survey of fellows and alumni was conducted. Respondents were asked to rate overall satisfaction with their fellowship training as well as perceived benefits and obstacles to participating in a fellowship program, and impact on their careers. A total of 155 (57%) fellows and alumni responded. Factor analysis was used to condense the variables, and a multiple regression explored factors predicting overall fellowship program satisfaction. Factors that represented perceived benefits had higher means than did factors that represent obstacles. Respondents highly valued the extent to which these fellowships enhanced their careers, with regard to job opportunities, academics, networking and leadership.

The growth of Public Psychiatry Fellowships (PPFs) has reached a new developmental stage, providing a wide array of academic partnerships and educational opportunities in psychiatric leadership and administration. The authors examine the evolution of these programs and illustrate three distinct models.

OBJECTIVE:The aim of this study is to analyze qualitative data collected during field-testing of an instrument to assess psychiatric residents' experiences with systems-based practice (SBP).METHODS:A total of 237 psychiatry residents from 6 levels of training in 12 different psychiatry residency training programs responded to a 60-item instrument measuring their experiences with SBP during residency. Qualitative techniques adapted from content analysis were used to review narrative responses to open-ended questions on the instrument.RESULTS:Certain themes emerged in the residents' answers reflecting their opinions about the opportunities for (and barriers to) performing SBP in their work.CONCLUSIONS:Psychiatric residents express an eagerness for opportunities to learn about and perform SBP but often feel constrained by the lack of resources, teaching, and supervision. Moreover, many residents desire a better understanding of healthcare economics and how to factor cost consideration into clinical care.

Background Behavioral health services involving multiple systems of care are increasingly being provided in community as well as hospital settings. Residents therefore should be familiar with multiple systems and the role of the psychiatrist in these systems. The authors describe a curriculum incorporating principles of systems-based practice (SBP), community psychiatry, and recovery. Methods This curriculum was designed to include lectures, clinical rotations, specialized written/oral presentations, and supervision focused on SBP and recovery principles. Residents also participate in home and site visits for further immersion into the multiple systems that their patients have to navigate. Results The essential elements of this curriculum are the 1) consistent review and emphasis on the four researched-based SBP roles of the psychiatrist; 2) recovery principles of person-centered care and shared decision-making; 3) requirement that residents interact with patients in community and home settings; 4) integration of didactic courses and clinical rotations; and 5) focus on the supervisor/supervisee relationship.

In order to improve recruitment into public/community psychiatry fellowships, a survey was administered to understand psychiatry residents' perception of benefits and obstacles to fellowship training. Using standard statistical methods, the responses of those residents who indicated interest in public/community psychiatry training were compared to those who were not. Residents who were interested in public/community psychiatry fellowships were earlier in their training. These same residents gave higher endorsements to items related to quality, location and flexibility of training program, recommendation of colleagues, opportunities for health policy training and networking as compared to residents who were not interested in pursuing a public/community. Those results attained statistical significance while philosophical approaches including emphasis on recovery and tailoring specific training experiences approached significance. Psychiatric residents appear to start residency training with some interest in public/community psychiatry and this interest can be nurtured if public/community psychiatry is emphasized during training.

A Four Factor Model of Systems-BasedPractices in PsychiatryJules M. Ranz, M.D., Michael Weinberg, Ed.D.Melissa R. Arbuckle, M.D., Ph.D., Joanna Fried, M.D.Anthony Carino, M.D., Hunter L. McQuistion, M.D.Glen Davis, M.D., Donovan Wong, M.D.Sosunmolu O. Shoyinka, M.D.Benjamin Brody, M.D., Kamala D. Sethi, M.D.Anna Skiandos, D.O., Wesley Sowers, M.D.David Stern, M.D., Anne Sullivan, M.D.Michael J. Vergare, M.D.

In response to the expanding public behavioral health care system, a network of 15 public-community psychiatry fellowships has developed over the past six years. The fellowship directors meet yearly to sustain and develop fellowships to recruit and retain psychiatrists in the public sector. This column describes five types of public-academic collaborations on which the fellowships are based. The collaborations focus on structural and fiscal arrangements; recruitment and retention; program evaluation, program research, and policy; primary care integration; and career development. These collaborations serve to train psychiatrists who will play a key role in the rapidly evolving health care system.

A crisis in the behavioral health care workforce has drawn considerable attention from consumers, families, advocates, clinical professionals, and system administrators at local, state, and federal levels in the past decade. Its effects have been felt in the recruitment, retention, and performance of psychiatrists in the public sector, where a focus on biological aspects of illness and efforts to cut costs have made it difficult for public psychiatrists to engage meaningfully in leadership, consultation, prevention, and psychosocial interventions. An array of training opportunities has recently been created to meet the needs of community psychiatrists at various stages of their careers, from psychiatrists just beginning their careers to those who have been working as medical directors for several years. This article describes the development of these initiatives and their impact on public psychiatry in four key areas--training of experienced psychiatrists, ensuring retention of psychiatrists in community programs, providing fellowship training, and creating professional identity and pride. Although these programs constitute only initial steps, opportunities for psychiatrists to obtain advanced training in community psychiatry are much greater now than they were ten years ago. These initiatives will enhance the professional identity of community psychiatrists and provide a solid foundation for future development of public service psychiatry in the behavioral health workforce.

Now in its 29th year, the Public Psychiatry Fellowship of the New York Psychiatric Institute at Columbia Medical Center selects 10 fellows per year for its 1-year program (1). This award-winning fellowship trains future leaders for the public mental health sector. The curriculum (2) employs a combination of a didactic seminar series, management-problem-focused presentations by guest speakers, field trips, and supervision by fellowship faculty to instill the values and skills required for practice and leadership in the public sector. Fellows utilize the framework of the academic curriculum to carry out a series of presentations throughout the year that allow them to organize, implement and evaluate concepts that they learn during the year. The following account, written from bird’s eye view, details one fellow’s day at his field placement in a State Hospital outpatient clinic setting, with the aim of illustrating how the concepts taught by the fellowship find application in day to day practice.

As the oldest, largest, and best known program for training psychiatrists to become public-sector leaders, the Columbia University Public Psychiatry Fellowship (PPF) at New York State Psychiatric Institute has frequently been consulted by other departments of psychiatry planning public and community fellowship programs. PPF's faculty has developed seven core elements for such training programs. The fellowship's longevity and the career paths of its graduates suggest that these core elements represent a best-practices model for fellowship training in public-community psychiatry.