California to Widen Pipeline of Psychiatric Nurse Practitioners

Even before the pandemic, California faced a serious shortage of mental health professionals, especially in rural areas.

This article was first published on Friday, May 1, 2020 in Kaiser Health News.

By Lori Basheda

Jane Gunter, a nurse practitioner in Tuolumne County, California, has long wanted to specialize in mental health so she can treat patients who have anxiety, depression and more complicated mental illnesses.

Her county, a rural outpost in the Sierra Nevada foothills with a population of about 54,000, has only five psychiatrists — "a huge shortage," she said.

But Gunter, 56, wasn't about to quit her job at the Me-Wuk Indian Health Center in Tuolumne and relocate to some distant campus for two years to get certified as a psychiatric nurse practitioner.

Then, in February, she learned that the University of California was launching a new program to provide that certification online in just one year. She fired off her application, and last month she received an acceptance letter.

"Sometimes I think, 'What are you doing?'" Gunter said, referring to the online classes that will take over her nights and weekends once the program starts. "But I care about the community."

The online certification program, conducted jointly by the nursing schools at the University of California-San Francisco, UCLA and UC-Davis, was scheduled to start in the fall, but it has been postponed until January because the on-site clinical hours required as part of the training are not possible during the COVID-19 shutdown.

Despite the delay, the potential expansion of psychiatric care is opportune given the expected increase in mental health problems due to the social isolation and financial stress stemming from the pandemic.

The need for more mental health nurses is about to be bigger than ever, said E. Alison Holman, a health psychologist at UC-Irvine who studies emotional responses to collective trauma.

"We now have 30 million Americans who have lost their jobs, who have no income — and how are they going to pay rent? How are they going to buy food?" Holman said. "And then you have to stay home. This event is rolling out like a long, chronic stressor."

Even before the current crisis, California faced a serious shortage of mental health professionals, especially in rural areas. California's psychiatrists and psychologists are approaching retirement age in large numbers, and fewer medical students are choosing psychiatry.

A UCSF study projected that the state would have 41% fewer psychiatrists than needed by 2028. More than half of Californians with mental illness receive no treatment, according to a February 2019 report by the California Future Health Workforce Commission.

UC's online mental health nurse practitioner program is one of the solutions recommended by the commission, a statewide, multisector panel that created a master plan to address the Golden State's shortage of health care workers.

The program is expected to put 300 more mental health NPs into California communities, particularly rural ones, over the next five years. Applicants such as Gunter, who live in underserved rural areas, will be given priority in the hope that they will stay in their communities upon completion of the training, said Deborah Johnson, a UCSF nursing professor who is co-director of the program.

Forty spots are available for the class that begins in January, and not all have been filled yet, Johnson said. Applications are being accepted until June 1, and 65 additional spots will open in fall 2021 and each fall thereafter for three more years, she said.

The UC system received a $1.5 million grant from the California Health Care Foundation to develop, design and launch it. But tuition is expected to make it self-sustaining. (Kaiser Health News, which produces California Healthline, is an editorially independent publication of the foundation.)

Applicants for the new program must already be advanced practice nurses, which means they hold either a master's degree or doctorate in nursing. More than 27,000 NPs now practice in California, but only 1,200 are certified to treat psychiatric patients.

Three hundred more psychiatric NPs won't completely fill the growing mental health care need, but they are expected to treat nearly 400,000 patients over a five-year period.

Though the online program means working nurses won't have to leave their jobs and their lives to relocate, they will still face challenges.

For one thing, their certification will require 500 hours of supervised clinical training with patients in hospitals, jails or schools. And some applicants live in communities where such opportunities may not be available, which could require them to commute long distances to meet the requirement.

Another challenge is that, even after nurse practitioners are certified, state law requires they find a medical doctor to supervise them. Havilyn Kern, a school nurse in Nevada City, California, quit her job two years ago so she could spend three days a week at UCSF — 155 miles away — to train as a psychiatric nurse practitioner.

She graduates in June, so the new online program is too late for her. Kern, who plans to work in her own community, hopes she will find a psychiatrist in the Bay Area willing to tele-supervise her.

"It shouldn't have to be this way," said program co-director Johnson. "California is so archaic. It's the most restrictive state in the western portion of the country."

Twenty-eight states plus Washington, D.C., allow nurse practitioners to work autonomously. Santa Rosa Assembly member Jim Wood, a Democrat, has introduced a bill, AB-890, that would allow California NPs to practice without doctor supervision. It passed the Assembly in January and is pending in the Senate.

"If AB 890 passes, it will certainly help fill the loss of specialty physicians such as psychiatrists everywhere, including in underserved areas," Wood said.

But that's a big "if."

California's powerful doctors' lobby, which has repeatedly scuttled similar legislation, is aggressively fighting it again. They argue that letting NPs order tests and prescribe medications independently would "dilute care."

Doctors also have a financial incentive to keep things the way they are. It restricts competition, and they bill NPs between $5,000 and $15,000 a year to review their charts and prescriptions every few months, according to a report by the California Health Care Foundation and UCSF.

Johnson suggested it is time for a change.

"We are the workhorses," she said. "Oh, my God, there is so much need. This new program could not come at a more important time."

This KHN story first published on California Healthline, a service of the California Health Care Foundation.