Integrating behavioral health into primary care strengthens scope of NP practice

By Courtney Mitchell 

“She’d been my patient for 15 years, and there wasn’t anything that would have led me to believe she was depressed.” 

In Sharpe’s primary care clinic, she’d just started screening all patients for anxiety, depression and substance use disorder. Though the patient had always appeared upbeat and engaging, her high scores on the depression screening told Sharpe something about the patient that she had never thought to bring up herself. 

“You have some people who are never going to reveal things, unless you ask. I was glad I asked. She broke down in tears. She was drinking more, going through a really tough time, and she was suffering with depression,” says Sharpe. 

They were able to talk about the depression and alcohol use and create a plan. The patient’s mental health became part of the conversation for later visits.  

“She was able to solve this problem,” she says. 

When Sharpe was the sole provider at Sylvan Community Health Center in Snow Camp, NC, her patients would often present with both physical health issues and mental health concerns of varying complexities. She’d turn to her UNC School of Nursing colleague, Victoria Soltis-Jarrett, a psychiatric mental health nurse practitioner, for advice.  

They called these “curbside consults,” a term for a brief discussion about behavioral health or substance use disorders in primary care. What did these patients need, and could Sharpe manage these conditions – depression, anxiety, substance use disorders and more – in house, without referring them to another clinic? 

“Victoria really helped me, and together we’d take that deeper dive into understanding what I saw going on with the mental health of my patients,” says Sharpe who joined the nursing school in 2013 to open Snow Camp’s community health center. She is now Team Lead for Education in the School’s Behavioral Health Integration (BHI) traineeship, which prepares primary care NPs to meet mental and behavioral health needs in rural community health centers in the state.  

“As I began learning more about what could be done for patients with behavioral health needs within primary care, and then teaching it, I became even more passionate about it,” says Sharpe.  

Soltis-Jarrett, PhD, PMHCNS-BC, PMHNP-BC, FAANP, FAAN, Carol Morde Ross Distinguished Professor, is BHI’s project director and principal investigator. She says she first worked closely with Sharpe when she got a grant to embed psychiatric mental health nurse practitioners (PMHNPs) into outpatient health care settings like Sylvan. 

“What we were both seeing wasn’t a new problem: patients with mental health issues were being referred from primary care directly into a mental health system that was already struggling and overwhelmed. They just would end up a waiting list,” says Soltis-Jarrett. “So together, we were using the TANDEM model that is built on 30 years of my work.” 

That model is TANDEM3-PC (Together All Nurses Deliver Extraordinary Methods, Meaning and Measures in Primary Care), where NPs and PMHNPs work together, in tandem, to provide care to individuals in primary care and avoid referral to specialty settings for behavioral health needs. 

The two recognized that, within a program like BHI, they could teach this model to the School’s NPs who would enter practices in rural and underserved areas, bringing the concept of the curbside consult into the classroom and improving the quality of lives for patients all over North Carolina. 

Integrating care for whole health 

The BHI traineeship teaches the integration of assessment and treatment for behavioral health and substance use disorders into primary care with a focus on providing culturally sensitive whole health care to individuals and families in rural and underserved regions of the state. The goal is to recruit, educate, train and provide financial support to primary care NPs, establishing a pipeline for NPs to fill the gaps in a shrinking rural healthcare workforce. 

Now in its fourth year, BHI is offered to the School’s FNP and AGNP (adult gerontology) students in both the Master of Science in Nursing and Doctor of Nursing Practice programs who have a desire to practice in rural areas.  

Addressing depression and anxiety in primary care is a step toward destigmatizing mental illness, says Leonora Tisdale, BSN, RN, who is a DNP student in the BHI traineeship. Learning to screen for these conditions and properly interview patients in ways that address their whole health, and understanding medication nuances, strengthens the level of care available in areas where individuals can face a scarcity of mental health resources. 

“A unique aspect of being a nurse practitioner is the ability to address the health of someone as a whole, to meet them where they are and build relationships as you see someone over time. If you, as a patient, go to your primary care provider, and they screen you for depression, they can identify with you whether you might need meds, or some talk therapy, instead of feeling dismissed by a provider who says they don’t do that.” 

Depression can be overwhelming, she says, and hearing that you have to be referred out can be demotivating, especially if you will have to travel for more care. If a patient knows it may be hard to find help, they’re less likely to follow up. It’s also an opportunity to teach patients the connection between their physical and mental health and instill a sense of trust.  

“We know that sometimes manifestations of physical ailments are likely to stem from psychological distress. In primary care, we can point out to a patient, that mysterious stomach ailment you have, it might be related to your mental health, and get them screened,” says Tisdale. 

Building awareness within a community about the importance of mental health is exactly what Soltis-Jarrett had in mind. When she and Sharpe were working with patients at Sylvan, word traveled fast that, in Snow Camp, there was a place you could receive treatment for depression and anxiety as well as substance use disorders.  

“Seeing self-referral, through the grapevine, was a real ‘a-ha’ moment for us,” says Soltis-Jarrett. “They were telling each other, ‘they will talk to you there.’ Imagine, so many of them were depressed for a decade and nothing helped them, but we were able to help. They went back to work, their diabetes got better, their hypertension was under control, all because we were not only able to prescribe the appropriate medication, but we could help them find therapy.” 

Strengthening a workforce 

A number of grants in the past five years have led to this moment for Soltis-Jarrett and her team, where their goal of preparing FNPs, AGNPs and PMHNPs, to meet the behavioral health needs of North Carolina is experiencing a groundswell of measurable impact.  

In 2019, Soltis-Jarrett received $6.2 million from the Health Resources and Service Administration (HRSA) to expand her current work in BHI within primary care and to create the NP residency in partnership with Goshen Medical Center, the largest Federally Qualified Health Center in rural North Carolina. The first cohort of eight residents started this year in Goshen clinics. (In July 2021, the School will introduce a PMHNP residency with a new academic-practice partnership.) 

Karley Bastien, MSN, FNP, a nurse practitioner resident at a clinic in Faison, NC, had rotated through Goshen clinics as a NP student in the BHI traineeship, where she quickly felt called to practice rural health. Her patients were often uninsured, experiencing a variety of hardships and facing complex health problems. She knew a similar setting was where she could work hard, improve her skills, and have the opportunity to serve patients who needed her skills the most, would be in her future.   

She sought the NP residency program to receive the extra training she felt she needed to work to the best of her ability. Federally Qualified Health Centers can lack resources to support new graduates, and the residency program provides clinical, academic and emotional support. 

“The need to be able to manage basic mental health concerns in primary care is big,” says Bastien. “As an NP resident, when I interview a patient, and I’m not exactly sure what their diagnosis is, or how to adjust their medications or initiate certain medication, I bring that case back for advice. Is it something that I’m going to be comfortable prescribing for, or is it something that really should be referred out to psychiatry? I’m getting more advanced skills not only within the realm of primary care, but with their support and consultation, I can go beyond that.” 

One of Bastien’s patients has Bipolar II disorder that has remained stable under her care, she says, “because I have this great support on how to care for this patient. I am doing more with mental health than I ever thought that I would be able to in primary care, and I’m growing as a nurse practitioner because of it.” 

When Bastien completes her residency, she’ll stay on in Faison, where she’ll continue to be part of the BHI traineeship’s ripple effect to support other NPs. Beyond building a nurse partitioner workforce to treat these issues, the School is building a mentorship base, says Sharpe.  

“We’re producing some incredible health care providers, and we’re growing preceptors and mentors, too,” says Sharpe. “To have NPs out there, they need support, because they have complex patients and don’t have the option of easing in slowly. You get thrown into the deep end of the pool. In BHI traineeship and in the NP residency, we’re also training these NPs to support the ones who come next.” 

Tisdale says it’s something she’s been able to see from the start, the modeling of the kind of provider she wants to be.  

“The leaders of this program are so clearly passionate about the welfare of their patients as the foremost goal of being a provider,” says Tisdale. “And that’s refreshing. I mean, that’s how it should be, right?” 

This article appeared in the Fall 2021 issue of Carolina Nursing magazine.