Interview with Leslie Sharpe and Victoria Soltis-Jarrett
June 13, 2018
Interview with Leslie Sharpe and Victoria Soltis-Jarrett
Heather Klusaritz interviewed Leslie Sharpe, RN, MSN, FNP-BC, faculty at UNC-Chapel Hill School of Nursing and Lead Provider at a rural, school-based health care center and Victoria Soltis-Jarrett, PhD, PMHCNS/NP-BC, FAANP, the Carol Morde Ross Distinguished Professor of Psychiatric Mental Health Nursing at UNC-Chapel Hill School of Nursing. Dr. Soltis-Jarrett and Leslie Sharpe have collaborated for many years in a unique partnership to advance nurse-practitioner-led care delivery models of integrated primary care and to train and educate the nursing primary care workforce.
Heather: Thank you for the opportunity to learn more about your IBH work. I’d like to start by asking you to reflect on some of the most critical issues that come up when you try to tackle how to teach learners about the integrated model?
Leslie: One of the major things that we have encountered with the current workforce is a resistance to provide integrated behavioral health that I believe is rooted in a lack of confidence – I think people just don’t feel confident. When you have so many pressures to focus on – diabetes and hypertension and all that – to add in another thing of depression, providers really perceive that this is going to take over the whole visit. So there’s just some reluctance there. For providers that have been out in the field for a long time, there’s the assumption that they know when their patients are depressed. And perhaps they do, but 50% of their patients with depression go undiagnosed in primary care. And the percent of patients with an accurate diagnosis doubled since we started this initiative.
Heather: That’s a remarkable achievement.
Leslie: Yes, and it doesn’t take over my visit. What we are trying to teach our students is when I walk into the room with my patient, I’m looking at the PHQ-9 as I do it, and I don’t look in detail but I’m able to tell if their scores are high or low, and if their scores are high I have to first address that issue to address the rest of their health needs. Otherwise, they’re not going to have the motivation to take care of their diabetes or to quit smoking or do anything else if the depression is so high that they’re barely getting through. A major barrier is the current state of education. The students just don’t get that education in the programs. They’re given a three-hour class, maybe. Until we can learn to integrate this throughout every class, these students aren’t ever going to get how to incorporate or integrate behavioral health into primary care. The students that are at our clinic have gotten to sit in and watch the whole model play out. They are so excited to see what a difference it makes.
Heather: You’ve highlighted a couple of strategies to convince existing providers that this is a model that has value – and for learners, having that experiential learning and witnessing firsthand how well the model can work – but do you have any strategies for the educators? How do we advance training in this space? Have either of you been successful in convincing educational leadership that this is necessary?
Victoria: I’ve been talking about this since I arrived in Chapel Hill, saying “we need to do this” and for a long time I was told it was “ahead of our time.” The strategy that has worked the best for me, to be quite honest, is for me just to do it. If I could tell you the number of primary care offices, how many faculty meetings or leadership members that I tried to convince that this is the future....everyone was always focused on the development of DNP programs. When the RFP came out for the HRSA Advancing Nursing Education Workforce grant – that was the opportunity to just do it. Having Leslie as such a wonderful partner, as well as the other family nurse practitioners at the clinic, has been so valuable to do this work. Now the state government is saying that they are willing to help fund providers in the workforce deliver integrated care, at the same time as we are teaching students. So, the strategy I learned is – you just have to go ahead and do it. When we are presenting at conferences people are coming up to us begging to know more. Actions speak louder than words – that’s my take on the strategy. And leadership will come around to the idea in time.
Leslie: The partnership we have helps others understand the model of care and buy-into integrated care. We have me as the primary care provider and Victoria as the psych mental health nurse practitioner and when we’re giving presentations together, people just “get it”. They understand it better. So we just have to keep disseminating our work to help advance care delivery.
Heather: That’s an interesting strategy, to “just do it” and once you begin to do it you generate the outcomes that you’re able to use to win hearts and minds. I think many providers and educators are hesitant to start without support from leadership. If you didn’t have to take the “just do it” and then convince them with outcomes approach – would there be other strategies to recommend to leadership in educational programs or your respective professional organizations? Are you hearing from leaders who are interested in advancing integrated behavioral health training for advanced nurse practitioners, or is the conversation not there yet? If not, what are the strategies to convince the professional organizations to move on that pathway.
Victoria: I think they’re along that pathway. I think that for the professional organizations, there were no barriers. It is really with the educational systems and the leadership of programs that we need to advance the conversation. Having been asked to provide consultation to another university, and help them do this – that was because the Dean of that school is highly innovative and willing to take risks. Schools may have their own agendas – especially the research focused universities – which inhibit changes in educational models. But nursing is a practice discipline. We need to do research while we are practicing. You can’t go in a laboratory, like basic science, and develop a theory of caring without ever practicing. The model that we are moving and advancing is all about practice. So when you have an innovative leader, you don’t have to do much convincing. Also, our patients are talking. So when you talk about patient-centered care, if you aren’t asking the patients, "what do you think about this?” you’re missing the whole point. One of the tools we are using to gauge this is a quality of life tool, and also we’re going to do some qualitative work with focus groups to talk to patients about their experience. Leslie and I have had so many talks with our patients that have expressed that this integration has “saved their life.” And we’re talking about people facing hunger and severe poverty.
Heather: That’s very motivating. And those patient stories are very valuable for our students to hear and also for education leaders to understand the importance of this work.
Leslie: After our Dean came out to visit the site and expressed excitement, we really began to think about how we can move the integrated way of thinking and providing care into our curriculum, because it is currently being revised anyway. I’m taking over a course on chronic illness, and I can tell you that every lecture will have intricacies of taking care of people with behavioral health issues woven into my classes. I agree with Victoria, we are starting to see some change and momentum. It’s slow, we are sort of mentoring one NP at a time, but there is momentum. We have to continue to build our force of followers and believers who totally get what this is about. Once they start seeing it in practice, it helps – they get it.
Heather: You’re both in an FQHC, but I’m wondering if you could highlight what some of the broader challenges are in the primary care landscape that limit our ability to advance integrated models of care and how you have been successful in overcoming some of those system-level challenges.
Victoria: Since I came to North Carolina, the biggest issue has been, “how do you pay somebody?” And I know our colleagues in social work have been able to do some of that, but it has also varied practice by practice. In January 2018, CMS released billing codes that could be used, and we are in the space now that we are testing new billing codes in the FQHC. The challenge that remains is, we can’t bill two E&M codes on the same day. Policy hasn’t caught up with what we need to do to achieve high-quality care.
Primary care has been the hardest nut to crack. Every primary care site I have been to that has loved the model, asks, “how do we pay for it?” We’re hoping that the data we are collecting will help provide evidence for the value of these models. This is meeting the quadruple aim of healthcare and, at the same time, is containing costs.
Leslie: We’re in a two-room trailer with just two patient rooms, so only one provider can really work at a time, though we squeeze in when Victoria is there. But, compared to the other FQHCs, our numbers have jumped significantly because when Victoria is there seeing patients, we can see 8 patients in four hours. It’s really amazing. My visits are 20 minutes and I’m bringing Victoria into them. We are the only clinic, and the smallest clinic, that is meeting their numbers every month.
Heather: Do you have colleagues around the country who have been able to get around the billing issues? Are there leaders in the field or innovative training programs that you want to highlight?
Victoria: I belong to an organization that is multi-disciplinary – and the models that are most successful right now are the ones that have Licensed Marriage and Family Therapists. They have been able to break through some of the private insurance barriers and get paid. But the barrier for them is they can’t bill Medicare/Medicaid, only LCSWs can. So they are working very hard to try and develop policy to get paid for themselves. I also think there is a movement that we can educate primary care nurse practitioners and not forget about the fact that they are the force that works in the rural and remote areas – not just big metropolitan areas where family medicine docs are taking the lead on doing models. We’re talking about the rural areas and how that is where the future for nurse practitioners is going to be and currently is, but there really just hasn’t been the education component so they are kind of lost.
A group of us wrote a position paper about the role of nurses in behavioral health integration and we laid out the different roles (LCPCs, health psychologists). As you know, 92% of the behavioral health workforce does not prescribe. I’m not saying that prescribing is the end all, be all. But if the more complex or severe patients are coming into primary care to be treated, it's great if they can have that brief intervention, but it’s not always working. What Leslie and I are able to show is that it is the ability to deal with all of their health problems, you know, looking at the medications they are on.
One of the things that is lacking is differential diagnosis. We’ve had patients that are very under-resourced and low-income thinking that they are facing a seizure diagnosis, but we learned that this person had actually been withdrawing from benzodiazepines and was having seizures from that. That’s the other piece. Being able to do it at the grassroots level, diagnosing, treating, and educating them.
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