Presented by: Cynthia Harrison, BSN, MS, RN Rowena Gillo, LCSW

1. Development of Health Career Pathway for CaliforniaPsychiatric Mental Health Nurse PractitionerClinical Nurse Specialist Presented by: Cynthia Harrison, BSN, MS, RN Rowena Gillo, LCSW Mission College Pacific Clinics September 17, 2013

2. CALIFORNIA’S POPULATION DIVERSITY • California is one of the most racially and ethnically diverse states in the country, and is projected to become even more so in the coming decades • Population projections suggest that by the year 2030, 66% of the state’s population will be non-White • Over the next 25 years the state’s population is projected to grow by roughly 12 million people. Over 90% of this population growth is projected to occur among California’s Latino (75%) and Asian (17%) populations. • These dramatic changes underscore the need to address the lack of racial and ethnic diversity among key mental health professions in the state Source: Lok, V. and Chapman, S., UCSF Center for the Health Professions, The Mental Health Workforce in California: Trends in Employment, Education, and Diversity

3. CALIFORNIA’S BEHAVIORAL HEALTH WORKFORCE CHALLENGES • A prolonged shortage of psychiatrists. Nearly 30 percent of physicians are over 60 years old - a higher percentage than any other state* • Increased demand for integrated services that are Multi-Culturally Responsive. Specifically, a need for more culturally responsive and competent provider practices to engage underserved populations+ • Increased demand for services that are Affordable and Accessible to the Community • An educational system that lacks capacity to provide the Behavioral Health workforce needed to meet future demands • Healthcare nursing professionals are not adequately prepared to work in community-based MH/Behavioral Health settings Source: * California Health Care Foundation, CA Health Care Almanac Regional Markets http://www.chcf.org/almanac/regional-markets +CIMH, Jarvis and Freeman Briefing Paper 4: Workforce Issues Today and in the Future Workforce Implications of Increased Demand for Mental Health and Substance Use Service, June 2012

4. REGISTERED NURSES (RNs) • The shortage of Registered Nurses (RNs) experienced in California is well documented • According to the “United States Registered Nurse Workforce Report Card and Shortage Forecast” published in the January 2012 issue of the American Journal of Medical Quality, a shortage of  registered nurses is projected to spread across the country between 2009 and 2030.  In this state-by-state analysis, the authors forecast the RN shortage to be most intense in the South and the West.* • There has been aggressive effort to expand the state’s capacity to train new RNs • Since 2000 the number of new licenses issued each year has approximately doubled • The California Board of Registered Nursing continues to offer a certificate to practice as a certified psychiatric/mental health nurse • As of May 2012, there are 330,943 RNs with active licenses in California+ Sources: *American Association of Colleges of Nursing , Nursing Shortage Facts Sheet http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage +OSHPD Healthcare Workforce Clearinghouse, Registered Nurses, June 2012

5. ADVANCED PRACTICE REGISTERED NURSES (APRNs) • Advanced practice registered nurses (APRNs) : • Are nurses who have received education beyond their initial registered nurse (RN) education to work in a specialized role in the delivery of health care services, preparing him/her for one of the four recognized APRN roles • Are prepared in master’s-degree programs that often carry a credit load equivalent to doctoral degrees in the other health professions. • Has acquired advanced clinical knowledge and skills preparing him/her to provide direct care to patients, as well as a component of indirect care • Has clinical experience of sufficient depth and breadth to reflect the intended license • Four types of APRNs in the United States: • Certified Nurse Midwives (CNM) • Certified Registered Nurse Anesthetists (CRNA) • Clinical Nurse Specialists (CNS): bring specialized knowledge about the patient population, the environment, and disease management • Nurse Practitioners (NP): focus on primary care activities • Sources: California Board of Registered Nursing http://www.rn.ca.gov/pdfs/forms/survey2010cns.pdf • National Council for State Boards of APRN Advisory Committee, APRN Joint Dialogue Group Report, July 7, 2008

6. CNS/PMHNP CERTIFICATION REQUIREMENTS • Certification requires 500 hours of specified clinical experience and a master’s degree • Certified psychiatric/mental health nurse requirements include education at the master’s level (the degree must be directly related to mental health) and two years of supervised clinical experience providing mental health counseling services • Certification for Psychiatric-Mental Health Nursing and is not required for practice in the state • As of February 2011: • there were 2,865 CNS and they are not widely distributed across the state • there were 14,623 NP • there were 334 certified psychiatric/mental health nurses • NPs tend to work in counties that have low health care provider per population ratios • Northern California has higher NP certifications per population ratios compared to Southern California • The annual number of certifications issued has declined steadily since 1985

7. SCOPE OF PRACTICE: CLINICAL NURSE SPECIALIST • CNS certification focuses on areas of clinical specialization in nursing practice, and provides direct patient care. The most commonly reported areas of primary focus are adult/gerontology (22.4%), and acute/critical care (20.4%) • CNSs influence care outcomes by providing expert consultation for nursing staffs and by implementing improvements in health care delivery systems • CNS education focuses on how clinical care is affected by the patient’s personal and family characteristics, the environment, the nursing personnel who provide care, and the health system organization • While the CNS certification began as a mental health specialization, only 16.3 percent of CNSs reported psychiatrics/mental health as one of their clinical areas of specialization • CNSs can not furnish or order medications • The CNS certification has been discontinued in California primarily due to low student enrollment rates in CNS programs. The Clinical Nurse Leader (CNL) has replaced the CNS. • The CNL is an advanced clinician with education at the master's degree level, but not prepared as an advanced practice registered nurse as the APRN is currently defined. The CNL is a Generalist that oversees the lateral integration of care for a distinct group of patients and may actively provide direct patient care in complex situations * Source: California Board of Registered Nursing http://www.rn.ca.gov/pdfs/forms/survey2010cns.pdf *American Association of Colleges of Nursing http://www.aacn.nche.edu/cnl/frequently-asked-questions

8. SCOPE OF PRACTICE: PSYCHIATRIC-MENTAL HEALTH NURSE PRACTITIONER The Psychiatric-Mental Health Nurse Practitioner (PMHNP) is:* • An advanced practice registered nurse who focuses clinical practice on individuals, families, or populations across the life span at risk for developing and/or having a diagnosis of psychiatric disorders or mental health problems • A specialist who provides primary mental health care to patients seeking mental health services in a wide range of settings • Primary mental health care provided by the psychiatric-mental health nurse practitioner involves the continuous and comprehensive services necessary for the promotion of optimal mental health, prevention and treatment of psychiatric disorders and health maintenance. This includes the assessment, diagnosis, and management of mental health problems and psychiatric disorders. • The psychiatric-mental health nurse practitioner is a provider of direct mental health care services • The scope of practice of NPs in California is regulated by the state. California requires that NPs work under standardized procedures developed through collaboration among administrators and health professionals, including physicians and surgeons and nurses.+ • NPs may obtain additional certification from the BRN to furnish or order drugs or devices under standardized procedures developed with the supervising physician and surgeon. • In October 2010, the Institute of Medicine recommended full independent practice for Nurse Practitioners: “Nurses should practice to the full extent of their education and training”.+ Source:* American Association of Colleges of Nursing http://www.aacn.nche.edu/leading-initiatives/education-resources/PMHNP.pdf +Institute of Medicine, The Future of Nursing http://www.iom.edu/nursing

9. SENATE BILL 491 (SB 491) FEBRUARY 2013: SENATE BILL 491 WAS INTRODUCED TO THE CALIFORNIA LEGISLATURE Section 1, Senate Bill 491 California Legislature found and declared the following: • (b) Nurse practitioners will play an especially important part in the implementation of the federal Patient Protection and Affordable Care Act, which will bring an estimated five million more Californians into the health care delivery system, because they will provide for greater access to primary care services in all areas of the state. This is particularly true for patients in medically underserved urban and rural communities. • (d) Nurse practitioners will assist in addressing the primary care provider shortage by removing delays in the provision of care that are created when dated regulations require a physician’s signature or protocol before a patient can initiate treatment or obtain diagnostic tests that are ordered by a nurse practitioner. Proposed Law: SB 491 would expand the scope of practice for nurse practitioners, by deleting the requirement that nurse practitioners provide certain services only under the supervision of a physician or surgeon. • Specifically, the bill would expand the scope of practice of a nurse practitioner by authorizing a nurse practitioner to provide the following services independently: - Order durable medical equipment - Certify disability claims - Manage patients’ health status - Make changes to a plan of treatment for certain home health patients - Assess patients, synthesize data, and apply the principals of health care; - Analyze data to identify the nature of a health problem and implement appropriate treatment - Examine a patient and establish a medical diagnosis - Order prescription drugs - Refer patients to other health care providers - Delegate duties to medical assistants - Order hospice care - Maintain malpractice insurance. Source: California Legislative Information, SB 491 http://leginfo.legislature.ca.gov/faces/billVersionsCompareClient.xhtml

10. SB 491 AMENDED AUGUST 2013: SENATE 491 AMENDED AS FOLLOWS: • Existing law, the Nursing Practice Act, provides for the licensure and regulation of nurse practitioners by the Board of Registered Nursing. Existing law authorizes the implementation of standardized procedures that authorize a nurse practitioner to perform certain acts, including, among others, ordering durable medical equipment, and, in consultation with a physician and surgeon, approving, signing, modifying, or adding to a plan of treatment or plan for an individual receiving home health services or personal care services. A violation of those provisions is a crime. • SB 491 Supporters withdrew their support. Supporters believed SB 491 would increase Californians' access to care, reduce paperwork burdens, and promote high-quality primary health care. • SB 491 Opposition believed this bill compromised patient safety. The physician groups emphasize collaborative care provided by a physician-led team is ideal. They indicate requirements for standardized protocols and physician review are in place to ensure that patient care includes the involvement and oversight of a physician who is substantially more qualified and experienced to oversee patient care, both in depth and in years of education and training, than a nurse practitioner practicing alone. Source: California Legislative Information, SB 491 http://leginfo.legislature.ca.gov/faces/billVersionsCompareClient.xhtml

11. FUTURE NEED • According to the 2012 Technical Assistance Collaborative (TAC) and the Human Services Research Institute (HSRI) California Mental Health and Substance Use System Needs Assessment : • Approximately 4.3 million Californians currently without health coverage will now be eligible for health insurance in 2014. Many of these newly insured will need mental health and substance use services. • Estimated 200,000 persons in increased demand for mental health services. Estimated 115,000 persons in increased demand for substance use services. • New enrollees can be expected to be more disabled and more expensive to serve than the Medi-Cal non-disabled population, but substantially less disabled and less expensive than the current Medi-Cal disabled population • Much of the heavy lifting for healthcare reform implementation will occur at the state and even county level • While experts interviewed indicated that it was “difficult” to estimate specific numbers of PNPs and CNSs needed upon the Patient Protection and Affordable Care Act (PPACA) implementation, the changing demands of this nation's complex healthcare environment require the highest level of scientific knowledge and practice expertise to assure quality patient outcomes* Source: *California Institute for Mental Health, Jarvis Brief Papers http://www.cimh.org/LinkClick.aspx?fileticket=qYRw198CQAo%3D&tabid=36

12. FUTURE NEED According to the National Association of Community Health Centers report Building a Primary Workforce for the 21st Century: • Health centers are increasingly challenged to meet their primary care workforce need. Health centers currently need 1,843 primary care providers, inclusive of physicians, nurse practitioners, physician assistants, and certified nurse midwives. On top of this need, they are 1,384 nurses short • To reach 30 million patients by 2015, health centers need at least an additional 15,585 primary care providers, just over one third of whom are non-physician primary health care providers. Health centers also will need another 11,553 to 14,397 nurses • To reach 69 million patients, health centers will need at least 51,299 more primary care • providers over the current number, as well as an additional 37,981 to 44,522 nurses Source: *National Association of Community Health Centers http://www.nachc.com/client/documents/ACCESS%20Transformed%20full%20report.PDF

13. CURRENT STATE KEY ISSUES AFFECTING FUTURE NEED • California’s RN workforce is growing, but aging as the average age of working RNs is 47.2, and nearly half of the workforce is over 50 years old • Over 40 percent of RNs are non-White, but the Latino population remains underrepresented • Men continue to be underrepresented, making up only 14 % of California’s RN workforce • Despite the large increase in nursing school enrollments, demand for education still far exceeds the supply DRAFT

14. CURRENT STATE KEY ISSUES AFFECTING FUTURE NEED • Patient Protection and Affordable Care Act (PPACA) is expected to both increase demand for health care services resulting from expanded insurance coverage • Potential for NPs to become needed providers, but barriers included the scarcity of post-graduate specialty programs and the prevailing culture of physician specialty practices • The role of NPs has been somewhat limited due to the lack of legislation expanding their scope beyond the traditional scope of practice for RNs

15. CURRENT STATE KEY ISSUES AFFECTING FUTURE NEED • Experts recommend focusing attention on the educational requirements, career ladders, and professional recognition of CNAs, HHAs, and MAs • Lack of qualified faculty to train new nurses and the key barrier is lower compensation for academic teaching than positions in clinical areas • LPTs and LVNs could potentially be a large source of future RNs • Investing in LPT/LVN-to-RN education programs offers an opportunity to increase the diversity of the RN workforce as the LVN workforce is more diverse than the RN workforce DRAFT

16. CALIFORNIA’S NURSING WORKFORCE DIVERSITY According to data from the 2008 National Sample Survey of Registered Nurses (NSSRN): • Nurses from minority backgrounds represented 16.8% of the registered nurse (RN) workforce. Considering racial/ethnic backgrounds, the RN population is comprised of 5.4% African American; 3.6% Hispanic; 5.8% Asian/Native Hawaiian; 0.3% American Indian/Alaskan Native; and 1.7% multi-racial nurses.  • Though men only comprise 6.2% of the nation’s nursing workforce, this percentage has climbed steadily since the NSSRN was first conducted in 1980. The number of men in nursing has increased from 45,060 nurses in 1980 to 189,916 nurses in 2008. • The ability of California Registered Nurses (RNs) to provide culturally competent care to Californians is associated with the language skills and diversity of the RN workforce. Diversity in the RN profession reflects progress in providing opportunities for young people to obtain postsecondary education and enter the health professions. + California’s Nursing Workforce also includes: • Psychiatric Technicians • Vocational Nurses Sources: *American Association of Colleges of Nursing http://www.aacn.nche.edu/media-relations/fact-sheets/enhancing-diversity +CA Board of Registered Nursing, UCSF The Diversity of California’s Registered Nursing Workforce http://www.rn.ca.gov/pdfs/schools/diversity.pdf

17. PSYCHIATRIC TECHNICIAN AND VOCATIONAL NURSE • Psychiatric Technicians (PTs) and Vocational Nurses (VNs) are licensed by the California Board of Vocational Nurses and Psychiatric Technicians (BVNPT) • PTs: • Entry-level practitioners who provide care for mentally disordered or developmentally disabled clients under the director of services • Limited number of PT educational programs in California (11 Community Colleges; 5 Private Universities) • No pathway for PTs to advance to RN • As of September 2012, there were 9,855 PTs with active licenses in California • VNs: • Vocational nursing is an entry-level practitioner responsible for basic nursing care under the direction of a physician or registered nurse • Vocational nurses programs, colleges and universities (42 Community Colleges; 123 Private Universities; 27 Adult Educational Programs; 5 Regional Occupational Programs) • Has increased dramatically, more than tripling between 2000 and 2010+ • As of August 2012, there were 87,514 VNs with active licenses in California Sources: California Department of Consumer Affairs Board of Vocational Nurses and Psychiatric Technicians Public Master File, September 2012 Revision 2/26/2013 via OSHPD Healthcare Workforce Clearinghouse, Psychiatric Technicians, November 2012 / Vocational Nurses, September 2012

18. PACIFIC CLINICS NURSING BRIDGE MODEL • In 2011, Pacific Clinics created its Nursing Bridge Program, a community-based collaborative model* • Pacific Clinics Nursing Bridge Program is a multi-tiered non-sequential community based collaborative model, that creates a seamless higher education & career pathways for Licensed Psychiatric Technicians (LPTs) and Licensed Vocational Nurses (LVNs); builds learning opportunities for RN and APRN students within community-based MH/BH settings; and educates, trains, and advances the behavioral health competencies of the nursing students and faculty. • (1) Higher education and career pathway for LPTs and LVNs to become Advanced Practice Nurses (e.g., Nurse Practitioner), beginning with the completion of their RN/ADN degree. LPT/LVN RN/ADN BSN MSN/FNP DNP An additional pathway is a fast-track into advanced practice nursing non-nursing Bachelor-level persons, including MH professionals (LCSW, LMFT, LPCC, Psychologists), bypassing the BSN degree. BA/BS ELM/FNP DNP • (2) Clinical and Transition-to-Practice Residency rotations for newly grad RN’s, master and doctoral-prepared nursing students specifically placed within various community-based mental/behavioral health organizations. • (3) Advance the behavioral health competencies of the nursing profession via community education and training, including faculty leadership development and student simulation lab learning. • Pacific Clinics Nursing Bridge Program: • Provides a creative and collaborative solution to the critical shortage of Psychiatry • Increases nursing workforce diversity • Increases community accessibility • Creates a skilled and advanced practice nursing workforce trained to provide multi-culturally responsive community-based integrated BH services • Cost-effective • Time efficient • Staff Recruitment and Retention: “Growing our Own” • Duplicatable Model *All rights, title and interest to this Nursing Bridge Program Community-Based Collaborative Model belongs to Pacific Clinics and shall not be duplicated in any manner whatsoever without the expressed written consent of Pacific Clinics.

19. IMPLICATIONS OF SB 491:ROLE AND SCOPE OF PSYCHIATRIC NURSE PRACTITIONERS IN INTEGRATED MH AND HEALTHCARE SYSTEM DELIVERY • Experts interviewed believe SB 491 will re-surface once California experiences the full impact of PPACA implementation • Use of terminology in SB 491 may have added to Opposition’s concerns: “Prescribing” vs. “Furnishing”; “Consultation” vs. “Supervision • Collaborative consulting relationship between NPs and Psychiatrists can amicably co-exist to benefit both parties: • Develop formal relationship between NPs and Psychiatrists that imbeds a set of Protocols where NPs can practice independently to the extent of their education and training • Both parties agree at what point in treatment is beyond the NP’s scope & training, whereby the NP refers the treatment to the Consulting Psychiatrist • NP pays psychiatrist to serve as a Consulting Physician (e.g., Glide Health Services in San Francisco) DRAFT

20. ROLES OF NPs v. PSYCHIATRISTS IN NEW MODELS OF INTEGRATED MH AND HEALTHCARE DELIVERY • Psychiatrists are traditionally educated and trained in the Medical Model: Disease-oriented and Disease Management • Nurse Practitioners are educated and trained in a Holistic Wellness and Recovery Model: Prevention-oriented, and Strategies to teach in educating the consumer/client within a holistic approach – easier for NPs to embrace the concept of integrated mental health and healthcare delivery • Build practice models that include community-based MH/Behavioral Healthcare organizations as Primary Care Providers • NPs can supervise/preceptor bachelor, master and doctoral-level nursing students during internship & residency rotations at community-based MH/BH clinics (e.g., Pacific Clinics Nursing Bridge model) • NPs can oversee triage functions within Peer Health Navigation programs • Develop collaborative partnerships between Community-based MH/BH and HMOs to serve new PPACA enrollees. NPs can expand access in providing services to new enrollees, especially those residing in underserved communities • Increase Nurse-managed community-based MH/BH clinics with Psychiatrist as paid Consultants (e.g., Glide Health Services in San Francisco) DRAFT

21. The Doctor of Nursing Practice (DNP) • In a 2005 report titled Advancing the Nation's Health Needs: NIH Research Training Programs, the National Academy of Sciences called for nursing to develop a non-research clinical doctorate to prepare expert practitioners who can also serve as clinical faculty • The Doctor of Nursing Practice is designed for nurses seeking a terminal degree in nursing practice and offers an alternative to research-focused doctoral programs. DNP-prepared nurses are well-equipped to fully implement the science developed by nurse researchers prepared in PhD, DNSc, and other research-focused nursing doctorates. • DNP curricula build on traditional master's programs by providing education in evidence-based practice, quality improvement, and systems leadership, among other key areas • Schools nationwide that have initiated the DNP are reporting sizable and competitive student enrollment. Employers are quickly recognizing the unique contribution these expert nurses are making in the practice arena, and the demand for DNP-prepared nurses continues to grow. • DNPs can contribute to the increase of direct practice nursing personnel, and nursing faculty with additional preparation that adds pedagogical skills to their base of clinical practice • Within an integrated model of MH/Behavioral Healthcare delivery system, DNPs can be wisely utilized to practice, to teach, and to provide Executive Practice Leadership in various behavioral health and healthcare arenas Source: American Association of Colleges of Nursing, The Doctor of Nursing Practice Facts Sheet http://www.aacn.nche.edu/media-relations/fact-sheets/dnp

22. TARGET GROUPS • Bachelor-Level non-nursing health professionals (Psychologists, LCSWs, LMFTs, LPCCs) • Middle School, High School, Community College Students, Undergraduates, and Graduate students • Incumbent Workers • Career Changers • Displaced Workers • Immigrant Health Professionals • Licensed Psychiatric Technicians • Licensed Vocational Nurses • Underserved ethnic groups • Under-represented groups • People with lived experiences • Veterans

23. THANK YOU TO OUR SOURCES CONSULTED: Subject Matter Experts BRANDMAN UNIVERSITYCALIFORNIA INSTITUTE OF NURSING AND HEALTHCARE (CINHC) Kathleen McCoy, DNSc APRN-BC FAANP Judith Berg, RN, MS, CHE Carolyn Orlowski, MSN, RN Director of Psychiatric & MH DNP Program President/Executive Director Southern California Regional Coordinator Deloras Jones, RN, MS (Retired) Executive Director NATIONAL UNIVERSITYCALIFORNIA STATE UNIVERSITY, LOS ANGELES Gloria McNeal, Ph.D., MSN Beatrice Yorker, J.D., R.N., M.S., F.A.A.N. Lori Judson, PhD, RN, NP, Professor Dean, School of Health & Human Services Dean, College of Health and Human Services Associate Director, School of Nursing Jovita Ezrihim, Clinical Assistant Professor Cythnia Hughes, Ed.D., PNP, Professor Nnenna Weathers, Ph.D., RN, FNP School of Health & Human Services Director, School of Nursing Assistant Professor, School of Nursing SADDLEBACK COLLEGE PACIFIC CLINICS Donna Rane-Szostak, EdD, MSN, CNE Susan Mandel, Ph.D. Peter Lopez, LPT Viola Gaffaney, LMFT, RN Dean, Health Sciences & Human Services President/CEO Division Director Division Director Tamera Rice, MSN, RN, CNE Wendy Wang, MPA Sharon Duris, LPT Samantha James-Perez, LPT Assist. Dean, Health Science & Human Svc Corp. Director, Public Policy Division Director Victoria Broussard, LPT Brian Gomez, LPT UNIVERSITY OF CALIFORNIA, SAN FRANCISCO Bethany Phoenix, RN, Ph.D., CNS, FAAN Vice Chair, and HS Clinical Professor, School of Nursing American River College Butte College College of the Canyons Golden West College Grossmont College Mission College Solano Community College Rio Hondo College San Jose State University UCSF Center For The Health Professions

24. SOURCES CONSULTED: Literature Review • American Association of Colleges of Nursing http://www.aacn.nche.edu • American Nurses Association, Nursing World: Advanced Practice Nurses http://www.nursingworld.org/EspeciallyForYou/AdvancedPracticeNurses • California Action Coalition http://www.CAactioncoalition.org • California Association for Nurse Practitioners http://www.canpweb.org • California Board of Behavioral Sciences http://www.bbs.ca.gov/pdf/mhsa/resource/workforce/mhsa_workforce_information.pdf • California Board of Registered Nursing http://www.rn.ca.gov • California Institute for Nursing & Health Care (CINHC) http://www.cinhc.org • California Health Care Foundation, CA Health Care Almanac Regional Markets http://www.chcf.org/almanac/regional-markets • California Institute for Mental Health, Jarvis Brief Papers http://www.cimh.org/LinkClick.aspx?fileticket=qYRw198CQAo%3D&tabid=36 • Institute of Medicine, The Future of Nursing http://www.iom.edu/nursing • Legislative Analyst’s Office, Streamlining Nursing Education Pathways http://www.lao.ca.gov/reports/2011/edu/nursing_ed/Streamlining_Nursing_Ed_Pathways.pdf • Lok, V. and Chapman, S., UCSF Center for the Health Professions, The Mental Health Workforce in California: Trends in Employment, Education, and Diversity (2009) http://www.futurehealth.ucsf.edu/Content/29/2009-03_The_Mental_Health_Workforce_in_California_Trends_in_Employment_Education_and_Diversity.pdf • Lok, V. , Christian, S. and Chapman, S., UCSF Center for the Health Professions, Restructuring California’s Mental Health Workforce: Interviews with Key Stakeholders (2009) http://www.thecenter.ucsf.edu/Content/29/2009-03_Restructuring_Californias_Mental_Health_Workforce_Interviews_With_Key_Stakeholders.pdf • National Association of Community Health Centers, Building a Primary Workforce for the 21st Century http://www.nachc.com/client/documents/ACCESS%20Transformed%20full%20report.PDF • National Council for State Boards of APRN Advisory Committee, APRN Joint Dialogue Group Report, July 7, 2008 https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf • OSHPD Healthcare Workforce Clearinghouse, Psychiatric Technicians, November 2012 http://www.oshpd.ca.gov/HWDD/HWC/FactSheets/PsychiatricTechnicians.pdf Vocational Nurses, September 2012 http://www.oshpd.ca.gov/HWDD/HWC/FactSheets/VocationalNurses.pdf • Raines, F. and Taglaireni, E. , “Career Pathways in Nursing: Entry Points and Academic Progression”, The Online Journal of Issues in Nursing, Vol 13 No 3 Manuscript 1 http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No3Sept08/CareerEntryPoints.aspx

25. NPs NOT ABLE TO PRACTICE INDEPENDENTLY

26. LIMITED INTERNSHIP, PRACTICUM & RESIDENCY SITES

27. LICENSED PSYCHIATRIC TECHNICIANS (LPTs):DIVERSE MH-TRAINED NURSING POOL LACKS CAREER PATHWAY

28. COST OF EDUCATION AND FACULTYLACK OF FINANCIAL INCENTIVES OR AWARENESS

29. LACK OF FACULTY DEVELOPMENT & SUPERVISION

30. CROSS CUTTING:LACK OF AWARENESS ON MH/BH CAREER PATHWAY

31. CROSS CUTTING: STIGMA

32. TOP 4 PATHWAY BARRIERS & RECOMMENDATIONS ADDRESS MHSA CORE VALUES & WET GOALS

33. Coordinated Health Workforce Pathway Pre-Training Health Professions Education Workforce K-12 Education Target Groups: Bachelor-Level non-nursing health professionals (Psychologists, LCSWs, LMFTs, LPCCs) Middle School, High School, Community College Students, Undergraduates, and Graduate students Incumbent Workers Career Changers Displaced Workers Immigrant Health Professionals Licensed Psychiatric Technicians Licensed Vocational Nurses Underserved ethnic groups Under-represented groups People with lived experiences Veterans Lack of clear employment opportunities for mental health/behavioral health NP and CNS Lack of clear employment opportunities for mental health/behavioral health NP and CNS Reduced number of career counselors Lack of financial incentives Health Professions Training Program Access Academic Preparation & Entry Support Financial & Logistic Feasibility Training Program Retention Financing & Support Systems Career Awareness Assessment Internships Hiring & Orientation Retention & Advancement Cultural Sensitivity and Responsiveness Lack of career pathway for LPTs Stigma about mental illness and substance use Quality, Diverse Health Workforce Impacted nursing school programs RN/ADN and BSN. LPTs low priority Lack of awareness about mental health/ behavioral health and substance use careers and access to different educational programs Cost of education a financial hardship; not affordable Limited residency practicum sites in community-based settings Lack of faculty development Lack of faculty Adapted from the coordinated health career pathway developed by Jeff Oxendine.

34. THANK YOU! Questions ??? DRAFT