A Practice Model to Integrate Mental Health Care at an Outpatient Burn Clinic

Background: The Center for Disease Control and Prevention (CDC) reports that more than 350,000 individuals sought medical treatment for burn injuries in 2020. Over half of those individuals will experience a mental health disorder within one year. Despite the known link between mental health disorders and their impact on patient clinical outcomes, evidence suggests that only fifty percent of burn patients will receive mental health screening or support. Mental health integration has been highly studied, modeled, and successfully implemented in primary care settings. This project aimed to identify and assess the clinical need for integrated mental health in the outpatient burn setting and then to develop and propose a psychiatric nurse practitioner-led model to address those needs. Local Problem: The University of Utah Burn Center is the only American Burn Association (ABA) accredited burn center in a five-state region capable of Level 1 Trauma services; the outpatient burn clinic serves over 4,000 patients yearly. To address the mental health needs of burn patients, the outpatient burn clinic follows the current standard of embedded psychological support using a Licensed Clinical Social Worker (LCSW) as needed to initiate referrals to community psychiatry services. This current model lacks timely, comprehensive mental health delivery. Methods: In this needs assessment/program development project, the mental health clinical gap was assessed by identifying current clinical practices in an outpatient burn clinic associated with a large academic health center. The current clinical practices were compared to those used in a second burn unit structured similarly. A literature review was conducted to identify evidence-based best practice recommendations for addressing mental health in general outpatient clinics, burn outpatient clinics, and the general burn patient population. Project data then guided the development of a psychiatric nurse practitioner-led evidence-based care model for mental health integration. An executive summary proposed the model to key healthcare partners for feedback. The provided response was incorporated into the care model resulting in a strategic plan for mental health integration at a local burn center. Results: Current practices to address mental health at a local outpatient burn clinic include utilizing LCSW screenings, standardized questionnaire screenings, and referral to psychiatric specialty. A review of the literature and ABA recommendations shows the need to address mental health in burn patients, with no clear specific guidelines. The synthesized result of gathered data is a psychiatric nurse practitioner-led evidence-based care model for mental health integration. Feedback on the care model showed a high willingness to implement and feasibility when expanded to include the inpatient service. Conclusion: There is clear evidence to support the need to address mental health in the burn population. Utilizing the psychiatric nurse practitioner to integrate mental health into the burn center can improve patient outcomes, generate cost savings, and may be more effective than traditional care models.

1 A Practice Model to Integrate Mental Health Care at an Outpatient Burn Clinic Alissa K. Harris, Kristen Quinn, Deborah Morgan College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 23, 2023 2 Abstract Background: The Center for Disease Control and Prevention (CDC) reports that more than 350,000 individuals sought medical treatment for burn injuries in 2020. Over half of those individuals will experience a mental health disorder within one year. Despite the known link between mental health disorders and their impact on patient clinical outcomes, evidence suggests that only fifty percent of burn patients will receive mental health screening or support. Mental health integration has been highly studied, modeled, and successfully implemented in primary care settings. This project aimed to identify and assess the clinical need for integrated mental health in the outpatient burn setting and then to develop and propose a psychiatric nurse practitioner-led model to address those needs. Local Problem: The University of Utah Burn Center is the only American Burn Association (ABA) accredited burn center in a five-state region capable of Level 1 Trauma services; the outpatient burn clinic serves over 4,000 patients yearly. To address the mental health needs of burn patients, the outpatient burn clinic follows the current standard of embedded psychological support using a Licensed Clinical Social Worker (LCSW) as needed to initiate referrals to community psychiatry services. This current model lacks timely, comprehensive mental health delivery. Methods: In this needs assessment/program development project, the mental health clinical gap was assessed by identifying current clinical practices in an outpatient burn clinic associated with a large academic health center. The current clinical practices were compared to those used in a second burn unit structured similarly. A literature review was conducted to identify evidence-based best practice recommendations for addressing mental health in general outpatient clinics, burn outpatient clinics, and the general burn patient population. Project data then guided the development of a psychiatric nurse practitioner-led evidence-based care model for mental health integration. An executive summary proposed the model to key healthcare partners for feedback. The provided response was incorporated into the care model resulting in a strategic plan for mental health integration at a local burn center. 3 Results: Current practices to address mental health at a local outpatient burn clinic include utilizing LCSW screenings, standardized questionnaire screenings, and referral to psychiatric specialty. A review of the literature and ABA recommendations shows the need to address mental health in burn patients, with no clear specific guidelines. The synthesized result of gathered data is a psychiatric nurse practitioner-led evidence-based care model for mental health integration. Feedback on the care model showed a high willingness to implement and feasibility when expanded to include the inpatient service. Conclusion: There is clear evidence to support the need to address mental health in the burn population. Utilizing the psychiatric nurse practitioner to integrate mental health into the burn center can improve patient outcomes, generate cost savings, and may be more effective than traditional care models. Keywords: burn, burn center, mental health, integration, psychiatric nurse practitioner 4 A Practice Model to Integrate Mental Health Care at an Outpatient Burn Clinic Problem Description In 2020 the Center for Disease Control reported that more than 350,00 individuals sought medical treatment for burn injuries. As many as 50% of all burn patients will experience a mental health disorder after injury (Cleary et al., 2018). Burn patients' development of a mental health disorder is associated with poor clinical outcomes. Despite the high prevalence of mental health disorders, only one-fifth of burn patients receive a psychiatric consultation, and of those patients who receive a consultation, as little as 25% receive recommended treatment (Mahendraraj et al., 2016; Palmu et al., n.d.). Locally, the University of Utah Hospital includes the only American Burn Association (ABA) verified Burn Center in a five-state region. The ABA is a governing body whose verification holds the center to a rigorous review program with standards for personnel qualifications, facility resources, organizational structure, and medical care services to ensure the best care is offered to their patients (University of Utah, 2021). The standard care model for addressing mental health in an outpatient specialty clinic utilizes screenings for identification and relies on the referral network for mental health treatment. It is estimated that over 60% of rural Americans live in a federally designated mental health shortage area (Weiner, 2022). The western region of the United States, including Utah, has the lowest supply of mental health providers per capita (Andrilla et al., 2018). The American Psychological Association (APA) found 69% of psychologists had no openings for new patients, and more than 40% have wait lists longer than 10 patients (APA, 2022). According to Jeremias (2022) this shortage is worse in Utah whose mental health was ranked 48th of the 50 states and District of Columbia in both illness prevalence and access to mental health care. The shortage of 5 mental health providers limits the feasibility of the standard model, delays treatment, and increases the patient burden. Available Knowledge Historically, the emotional needs of burn patients were an unfortunate casualty of the focus on survival. As modern medicine improves the survival rate of burn patients, healthcare providers must integrate psychological and psychiatric support into the care team and can no longer consider it secondary (Vlastelica, 2014). As burn mortality has decreased, the research focus has shifted to assisting the burn survivor in recovering from physical injury and thriving in all aspects of health, mental well-being, and social participation (Carmean et al., 2019). It is well established that burn injuries can have significant impacts on mental health. Research studies have consistently shown that individuals who experience burn injuries are at an increased risk of developing mental health disorders such as anxiety, traumatic stress reactions, behavioral problems, and post-traumatic stress disorder (PTSD) (Cleary et al., 2018). For instance, a literature review conducted by Bakker et al. (2013) found that child anxiety, traumatic stress reactions, and behavioral problems were considerably prevalent (2529%) after burn injury. Similarly, Dahl et al. (2016) reported that the prevalence of PTSD was as high as 50% in adult burn patients three months post-discharge. Moreover, Logsetty et al. (2016) utilized national burn registry data and discovered that burn patients have an increased prevalence of pre-injury depression (16.6% v 7.8%; p=0.0005) and substance use disorders (8.9% v 3.2%, p=0.001) when compared to control groups. These are only a few examples of many, suggesting that individuals who have experienced a burn injury may require mental health interventions, and healthcare providers should be aware of the potential mental health impacts of burn injuries to provide appropriate support and treatment. 6 Although patients with major burns are expected to be at risk for mental health disorders, even minor injuries can cause significant psychological distress and psychiatric symptoms. It is not injury severity that predicts the development of a mental health condition (Cleary et al., 2018; Herndon, 2018). Pathophysiological changes, including inflammation, nutritional deficits inherent to burn injury and wound healing pain, itching, stress during acute treatment, alcohol and drug use, family dynamics, and many other factors contribute to the complex etiology of psychiatric problems such as sleep disorders, depression, PTSD, and anxiety (Cleary et al., 2018; Herndon, 2018). Many normal psychological processes of coping, grief, trauma, and adjustment occur concurrently with, and as part of, the physiological responses to massive injury. The body's physiological response mechanisms can exacerbate the psychological responses to the burn. Stress not only mediates the process of wound healing, but burn pathophysiology also includes the release of inflammatory mediators and stress hormones, changes in metabolism, and gastrointestinal function, which may result in heightened levels of anxiety and stress, with a decreased ability to manage and cope during the acute phase of injury (O'Brien, 2018). Many clinical syndromes, such as delirium, acute stress, acute psychosis, suicidality, and pain, need treatment prior to surgical intervention of burn injury. At the same time, treating disorders such as posttraumatic stress disorder, depression, and adjustment disorders aid in improving long-term outcomes (Ilechukwu, 2002). O'Brien (2018) found that outpatient psychological support directly affected burn patients' adherence and engagement in rehabilitation treatment, highlighting the vital role of psychological support in the outpatient burn clinic. The expertise and skills needed to treat and manage burn patients' complex psychological needs make mental health professionals a critical part of the collaborative care team (Herndon, 2018). 7 Preexisting psychiatric disorders are common in burn patients and frequently contribute to the etiology of injury. The prevalence of preinjury mental health diagnoses is estimated between 28-75% (Patterson et al., 2003). Burn injuries often result from preventable causes associated with mood disorders, psychoses, cognitive disorders, and substance use disorders (Ilechukwu, 2002). Furthermore, a mental health condition before injury can complicate treatment and rehabilitation, leading to more extended hospital stays, higher complications, and increased morbidity (Cleary et al., 2018). Screening, assessing, and treating mental health in burn patients with increased risk of psychopathology and complex ongoing care needs is not always feasible within the traditional consultation model (Erdoğan & Delibaş, 2020). In the standard model, psychiatric consultations tend to follow the course of acute hospital-based burn treatment, compared to the course of the mental disorder and response to treatment. Deferring psychological assessment at initial presentation, as the burn injury takes priority, may explain this atypical pattern (Palmu et al., n.d.). The University of Colorado Health Hospital burn center began screening patients for acute stress disorder (ASD) and PTSD in 2016 after ABA verification recommended better screening tools. In 2017 a poster presentation of the ASD/PTSD screening data at the ABA annual meeting revealed that relatively few burn centers have implemented screening procedures, despite medical literature that indicates the incidence of PTSD in burn patients is as high as 45% (T. Smith, 2018). According to Smith (2018), even nationally recognized medical care that the burn center provides might not meet all patient needs. The Sumner M. Redstone burn center, located within Massachusetts General Hospital, is one of the few burn centers in the country with embedded psychiatry working in a collaborative 8 care model. In order to address the mental health needs of their burn patients, the Sumner M. Redstone burn center provides evaluation and early intervention within all locations of the hospital setting, including the emergency department, acute inpatient, and outpatient settings (Psychiatry Service at the Burn Center, n.d.). A pilot study implemented a 14-session manualized treatment protocol based on cognitive behavior therapy (CBT) to understand better the feasibility, acceptability, and preliminary efficacy of a treatment protocol aimed at addressing PTSD, depression, coping, and community reintegration among adult burn survivors. Findings included mean PTSD scores decreasing by 36% post-treatment showing promise in treating PTSD. Findings from this study support the idea of integrating mental health for early intervention and treatment and that symptoms should not be dismissed as an unavoidable consequence of injury (Cukor et al., 2015). The APA clinical practice guidelines for the treatment of adults with PTSD reports strong evidence for psychotherapy intervention, as well as conditional evidence for the inclusion of pharmacotherapies such as fluoxetine and sertraline (APA, 2017). Further, the APA clinical practice guidelines for many individual mental health disorders such as depression, anxiety, bipolar disorder, and psychosis include strong evidence for pharmacological intervention alongside psychological intervention. The standard model of embedded psychology support with external psychiatric referral may delay evidence based treatment when compared to a model utilizing the psychiatric nurse practitioner. Rationale The Collaborative Care Model, based on Wagner's chronic care model, is an evidencebased approach to healthcare that has been shown to reduce disparities in health care based on social determinants of health (Stewart et al., 2018). Collaborative mental health within the 9 primary care setting is effective, cost-efficient, patient-centered, and improves provider satisfaction (Stewart et al., 2018). According to (World Health Organization [WHO], 2022), integrating mental health into health programs for specific physical diseases or populations has also been shown to be feasible and cost-effective in improving patients' mental and physical outcomes. The WHO urges increased attention in access to quality and effective treatment for all mental health disorders, and reports that people with comorbidities who receive support via integrated care models are more likely to adhere to medical and mental health intervention, and experience better quality of life (WHO), 2022). A predictive established model with integrative mental health would address social determinants of health by increasing access to timely mental health care and decreasing the burdensome delay associated with referrals, consults, and care coordination within the standard model. Utilizing Psychiatric Mental Health Nurse Practitioners (PMHNP) to fulfill the psychiatric role in the Collaborative Care Model can improve early identification and treatment for individuals needing mental health care, has been shown to give higher quantity, and generate cost savings (Emerson, 2019). The American Nurses Association (ANA) Code of Ethics outlines and guides nurses to recognize and develop skills to be vital leaders in the delivery and design of care, providing further evidence for utilizing a psychiatric nurse practitioner (M. A. Smith, 2017). Research also shows that Nurse practitioners enhance relationships with all health team members (Wei et al., 2020). Numerous studies conclude that nurse practitioners are effective clinicians in many care domains, including availability, acceptance, satisfaction, cost, and clinical outcomes (Wand et al., 2006). Nurse practitioners adopt the holistic nursing model and bring this to their practice. They identify and develop a nursing perspective to apply in new areas of care, identify and comment on current issues, participate in research, and demonstrate the 10 implementation of theory-based practice to other nurses. This unique approach allows nurse practitioners to avoid simply repeating or replacing work but rather complement other healthcare approaches (Klein, 2009) While all members of the burn treatment team can recognize the effects of psychological stress on physical recovery, the psychiatric nurse practitioner is able to manage, order and perform both pharmacological and non-pharmacological therapies (Klein, 2009; Wand et al., 2006). A collaborative care model utilizing the PMHNP allows for comprehensive mental health integration by embedding psychiatric care in addition to psychological support. According to Wand et al. (2006) complete integration of mental health can reduce wait times and increase cost-efficiency. The collaborative care model for mental health integration would allow burn patients who return to the outpatient clinic for wound care and medical follow-up access to a psychiatric evaluation, recommendations, and treatment in a familiar environment. Guidelines established by the National Institute for Health and Care Excellence (NICE) state all members of the healthcare team should work together to design integrated care pathways that promote a care delivery model that provides the least intrusive, most effective intervention first, minimize the need for transition between different services or providers and focus on entry with multiple points of access (National Institute for Health and Care Excellence (NICE), 2011). The PMHNP is competent in neuroscience, pharmacokinetics, and coexisting physical conditions and medications, allowing for improved treatment planning, particularly in comorbid burn injuries. The PMHNP can also provide better patient and family education regarding underlying mechanisms, risks, benefits, side effects, and alternative treatment options than their counterparts (Wand et al., 2006). The clinical autonomy of the mental health nurse practitioner combined with an expanded clinical role allows for greater availability of clinical expertise when 11 needed. Surveys of staff from a study in an Australian emergency department with an embedded PMHNP indicate that a readily available expert assessment and hands-on management of mental health presentations contribute to better quality of care and shorter time spent in the emergency department (Wand et al., 2006). The nurse practitioner is also competent in policy and guideline development, as well as research and education related to the collaborative care team. As a fully integrated member of the burn treatment team, the psychiatric nurse practitioner is in a better position to assist and educate staff in recognizing crisis states, normal responses, and appropriate use of non-pharmacological interventions versus psychotropic medications. The presence and collaboration of the PMHNP provide staff with the reassurance that if a psychological problem arises, they will have the appropriate training and resources and assist them (Klein, 2009) Specific Aims The purpose of this project is to develop a PMHNP-led integrative care model for mental health in a large academic ABA verified Burn Center's outpatient burn clinic and evaluate the feasibility, useability, limitations, satisfaction, and willingness of the care team to implement the developed practice model. Methods Context The University of Utah Health system serves a broad demographic population from Utah and five surrounding states, providing care for a referral area encompassing more than 10% of the continental United States (University of Utah, 2021). The University of Utah Hospital houses the only ABA verified burn center within the referral area capable of Level 1 trauma services. The burn center contains a 15-bed inpatient intensive care unit, an operating room (OR) suite, a 12 physical therapy gym, and a comprehensive outpatient clinic with a procedural suite. This project was conducted within the outpatient clinic. The clinic treats newborn to geriatric patients for burn and non-burn-specific injuries and chronic non-healing wounds. The Burn Outpatient clinic provides follow-up care for patients discharged from the Burn Trauma Intensive Care Unit (BTICU) and those from outside referral sources not requiring inpatient admission. The Burn Outpatient Clinic also provides telehealth and consultation services to referring providers within and outside the University of Utah Health. The team involved in this project work includes eight advanced practice clinicians (APCs) consisting of both nurse practitioners (NPs) and physician assistants (PAs), registered nurses (RNs), health care assistants (HCAs), a patient relation specialist (PRS), physical and occupational therapists (PT/OT), a child life specialist (CLS), and a licensed clinical social worker (LCSW). Intervention(s) The first objective was to assess current practices for mental health identification, diagnosis, and treatment. A survey based on standardized questions and expertise working within the burn center was developed, reviewed, and emailed to all members of the Burn Outpatient Clinic to assess healthcare partners' attitudes and beliefs in current practices and perceived clinical gaps. Informal, semi-structured interviews were conducted with key healthcare partners during their regular team meetings, or a one-on-one sit down. The second objective in developing a practice model for mental health integration was to identify evidenced-based best practice recommendations and credentialing requirements for mental health identification, diagnosis, and treatment in the outpatient burn clinic, from the ABA, and at other outpatient burn clinics. Meta-analysis and literature review accomplished the 13 objective of identifying current practice recommendations. Databases CINAHL, PsycINFO, and PubMed were searched using various combinations of search terms "burn," "burn injury," "psychiatry," "psychology," and "recommendations" or "guidelines," etc. The search yielded 1,222 articles, 74 were selected based on relevant population, evidence level I-II and moderate to high quality ratings utilizing an evidence-based research evidence appraisal tool. A search of the ABA's website and informal communication with current members identified any credentialing or guideline requirements set by the ABA. Finally, an informal interview was conducted with the attending psychologist at a similar burn center housed in Harborview Medical Center in Seattle, Washington, to gather data from a comparable burn center. The third objective was to use the information gathered to develop an evidence-based integrative psychiatric co-management care model for implementation at the University of Utah Hospital Burn Outpatient Clinic. An executive summary and PowerPoint presentation were developed, and the care model was proposed to healthcare partners. The final objective was to evaluate healthcare partners' feedback on the care model and apply changes to the model. A survey utilizing open-ended questions about feasibility, useability, limitations, satisfaction, and willingness for implementation was created and emailed to all members of the Burn Outpatient Clinic. This feedback was incorporated into finalizing a strategic plan to adopt the integrative mental health care model. Study of the Intervention(s) While this project did not extend beyond the assessment, design, and proposal of the PMHNP-Led care model, the impact was assessed based on key healthcare partner feedback. 14 Measures The authors developed a twenty-six-question survey (see Appendix A) incorporating open-ended, multiple-choice, and rating scale questions to addressed available mental health resources, screenings, barriers, and clinician comfortability in assessing and treating mental health disorders. The survey was designed to gather information on current practices and policies relating to mental health and attitudes and beliefs towards these practices and identify any perceived care gaps. The survey was then distributed to all outpatient burn clinic staff members regardless of clinical role and address participant comfortability in assessing and treating mental health disorders where applicable. A literature review was conducted to identify evidence-based best practice recommendations for addressing mental health in an outpatient clinic, burn outpatient clinics, and the general burn patient population. Additionally, ABA official guidelines for mental health recommendations were reviewed, and a one-on-one interview with the attending psychologist from a similar academic burn center was conducted to identify an equivalent burn center's care model. Finally, the care model (see Appendix B) and executive summary (see Appendix C) were disseminated to key healthcare partners whose feedback on feasibility, useability, limitations satisfaction, and willingness to implement was reviewed and applied to meet objective four and result in a strategic care model for mental health integration at a local burn center associated with a large academic level 1 trauma center. Analysis A content analysis was conducted on the open-ended survey questions. The responses were read word for word and then coded. Next, the coded data were categorized, organized, and 15 summarized. Detailed notes from feedback and interviews with healthcare partners were taken, and a content analysis was conducted by analyzing the notes line by line to develop common categories and organized into themes. Ethical Considerations The University of Utah's Institutional Review Board determined this project to be nonhuman subject research. No conflicts of interest were identified in this project's development and completion. Results A total of 7 of 76 Outpatient Burn Clinic staff members completed the 26-question survey. 2 were APCs (29%), 2 were RNs (29%), 1 was an LCSW (14%), 1 Clinical Nurse Manager (CNC) (14%), and 1 Health Care Assistant (14%), no MDs responded. All respondents identified LCSW screening for all new patients as the standard of practice for addressing mental health. One nurse reported personally asking each patient they interact with if they are presently "having any emotional or mental health challenges that they would like to discuss today with either social work or the provider." Results showed that current mental health resources available at the Outpatient Burn Clinic include LCSW and psychiatric referral. There is no referral relationship established with University of Utah or local community mental health services. The LCSW prints a list of providers located near the patient before they leave the appointment. There is no standardized or written workflow to ensure patient was able to follow through with the referral. Six (86%) respondents reported no known written policies or procedures addressing mental health, and 1 (14%) reported written policies related to non-accidental trauma and abuse or suspected abuse situations but no known standards for other mental health concerns. 16 Concerning screening frequency, the responses varied significantly. One respondent reported mental health screening at initial visit and every 3-4 weeks after that, while three respondents answered daily/every visit, the remaining three respondents did not answer the question or could not recall how often screenings were implemented. The primary screening tool utilized is the mEval, a generalized screener tool which utilizes patient-reported outcomes. When indicated by the mEval, the LCSW and APCs use additional screenings, such as the PHQ-9, to screen for depression, GAD-7 for anxiety, or PCL-5 for PTSD. When asked, "What percentage of your patients would you identify as needing mental health services?" Five (71%) respondents identified 50% of patients as needing mental health services, 1 (14%) respondent identified 3049% of patients in need, and 1 (14%) respondent identified <10% of patients in need of mental health services. Barriers to accessing mental health care identified included cost (n=5, 71%), transportation (n=5, 71%), stigma (n=3, 43%), access to care difficulties (n=6, 86%), cultural barriers (n=3, 43%), lack of knowledge related to available services (n=6, 86%), large referral region (n=1, 14%) and challenges with follow-up compliance in homeless, severe persistent mental illness, or substance use disorder patients (n=1, 14%). All respondents felt comfortable identifying a mental health disorder as it pertained to their clinical role. Two (100%) of the 2 respondents with prescriptive practice authority reported "somewhat comfortable" in prescribing and managing psychopharmacological medications, despite direct informal interview revealing burn advanced practice providers do not initiate, manage or prescribe any pharmacological treatment for common mental health disorders. The remaining five respondents reported "NA" prescribing did not apply to their clinical role. 2 (29%) respondents reported "average comfortable" educating and discussing mental health 17 diagnosis and treatment with patients and families. In comparison, 1 (14%) respondent reported "very comfortable," and 1 (14%) respondent reported "not at all comfortable" in educating and discussing mental health. Reported responses on current standards of practice included, "I think we do the best with what we have. I wish there was a more robust referral network that would be more commonly accepted by all insurances," "we need more options for patients' mental health," and "it's better than it used to be," showing there has been improvement, and still a need. When asked to identify specific care gaps, respondents identified provider medication knowledge, ability to provide psychotherapy, substance use disorders, and chronic pain management. A literature review addressed objective two. Search results did not find any official local organizational, state, or national guidelines addressing mental health in the burn patient population. International guidelines from the United Kingdom were returned in the search. The British Burn Association and National Network for Burn Care (NNBC) developed burn care standards in 2018. According to the NNBC (2012) burn centers should have psychological care available for patients, their families, and carers. NNBC (2012) also recommends we deliver care in a tiered approach ensuring appropriate care can be given to the right patient at the right time. Staff providing psychological care should be members of the multidisciplinary burn team, have appropriate training in caring for burn patients, and be available at least five days a week, seven days being more desirable (NNBC, 2012). Available care must include initial and ongoing assessments, monitoring of psychological state, interventions, and responses during the burn pathway. It is further recommended that screenings are used to assist in identification and treatment planning. Additionally, the NNBC (2012) burn standards of care state that all members of the burn care team must receive psychological specific training appropriate to their role. 18 Psychological care services should also be available to staff as individual interventions and regularly scheduled in-house debriefings (NNBC, 2012). A review of the ABA’s criteria for verification revealed that burn centers seeking verification must have a psychologist or psychiatrist available to the burn service on an asneeded basis (ABA, 2019). The University of Utah burn center achieves this by placing consult to general psychiatry services or calling emergency room crisis worker to facilitate evaluation in the emergency department. The final component of objective two included a one-on-one interview with the attending psychologist at Harborview Medical Center. Harborview Medical Center is also a level 1 trauma center associated with a large academic institution located in an urban area. For feasibility, this interview utilized a video conferencing platform. The interview disclosed that the care model used at the Regional Burn Center at Harborview is generalized to their entire center rather than specific to an outpatient clinic. Embedded into the multidisciplinary team include one full-time equivalent (FTE) psychology attending filled with two part-time providers, two FTE licensed clinical social workers, and a robust residency program allowing two psychology residents to function as mid-level extenders. The LCSW completes screenings while the resident or attending psychologist implements most interventions as billable services. Psychiatry services typically function as a standard consult service for medications, restraints, and risk assessments for suicidal ideation. They do not usually remain involved as members of the burn team (S. Wiechman, personal communication, September 21, 2022). A proposed care model for mental health integration was then developed (see Appendix B, Figure 1). 19 An executive summary (see Appendix C) of the developed model was then proposed to the key contributors. Feedback included "A collaborative model allows each clinician to treat the patient that best fits in their scope of skills," "It would be nice to know how the PMHMP would improve wait times and efficiency [and] how to measure these outcomes," and a recommendation to expand the care model to the entire burn center for concern there would not be enough psychiatric need in the outpatient setting. The medical director’s feedback recommended including "collaboration with burn pharmacist to address drug interactions and potential side effects that would impact effectiveness of medications for ongoing burn scar/wound management and appropriate dose adjustments" as well as a strong desire and willingness to implement the described PMHNP-led model (G. Lewis, personal communication, March 21, 2023). The lack of survey responses and engagement from the staff was an unintentional failure. It also became evident that the clinical gap in mental health included psychoeducation of differentiating clinical roles. Despite the belief of needing more mental health services, staff did not fully buy into the need for the PMHNP in addition to the LCSW already utilized. Due to time constraints associated with the project, it was not feasible to gather local burn patient data, as responses to requests for available data were not received on time. Consequently, including mental health disorder prevalence data for local burn patients was not possible within the given timeframe. Discussion Summary The PMHNP model for integrated mental health directly impacts patient adherence, outcomes, complications, and overall well-being (Wand et al., 2006). This project highlights the 20 clinical need for improved mental health treatment seen in literature reviews. There is limited evidence and research on guidelines and recommendations for addressing mental health in the burn patient population. Evidence agrees that we should address mental health; however, there is no consensus on how or how often. Additional research is needed in this area, and this project shows a clear desire for expanded mental health services in the burn clinic. In addition, this project also revealed an educational gap among healthcare providers regarding the evidencebased role of psychiatry alongside psychological interventions for mental health. This project successfully addresses this clinical need based on feedback from key healthcare partners. Interpretation There is extensive literature discussing mental health and psychological support among burn patients, and the same literature also points out the limitations of current traditional care models of embedded psychology with referral to psychiatry. Limited studies have looked at the role of psychiatry in burn patients; however, research has demonstrated that embedded psychiatry in primary care is both feasible and sustainable. (Kroll et al., 2019). This project was the first to look at using a PMHNP to integrate mental health in an outpatient burn clinic. Concerns regarding feasibility in the outpatient setting are valid, suggesting the PMHNP-led model for mental health integration may be better suited for the burn center than the burn outpatient clinic. By expanding the model to the entire burn center, administrators and healthcare partners can feasibly and realistically implement the model based on patient volume. Dissemination of the model is also a consideration as burn centers vary significantly in size ranging from small rural centers to large academic level 1 trauma centers, further supporting the need to expand the model to the burn center. Broadening the model would allow other burn centers to adapt it to their specific size more easily. 21 Limitations This project had several limitations. First, the time allotted for project implementation was limited, potentially contributing to low responses. Second, the small number of responses may not reflect accurate data. In addition, time constraints resulted in an inability to collect local data regarding the mental health status of burn patients for comparison with the global data gathered. This lack of crucial local data may potentially hinder the successful implementation of the project at the local level, as it is necessary to have a comprehensive understanding of the mental health status of local burn patients. Conclusions Burn injury affects thousands of individuals each year. Research shows that psychiatric disorders are common in burned patients and frequently contribute to the etiology of injury (Ilechukwu, 2002). Integrated mental health is a proven sustainable, feasible model in primary care. Despite this evidence, mental health care within burn centers continues to rely on referrals. The PMHNP-led collaborative care model for mental health integration expands services to narrow this clinical gap and improve efficiency and patient experiences (Klein, 2009; Wand et al., 2006) 22 Acknowledgements I would like to personally acknowledge and thank the University of Utah Burn Center, including Giavonni Lewis, MD, medical director, for allowing me to conduct this needs assessment project in their center. A personal thank you to Kristen Quinn, CMHC, CCLS; Lisa McMurtrey, BSN, RN; and Heidi Stirling, CSW, for being available, responsive, and beyond helpful in the completion of this project—a warm shout out to all the Outpatient Clinic staff for completing my survey. I would also like to thank my project chair, Deborah Morgan, DNP, APRN, PMHNPBC, for her guidance, patience, and advice throughout the entire process of this project. A final thank you to all my friends and loved ones for supporting me through the adventures of DNP school. 23 References American Burn Association. (2019, October). Verification Criteria. https://ameriburn.org/quality-care/verification/verification-criteria/verification-criteriaeffective-october-1-2019/ American Psychological Association. (2017). Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. https://www.apa.org/ptsd-guideline/ American Psychological Association. (2022). Psychologists struggle to meet demand amid mental health crisis: 2022 COVID-19 practitioner impact survey. https://www.apa.org/pubs/reports/practitioner/2022-covid-psychologist-workload Andrilla, C. H. A., Patterson, D. G., Garberson, L. A., Coulthard, C., & Larson, E. H. (2018). Geographic Variation in the Supply of Selected Behavioral Health Providers. 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Tables and Figures Figure 1 Psychiatric Nurse Practitioner Integrated Care Workflow 28 All patients with SUD, SPMI, or comorbid mental illness contributing to injury etiology Referral from LCSW/Burn Team PMHNP conducts psyciatrich assessment *inpatient unit consult PMHNP determines ongoing mental health treatment need Referral to local mental health services facilitated by PMHNP Transfer to PCP/Burn Medical Team with treatment recomendations Mental Health Stabilization Mental Health Destabilization PMHNP continues treatment until stable 29 Appendix A Survey 30 31 32 Appendix B PROPOSED MODEL FOR PSYCHIATRIC NURSE PRACTIONER INTEGRATION Assessment and Screening: Burn Outpatient Clinic providers will screen all patients for mental health disorders during routine visits using validated tools, such as the mEVAL. Patients identified with mental health concerns will receive a comprehensive mental health evaluation from the psychiatric nurse practitioner. Care Coordination: The psychiatric NP will collaborate with burn providers to develop a comprehensive care plan that includes medication management, psychotherapy, and other evidence-based treatments. The psychiatric NP will determine ongoing mental health needs and continue care, refer a patient with treatment plan/medication recommendations, or discontinue mental health services if no longer indicated. Evidence-Based Treatment: The psychiatric nurse practitioner will develop care based on the latest evidence and best practices. Care should be tailored to meet the unique needs of each patient. The care plan should include evidence-based psychotherapies, such as cognitivebehavioral therapy (CBT) and dialectical behavior therapy (DBT), trauma-informed therapies, and medication management when appropriate. Continuous Quality Improvement: The care model will be evaluated yearly for improvement opportunities based on patient outcomes and feedback. Quality improvement data will be measured to ensure that patients receive high-quality, evidence-based care. Quality Assurance: Quality assurance metrics such as (patient-reported outcomes, wait times, and availability) will be tracked and monitored to ensure that providers are adhering to the established care model and providing high-quality, evidence-based care. 33 Access to Care: The psychiatric nurse practitioner-led care model for mental health integration will ensure that patients have timely access to mental health services, regardless of their ability to pay or location. Telehealth services will be utilized to improve access to care for patients in remote or underserved areas when appropriate. Appointments will be offered stacked, as available, to limit patient appointment burden. Education and Training: Burn care providers and Psychiatric nurse practitioners will receive education and training on the care model, including best practices for screening, assessment, and treatment of mental health conditions. Continuing education opportunities will be provided to keep providers up-to-date on the latest research and best practices in mental health care. Billing & Cost: Insurance providers will reimburse mental health services in a manner that reflects the time and effort required to provide comprehensive care. Billing codes will be used to accurately document the services provided, including evaluation and management codes, psychotherapy codes, and medication management codes. Providers will also ensure they meet specific payer contracts' documentation and billing requirements. The psychiatric nurse practitioner-led care model for mental health integration will cost the salary of one full-time equivalent PMHNP. In Utah, the average salary for a PMHNP is $130,000 (US Bureau of Labor Statistics, 2021). Workflow: All patients with acute substance use disorder (SUD), severe persistent mental illness (SPMI), or comorbid mental illness contributing to the etiology of injury will receive a comprehensive psychiatric evaluation from the psychiatric NP, along with all patients referred from LCSW or the inpatient unit. The psychiatric NP will determine ongoing needs based on assessment findings and continue care or refer with treatment recommendations as clinically indicated. It is essential to consider the structures involved, and therefore the psychiatric NP will 34 conduct appointments from an office separate from the outpatient patient rooms. This will allow the outpatient clinic flow to be uninterrupted and gives the patient a non-medical space to discuss mental health concerns. Electronic health records (EHRs) will be utilized to streamline communication and coordination between burn care providers and mental health specialists. Patient portals will also allow patients to communicate with providers, access educational materials, and track their progress. 35 Appendix C EXECUTIVE SUMMARY PROBLEM Individuals who have suffered a burn injury are up to 50% more likely to develop a mental health disorder. As burn mortality has decreased, the research focus has shifted to assisting the burn survivor in recovering from physical injury and thriving in all aspects of health, mental well-being, and social participation (Carmean et al., 2019). A substantial amount of research confirms the link between burn injury and mental health disorders. A mental health condition before injury can complicate treatment and rehabilitation, leading to more extended hospital stays, higher complications, and increased morbidity (Cleary et al., 2018). Pain, itching, stress during acute treatment, alcohol and drug use, family, and many other factors also contribute to the risk of developing psychiatric problems (Cleary et al., 2018; Herndon, 2018). O'Brien (2018) found that outpatient psychological support directly affected burn patients' adherence and engagement in rehabilitation treatment, highlighting the importance of integrated mental health in the outpatient burn clinic. Further, evidence shows that the best practice for treating mental health conditions includes psychological and psychiatric intervention. PROPOSED SOLUTION The traditional care model of integrative mental health often utilizes the clinical social worker to provide psychological support while relying on referrals to psychiatry. A collaborative care model utilizing the psychiatric nurse practitioner allows for embedded psychiatric care in addition to psychological support. 36 The psychiatric nurse practitioner-led collaborative care model for mental health integration would address issues such as stress, emotional disturbances, anxiety, and panic with primary intervention while improving access to mental health services for individuals who fall outside the capacity of the overwhelmed community mental health services (Klein, 2009; Wand et al., 2006) VALUE Integration of complete mental health can reduce waiting times and increase costefficiency, according to Wand et al., (2006). Utilizing Psychiatric Nurse Practitioners to fulfill the psychiatric role in integrated healthcare can improve early identification and treatment, give higher quantity, and generate cost savings (Emerson, 2019). The PMHNP can utilize higher billing codes than the LCSW while costing less than the psychiatrist. While all members of the burn treatment team can recognize the effects of psychological stress on physical recovery, the psychiatric nurse practitioner is able to manage, order and perform both pharmacological and non-pharmacological therapies (Klein, 2009; Wand et al., 2006). While the American Burn Association only requires psychology services available, evidence continues to support that the best treatment for mental disorders includes assessment for both psychological and psychiatric intervention. As a fully integrated member of the burn treatment team, the psychiatric nurse practitioner is in a better position to provide billable services to payers, assist and educate in crisis, and provide staff education regarding the appropriate use of non-pharmacological interventions versus psychotropic medications. The presence and collaboration of the PMHNP provide staff with reassurance that support will be present in a crisis, improving team morale (Klein, 2009) 37 CONCLUSION The psychiatric nurse practitioner-led practice model for mental health integration, directly impacts patient adherence, outcomes, complications, and overall patient well-being. The psychiatric nurse practitioner can expand mental health services to include psychiatric services increasing access to services and improving wait times, efficiency, and patient experiences.