The Evolution of Public Psychiatry Fellowships

Abstract

Objective

The growth of Public Psychiatry Fellowships [PPF’s] has reached a new developmental stage, providing a wide array of academic partnerships and educational opportunities in psychiatric leadership and administration. The authors examine the evolution of these programs and illustrate three distinct models.

Methods

Data from yearly surveys and discussions with PPF Directors were used to identify key similarities and areas of divergence as the programs have evolved.

Results

The first period of program expansion took place 8–10 years ago when new programs were modeled on the Columbia PPF, and key elements of that program and the American Association of Community Psychiatrists (AACP) guidelines were incorporated broadly. Examples of multiple source (Columbia), single source (Yale and UCSF), and grant-funded programs (Alabama and UCSD) are presented.

Conclusions

A review of the current status of PPF’s reveals a diversity of structures and strategies for success, which can be attributed to the range of their funding sources. The advantages and potential disadvantages of those models are outlined with respect to the educational experience and opportunities for growth and sustainability.

Public Psychiatry Fellowships (PPF's) provide advanced training to psychiatrists who are interested in engaging in clinical care, teaching, and program/policy development and evaluation within the public sector. They are based in diverse settings, including urban, rural, hospital, and community locations, but share a vision and commitment to promoting recovery oriented care to the most vulnerable individuals within the system of care.

Among current PPF’s, the first program was established at the New York State Psychiatric Institute and Columbia University in 1981 [1]. A burst of growth of similar fellowships began approximately eight years ago. Program Directors in academic institutions across the country structured the fellowships in somewhat different ways, but the initial emphasis was to develop programs that were aligned with the Columbia program. In the past few years there have been 14–15 active PPFs at any given time, and Dr. Jules Ranz created a network of PPF Program Directors who share data about multiple parameters of their programs including details about the source and allocation of their resources.

Methods

Fellowship Directors complete yearly surveys that pose specific questions about the level of adherence to the core elements for PPF’s published by Columbia faculty [2] and guidelines from the American Association of Community Psychiatrists (AACP) [3]. The results are reviewed and discussed at the meetings of the fellowship directors. Additional analysis of survey results plus a review of program updates have been held via electronic communication.

Results

The yearly reviews, held in an open format, have encouraged a certain degree of comparability between programs. By sharing the data and discussing the results at the yearly meetings of Fellowship Directors, two outcomes were achieved: 1) we gained a sense of shared identity, since all programs had common goals of educating and preparing early career psychiatrists to work in the public sector and to enhance the recruitment and retention of psychiatric leaders in this arena; and 2) we developed an understanding and appreciation of the differences in the structures of the programs.

Some of the diversity can be attributed to obvious factors such as geography, i.e. urban vs. rural location of the host academic center. However, the most significant differences appear to be related to the funding mechanisms for the fellowships and how each local system of care is organized. The specific source and stability of the funding stream is likely the most salient feature that influences the structure of each fellowship and its clinical and administrative placements. In addition to Columbia, four examples of evolving funding arrangements are programs affiliated with Yale University, the University of California San Francisco (UCSF), the University of Alabama, and the University of California San Diego (UCSD) (see Table 1). The five PPF’s highlighted in this article were chosen after discussion within the listserv of all PPF directors in the USA. They are prototypic cases of the three models of funding outlined in the article.

Table 1.

Fellowship	Funding Type	Clinical Placements
Columbia University	Multiple sources: 1/3 NY State and 2/3 community agencies	Agencies throughout New York City
Yale University	Single source: State of CT Dept. of Mental Health & Addiction Services	Rotation through inpatient services at State hospital, or outpatient programs at CMHC in New Haven
University of California, San Francisco	Single source: San Francisco County Behavioral Health Services [CBHS]	Year long placement at one of the CBHS-affiliated clinics
University of Alabama	Grant funded: Bristol Meyers Squibb, transitioned to CMHC/VA funds	Rural CMHC with mobile and telemedicine services
University of California, San Diego	Grant funded: County of San Diego	Longitudinal sites [2–3 days/week] for entire year, and rotational [1–2 days/week for 4–6 weeks]

Multiple funding sources and sites – the Columbia Model

The Columbia PPF receives one third of its funding from the State Mental Health Authority—the New York State Office of Mental Health—and two thirds from community agencies where the fellows make a significant contribution to clinical service needs [4]. One advantage of the Columbia PPF arrangement is that the fellows become very familiar with their sites, and are often offered opportunities for employment at the completion of the fellowship. Another significant advantage is the large number of public agencies in the New York City area, which means a large base of funding and multiple opportunities for expansion. A potential disadvantage is the lack of direct oversight or control by the Fellowship Director over the quality of the experience at those sites.

Single funding source – Yale and UCSF

The Yale PPF is an example of a program that is funded through a single source, which in this case is the state mental health authority, the Connecticut Department of Mental Health and Addiction Services (DMHAS). The program was built into an existing relationship between DMHAS and Yale University to manage and provide professional services for an academic community mental health center. The State pays the University through a “staffing contract” to hire Yale physicians, psychologists and senior administrators. A single cost center within this contract funds positions for residents and attending psychiatrists.

When the Yale PPF was developed in 2007 and expanded in 2012, DMHAS provided additional funds to the staffing contract, which covers the fellows’ clinical and academic commitments. The fellows’ commitment for 50% clinical time is spent within ambulatory services at the Connecticut Mental Health Center, an urban CMHC run jointly by the State and Yale; or on inpatient services at Connecticut Valley Hospital, a 900 bed state facility. The fellows’ other 50% effort is devoted to academic activities such as seminars, Department of Psychiatry Grand Rounds, and scholarship. This structure provides flexibility for fellows to be exposed to a variety of treatment settings in the state’s system of care within their weekly schedules [i.e. outpatient Hispanic Clinic, ACT team, forensic and general inpatient units], and opportunities to modify their schedule during the course of the year according to their specific interests. One advantage of this arrangement is that the fellowship leaders also hold direct administrative responsibility for management of the clinical services where the fellows are placed, e.g. the Fellowship Director is also the Medical Director of the CMHC. An “apprenticeship” model is provided, whereby the fellows participate in hospital and statewide administrative meetings along with the Program Directors. A disadvantage of this program is the reliance on a single source of funding, which is subject to state budgetary constraints. The risk of funding cuts is mitigated, however, by the successful recruitment of graduates of the fellowship into positions within the state mental health system.

The UCSF PPF is another example of a program that is primarily funded through a single source. The San Francisco County Behavioral Health Services (CBHS) uses a portion of allocated Mental Health Services Act (MHSA) funds to support the fellowship infrastructure (faculty, administration) and fellows are placed in CBHS-affiliated clinics. As the fellowship has gained recognition in San Francisco, local non-profit community mental health clinics have approached UCSF to provide funding to support individual fellows at their sites as well. Regardless of the funding source, all fellows are technically UCSF academic employees and are all paid through the University. Similar to Columbia’s PPF, all fellows are placed at a single site throughout the academic year. This provides the main advantage of becoming very familiar with sites. The disadvantage, particularly with non-CBHS clinics, has been the expected growing pains that come with new placements. In these situations, the Fellowship Director focuses on ensuring weekly individualized clinical mentorship at the new sites from strong supervisors and using the “growing pains” as learning experiences for the fellows during fellowship supervision time.

The UCSF single-site model is critical given the evolution of this particular fellowship to incorporate a rigorous mental health services research component [5]. Fellows are expected to implement a mental health services research project addressing a specific systemic issue at the clinic during the year. CBHS provides funding to support a part-time research faculty mentor, a half-time research assistant, and travel to disseminate findings at academic meetings. These projects are designed and carried out with clinical leadership at the sites to ensure relevance to CBHS priorities. These projects are presented at academic meetings and/or published in peer-review journals. The evolution of the UCSF PPF to embrace research in the public sector is a reflection of both the institution—UCSF being a leader in both public health and biomedical research—and also both Fellowship Directors who are NIMH-funded health services research investigators. The UCSF PPF intentionally trains fellows to value mental health services research and develop skills and a network of connections to effectively collaborate with academic partners to conduct research in the public sector.

Grant funded programs – Alabama and UCSD

The University of Alabama PPF was developed in collaboration with a parallel Behavioral Medicine Fellowship in Primary Care. Both fellowships started in 2009 and were initially funded by a larger Bristol Meyers Squibb (BMS) grant focused on increasing mental health services to the rural Alabama “Black Belt” region, one of the poorest areas in the United States. The grant funded three years of the fellowship in which the fellows spent the majority of their clinical time in a rural community mental health center (CMHC) incorporating the extensive use of telepsychiatry to provide services to remote rural areas. In 2013, BMS seed money ran out. However, the positive experience of the fellows at the rural CMHC convinced the CMHC board to continue funding the fellowship. Currently, the CMHC funds 4/5 of the fellowship while the VA funds 1/5 with a focus on rural outreach via mobile clinics and telemedicine. The overall philosophy of the fellowship is to train psychiatrists to become leaders in public psychiatry with focus on rural underserved areas and collaboration with primary care colleagues. So far, the fellowship program has produced two public psychiatry and two family physician graduates. One of the psychiatry graduates is involved in rural public psychiatry while the other seeks to expand training. The two family physician graduates are practicing primary care in rural areas and utilizing their psychiatry training extensively as the main providers of psychiatric care in underserved populations.

The current funding and organizational structure of the Alabama PPF offers several advantages. First, psychiatry fellows are offered the opportunity to collaborate with primary care physicians in an innovative approach to integrating psychiatric services with primary care through shared training. Second, fellows provide valuable clinical services to underserved rural areas of Alabama using telemedicine. Third, fellows are required to conduct research based on a perceived need related to quality improvement in psychiatric services focused on rural areas. A disadvantage is the lack of on-site supervision in remote rural sites, which has been addressed by weekly face-to-face supervision with the program director and use of telemedicine equipment for immediate supervision when necessary. Currently, the program is attempting to expand rural sites and obtain funding from other CMHCs that have on-site supervision available.

The UCSD PPF was developed as a contract between County of San Diego and UCSD. The initial discussions started in 2010 and the contract terms started in 2011. UCSD graduated its inaugural class in 2013. The funding is 100% allocated from the County’s MHSA Work, Education and Training (WET) program. This is a time limited funding source, likely to be phased out in 2016 to 2017. During the duration of the contract, all direct and indirect costs associated with the PPF are covered by the WET funding. It is expected that UCSD aggressively seek outside funding to sustain the program after the contract termination. This arraignment poses a unique situation for UCSD PPF. On one hand, the contract’s Statement of Work mandates certain deliverables and the program reports to the County’s Contracting Officer’s Technical Representative. This is in addition to the reporting to the UCSD Department of Psychiatry and to the County leadership. Meanwhile, the program must establish and nurture relationship with community partners to gradually replace the WET funding with outside resources.

The shared vision of the PPF between the County of San Diego and UCSD is to “train the next generation of Community/Public Psychiatry Clinicians and Leaders.” To this end, the program takes a lifespan approach to mental health in the public sector, emphasizes leadership and managerial skills, and requires health services related projects. The fellows are placed in both longitudinal (approximately 2–3 days a week for the entire year) and rotational (approximately 1–2 days a week for 4–6 weeks) sites to expose them to as many learning environments as possible. The longitudinal sites are then ideally suited for quality improvement projects while a rotational site is opportunity for smaller individual research project. The didactics are hosted by UCSD but the invited educators are a mix of UCSD faculty and community mental health directors, executives and clinicians. Under the terms of the contract, UCSD PPF works with UCSD medical school and general psychiatry residency programs. The PPF directors have taken on roles to provide community psychiatry perspective to the medical school years 2–4 training and now lead the community psychiatry didactics track within the general residency. The fellows are expected to mentor medical students and general residents during their third year clerkships and post-graduate year 2 and 3, respectively.

Discussion

The establishment of a network of Public Psychiatry Fellowship Directors and the distribution of yearly surveys within this group provide an effective mechanism to share information, including strategies for success. In the first phase of program expansion, the PPF’s developed a common vision and set of goals according to the Columbia and AACP guidelines. This was an important developmental stage in order to insure consistency and quality across disparate institutions and systems of care. At this current juncture, however, when approximately 15 PPF’s are in existence, we have come to value their diversity as they strive for sustainability in creative and distinct ways.

A basic educational principle emphasized within each of the PPF’s didactic and experiential components is that the organization of clinical and recovery services within any system of care is dependent to a great extent on sources of funding and how they are administered. In the same vein, the PPF’s themselves have developed in association with each other across the country, but their identities and future success are dependent on the financial and workforce development relationships they have established within their own local, state and academic homes.

Implications for Academic Leaders.

• Public Psychiatry Fellowships provide educational opportunities for psychiatrists who are interested in developing leadership skills and administrative experience.

• Public Psychiatry Fellowships have been established in 14–16 academic Departments of Psychiatry and serve as an example of innovative academic/state partnerships.

• Formation of a network of Fellowship Directors has proved to be an effective mechanism to share data about strategies for development and enhancing quality of the programs.

• Three models of public funding - single source, multiple source, and grants - are examined with respect to potential advantages and disadvantages for educational experience and sustainability.