SO PLEASE DON’T EVER CHANGE

         The Institute of Medicine:  Last year the Institute of Medicine (IOM) issued its report Informing the Future: Critical Issues in Health.  Released prior to the final enactment of President Obama's landmark health care reform legislation, the Patient Protection and Affordable Care Act [PPACA], the IOM foresaw the changes coming.  "Increasing effectiveness and efficiency of the health care system.  By all accounts, the nation's current health care system is flawed, marked by rising costs, lack of evidence about the effectiveness of even the most widespread medical procedures, and a growing number of people who are uninsured.  Among suggested changes, HHS should work with Congress to establish a capability for assessing the comparative value – including clinical and cost effectiveness – of medical interventions and procedures, preventive and treatment technologies, and methods of organizing and delivering care.  This effort will require expanded information sharing, both within the department as well as with external organizations, in order to better evaluate and inform the health care system."

The IOM called for the federal government to: * Define a 21^st century vision for how to provide the greatest value in protecting and improving health in today's climate of varied, complex, and sometimes changing health needs.  * Strengthen the health care workforce.  Serious shortages exist across the health care spectrum of professionals with the right backgrounds, training, and skills.  There is an aging workforce, new health challenges requiring new skills, an imbalance between primary care providers and specialists, and an underrepresentation of minority groups.  And, * Assessing what works in health care.  Many studies have documented spending on ineffective care and significant variations in how multiple health care providers treat the same condition.  At the same time, health plans face the need to constantly learn how their beneficiaries might benefit from – or be harmed by – newly available health services.  Rigorous standards for creating clinical practice guidelines which could help clinicians and patients make informed decisions about appropriate health care for specific clinical conditions should be developed and promoted.  Evidence-based health care is critical as we enter the 21^st century.  And yet, it is unquestionably an evolving and highly complex process.

            APA – Getting Ahead of the Curve:  During the past year, President Carol Goodheart's APA Presidential Task Force on Advancing Practice, on which Hawaii's Darryl Salvador and long time colleague Jeff Zimmerman serve, addressed their basic mission of identifying educational and other resources needed by practicing psychologists and prioritizing and advancing the development and dissemination of such resources.  The ultimate objective is to create an outcomes framework and a clinical resources framework in order to integrate practice and science in useful ways that support practitioner efforts to develop quality services.  "In this era of ever increasing demands for accountability, the best way for psychologists to demonstrate the effectiveness of services is to measure outcomes."

            Jeff's report: "So, you're sitting in your office and have a question about practice (clinical issues, practice management, insurance, etc.) or you are involved in research and want to float some ideas, or you are searching for information about outcome measures.  What do you do?  Well typically we use one of the common search engines, pose a question and get millions of hits to sort through.  While search engines can offer a great diversity of hits, we are often unsure how to better pinpoint what we need and we can be unsure of the quality of information obtained.  Similarly, on the many list serves we may be on, we have to sort through countless e-mails or digests to find pertinent information.  Now members of APA have another choice – PsycLINK.

            "If you go to my.apa.org and click under Tools, you will be taken to APA's new wiki platform PsycLINK.  There you will find the beginnings of a new initiative started by the APA Task Force appointed by Carol and chaired by Karen Zager.  Thanks to the work of the task force, which included APA members and Practice Directorate Executive Director Katherine Nordal and her staff Lynn Bufka and Joan Freund, PsycLINK is a platform that is continuing to develop and is a community built by psychologists for psychologists.  As it grows, the breadth and depth of information will grow as well.  Searches will be more comprehensive and to the point, as many results of the public search engines will be screened out.  Additionally, the diversity of input from colleagues in different Divisions and professional roles can be more easily realized, when compared to a more singular listserv hosted by one professional subgroup.

            "PsychLINK is not e-mail intensive in the slightest.  You can set it to send you one e-mail a day of all the titles of the postings, or you can check it when you care to.  To post comments or start new posts you have to register – again, a very simple process.  So, check it out.  Ask a question, post something you think may be of use, or comment on a posting to lend a hand to a colleague.  This isour virtual community.  Let's help it grow."

            A Highly Complex Process:  Another IOM report focused upon Policy Issues in the Development of Personalized Medicine in Oncology and noted that personalized cancer medicine is defined as medical care based on the particular biological characteristics of the disease process in individual patients.  In oncology, personalized medicine has the potential to be especially influential in patient treatment because of the complexity and heterogeneity of each form of cancer.  However, the current classifications of cancer are not as useful as they need to be for making treatment decisions.  Treatment needs to evolve toward a focus on targeted treatments based on individual characterizations of the disease.  Although this underlying concept has great promise, a number of policy issues must be clarified and resolved before personalized medicine can reach its full potential.  These include technological, regulatory, and reimbursement hurdles.  Addressing the reimbursement possibilities, the report noted that while some Medicare coverage decisions are made at the national (CMS) level, approximately 85 to 90 percent of coverage decisions are actually made by local contractors.  That is, local contractors can increase national coverage and reimburse additional procedures and tests, if deemed to be "reasonable and necessary" in order to improve clinically meaningful health outcomes.  Evidence is assessed using standard principles of evidence-based medicine.

            Women Veterans:  With the significant number of active duty personal, veterans, and called up national guard troops in Hawaii, another IOM report should be of particular interest.  That document recommended that DoD and VA quantify the number and distribution of mental health professionals needed to provide treatment to the full population of returning service members, veterans, and their families who might suffer from mental health disorders such as PTSD, major depression, and substance abuse, so that they can readjust to life outside of theater.  The committee also recommended that DoD and VA continue to implement programs for the recruitment and retention of mental health professionals, particularly to serve those in hard-to-reach areas.  Women now constitute 14% of deployed forces in the U.S. military, and although technically they are barred from serving in combat, a growing and unprecedented number of female soldiers are deployed to combat areas where their lives are at risk.  All service members are exposed to high levels of workplace stress; however, women in the military were found to face some unique stressors, such as sexual harassment and trauma exposure that may affect their mental health and emotional well-being.  Female veterans report a higher burden of medical illnesses, worse quality-of-life outcomes, and earlier psychologic morbidity than do men who are exposed to the same levels of trauma.  Both the military and family life requires commitment and loyalty, and servicewomen who have families may experience intense conflict between the demands of their military roles and their family roles.  Deployment involves being separated from children and families for months at a time and leaving children behind with spouses or alternative caregivers.  Single mothers confront special challenges.  Interestingly, deployment appears to affect the marital stability of male and female soldiers differently.  It has been found that deployment led to a large, statistically significant increase in divorce rates in women in the military, but not men.  Psychologists Margarita Alegria, John Corrigan, and Janice Krupnick served on this IOM committee.  I KIND OF LIKE YOU JUST THE WAY YOU ARE (Beatles, 1963).  Yet, fundamental change is definitely coming.  Aloha,

 

Pat DeLeon, former APA President – Hawaii Psychological Association – December, 2010

 

A REFRESHING LONG-TERM VISION FOR THE NATION

Over the next five to ten years, our nation will experience the steady implementation of President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act [PPACA].  It is important to appreciate that the underlying vision behind this wide ranging initiative is the nurturing of a patient-centered (and not provider-centric) comprehensive delivery system in which timely access to high quality Primary Care is the highest priority.  The Act represents the broadest changes to the health care system since the enactment of Medicare and Medicaid in 1965 under President Lyndon Johnson's Great Society.  Over time, various technical modifications will undoubtedly be made.  With the States being given considerable latitude to experiment with local options, we should experience a revitalization of their historical role as "laboratories of social change."  And, notwithstanding many highly emotional campaign promises, we are confident that there is very little likelihood that the President's fundamental vision will be significantly modified during the next decade.  Health Promotion, Disease Prevention, and encouraging Healthy Lifestyles will finally become a priority.  Interdisciplinary care and multidisciplinary training initiatives are the future.  Historically isolated professional silos of treatment and training will simply be unacceptable.  The behavioral sciences couldflourish.

The federal government will increasingly invest in Health Information Technology (HIT) and data-driven Comparative Competitive Research (CER) in order to ensure that the care provided will, in fact, be appropriate and based upon the most up-to-date scientific knowledge.  An additional 32 million previously uninsured Americans will have access to necessary health insurance, while the Congressional Budget Office (CBO) estimates that the bill will reduce the deficit by $143 billion over the first decade of enactment and effectively bend the ever-escalating cost curve.  No longer will the Institute of Medicine (IOM) report: "The lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of about 15 to 20 years.  Even then, adherence of clinical practice to the evidence is highly uneven."  Licensure mobility will become the norm.  The public sector with its budgetary resources, and especially the Department of Defense (DoD) and the Veterans Administration (VA), will undoubtedly take the lead in demonstrating the effectiveness of "seamless care" and the unprecedented opportunities for developing individualized gold standard protocols utilizing the unprecedented advances occurring within the communications and technology fields.  Virtual realities, 24/7world-wide expert consultations, and home-based care will become what the public (and their elected officials) expect.  Over the years we have learned that change is always unsettling, especially for those whose future suddenly seems unpredictable and perhaps out of their control.  And yet, unprecedented change is undoubtedly upon us.

This Fall the IOM, in conjunction with the Robert Wood Johnson Foundation, released a truly visionary report: The Future of Nursing: Leading Change, Advancing Health.  Nursing is the largest sector of the health professions, with more than 3 million registered nurses in the United States.  Acknowledging that the American health care system is undergoing fundamental transformation and chaired by former HHS Secretary Donna Shalala, the IOM committee proclaimed: "Nurses should practice to the full extent of their education and training.  To ensure that all Americans have access to needed health care services and that nurses' unique contributions to the health care team are maximized, federal and state actions are required to update and standardize scope-of-practice regulations to take advantage of the full capacity and education of APRNs [Advanced Practice Registered Nurses].  State and insurance companies must follow through with specific regulatory, policy, and financial changes that give patients the freedom to chose from a range of providers, including APRNs, to best meet their health needs.  Removing regulatory, policy, and financial barriers to promote patient choice and patient-centered care should be foundational in the building of a reformed health care system."

The committee urged: "Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.  Major changes in the U.S. health care system and practice environment will require equally profound changes in the education of nurses both before and after they receive their licenses.  An improved education system is necessary to ensure that the current and future generations of nurses can deliver safe, quality, patient-centered care across all settings, especially in such areas as primary care and community and public health….  Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States."  For many health care providers the vision of the President and the IOM calls for a fundamental re-conceptualization of the role of nursing, as well as that of a wide range of non-physician providers.  In particular, practitioners must come to appreciate that it is the patient who ultimately will assume primary responsibility for his or her own health care, as the all important psychosocial-economic-cultural gradient of care becomes appropriately recognized and reimbursed.

The clinical skill set of professional nursing covers a broad continuum from health promotion, to disease prevention, to coordination of care, to cure – where possible – and to palliative care when cure is not possible.  Many members of the nursing profession admittedly require more education and preparation to adopt new roles in response to rapidly changing health care settings and the evolving health care system.  Today's restrictions on their scope of practice, policy- and reimbursement-related limitations, and professional tensions have undermined the nursing profession's ability to provide and improve both general and advanced care.  Developing a health care system that delivers the right care – quality care that is patient centered, accessible, evidence based, and sustainable – at the right time will require transforming the work environment, scope of practice, education, and numbers of America's nurses.  If today's generation of psychologists reflects upon the efforts of their senior colleagues who worked hard to obtain the statutory right to "diagnose and treat," obtain direct reimbursement from public and private insurance companies (i.e., enact freedom-of-choice legislation), seek hospital privileges, and most recently obtain prescriptive (RxP) authority, the necessary foundation for their success in challenging the medically-oriented status quo was obtaining and demonstrating to the public (and to their elected officials) that they possessed the quality education necessary to competently fulfill these sought after clinical responsibilities.  And, we must not forget that they almost always experienced the vocal opposition of organized medicine, proffering that non-physicians would harm patients (i.e., were "public health hazards") if we were allowed to treat our patients without direct physician supervision and control.

The IOM committee was truly interdisciplinary in composition, including a former Administrator of HCFA (now CMS).  It appreciated that: "Strong leadership is critical if the vision of a transformed health care system is to be realized.  To play an active role in achieving this vision, the nursing profession must produce leaders throughout the system, from the bedside to the boardroom.  These leaders must act as full partners with physicians and other health professionals, and must be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions.  Being a full partner transcends all levels of the nursing profession and requires leadership skills and competencies that must be applied within the profession and in collaboration with other health professionals….  To be effective in reconceptualized roles, nurses must see policy as something they can shape rather than something that happens to them.  Nurses should have a voice in health policy decision making and be engaged in implementation efforts related to health care reform.  Nurses also should serve actively on advisory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care."  Those colleagues fortunate to have attended the APA Practice Directorate State Leadership conferences will recall that these are the same powerful messages that Katherine Nordalinspirationally delivered to her audiences.

Over the years we have learned that substantive change always takes time.  In June 2005 Senator Dodd, one of the major architects of PPACA, re-introduced the Information Technology for Health Care Quality Act which is a major component of the President's initiative.  "By encouraging health care providers to invest in information technology (IT), this legislation has the potential to bring skyrocketing health care costs under control and improve the overall quality of care in our nation….  (E)xpanding the use of IT in health care is the best tool we have to control costs.  Studies have shown that as much as one-third of health care spending is for redundant or inappropriate care….  Most experts in the field of patient safety and health care quality, including the IOM, agree that improving IT is one of the crucial steps towards safer and better health care….  (T)his legislation would provide for the development of a standard set of health care quality measures."

Calling for an increased investment in obtaining reliable data on which to transform our nation's workforce and practitioners' scopes of clinical practice, the IOM made a series of far-reaching policy recommendations including: * Expanding the Medicare program to include coverage of APRNs just as physicians are currently covered; * Authorizing APRNs to perform admission assessments, as well as certification of patients for home health care services and for admission to hospice and skilled nursing facilities under Medicare; * Requiring third-party payers that participate in fee-for-service arrangements to provide direct reimbursement to APRNs; * Amend or clarify the requirements for hospital participation in Medicare to ensure that APRNs are eligible for clinical privileges, admitting privileges, and membership on medical staff; and, Requiring the Federal Trade Commission to review existing and proposed state regulations concerning APRNs to identify those that have anticompetitive effects without contributing to the health and safety of the public.  State Boards of Nursing, accrediting bodies, government, and health care organizations were urged to support nurses' completion of a transition-to-practice nurse residency.  Schools of nursing should double the number of nurses with a doctorate degree by 2020.  And, nurses should be systematically encouraged to engage in lifelong learning by making the necessary resources available to facilitate interprofessional continuing competency (i.e., CE) programs.

"The [IOM] committee recognizes that improved primary care is not a panacea and that acute care services will always be needed.  However, the committee sees primary care in community settings as an opportunity to improve health by reaching people where they live, work, and play.  Nurses serving in primary care roles could expand access to care, educate people about health risks, promote healthy lifestyles and behaviors to prevent disease, manage chronic diseases, and coordinate care….  Recognizing the importance of primary care… the committee viewed the potential contributions of these nurses to meeting the great need for primary care services if they could practice uniformly to the full extent of their education and training."  Education has always been the key to our nation's future.  As we enter the 21^stcentury, times are definitely changing.  Those colleagues who possess degrees in both nursing and psychology – one of whom is APA President Carol Goodheart – must be particularly proud.  They instinctively invested in their future long before many of us began to understand the intimate connection between the mind, body, and psychosocial-economic-cultural gradient of health care.  Aloha,

Pat DeLeon, former APA President – Division 42 – December, 2010

 

THE IMPORTANCE OF VISIONARY LEADERS

International:  Last year the Institute of Medicine (IOM) released its report The U.S. Commitment to Global Health.  AGlobal health is the goal of improving health for all nations by promoting wellness and eliminating avoidable disease, disability, and death.  It can be attained by combining population-based health promotion and disease prevention measures with individual-level clinical care.  This ambitious endeavor calls for an understanding of health determinants, practices, and solutions, as well as basic and applied research on risk factors, disease, and disability....  The U.S. government, along with U.S.-based foundations, nongovernmental organizations, universities, and commercial entities, can take immediate concrete action to accelerate progress on the urgent task of improving health globally by working with partners around the world to scale up existing interventions, generate and share knowledge, build human and institutional capacity, increase and fulfill financial commitments, and establish respectful partnerships.  U.S. leadership in global health reflects many motives: the national interest of protecting U.S. residents from threats to their health; the humanitarian obligation to enable healthy individuals, families, and communities everywhere to live more productive and fulfilling lives; and the broader mission of U.S. foreign policy to reduce poverty, build stronger economics, promote peace, increase national security, and strengthen the image of the United States in the world.@  As has often been said: AWhen you=re up to your neck in alligators, it=s hard to focus on draining the swamp.@  However, as we evolve into the 21^st century and President Obama=s vision for implementing his landmark Patient Protection and Affordable Care Act (PPACA) takes hold, psychology (and the other health professions) must accept their societal responsibility for providing visionary leadership in addressing our nation=s and world=s most pressing needs.  This is especially true for our professional schools.  The alternative is to become obsolete, if not irrelevant.  Protecting the status quo is not a viable option.

The IOM emphasized that health is inextricably connected to the broader goals of hastening development and reducing poverty.  Significant progress has been made in the last 50 years with life expectancy increasing more than in the preceding 5,000 years.  The creation, dissemination, and adoption of knowledge has been one of the main drivers of these health gains, delivering marked improvements in low- and middle-income countries that have invested in sustainable and equitable systems to deliver proven, cost-effective interventions.  Our nation has an unprecedented opportunity to improve global health.  The promise of potential solutions has captured the interest of a new generation of philanthropists, students, scientists, healthcare professionals, private sector leaders, and citizens B all eager to make a difference in this interconnected world.

The IOM identified five areas for action: * Scale up existing interventions to achieve significant health gains; * Generate and share knowledge to address health problems endemic to the global poor; * Invest in people, institutions, and capacity building with global partners; * Increase U.S. financial commitments to global health; and, * Set the example of engaging in respectful partnerships.  The global health community has reached a critical juncture.  The knowledge, innovative technologies, and proven tools to help millions of people in need are within reach.  Yet even with demonstrated success in tackling certain health issues, a wide gap remains between what can be done with existing knowledge, and what is actually being done.  Existing interventions are not widely used even though many are inexpensive and easy to administer.  As the advocates for PPACA constantly pointed out, even within our own modern day health care delivery system, the lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of about 15 to 20 years.  The timeless health problems associated with poverty are now coupled with new challenges.  Infectious diseases are emerging at the historically unprecedented rate of one per year.  With airlines carrying more than 2 billion passengers annually, and systems of trade more interconnected than in any time in human history, the opportunities for the rapid international spread of infectious agents and their vectors have vastly increased.  The rising tide of chronic diseases and injuries in low- and middle-income countries, where 80 percent of the world=s deaths from chronic, non-infectious diseases now occur, cannot be ignored.

One of the greatest contributions we can offer to the global campaign to improve health is to share America=s traditional strength B the creation of knowledge B for the benefit of the global poor.  Not surprisingly, Americans traditionally focus upon conditions that affect people within our own borders and as a result, we often ignore or significantly neglect diseases or conditions that are overwhelmingly or exclusively incident in low- and middle-income countries.  For example, globally more than 2 billion people are at risk of malaria each year.  Despite dramatic reductions in malaria incidence and mortality in many parts of the world, approximately 500 million people still contract the disease, resulting in 1 million deaths annually.  The IOM expressly noted that global health would greatly benefit from developing and disseminating a variety of novel behavioral and biomedical prevention strategies to combat infectious diseases.  Focusing upon two disease entities for which the behavioral sciences clearly have particular expertise: Obesity is escalating worldwide at an alarming pace, along with rates of type 2 diabetes, hypertension, and lipid abnormalities associated with obesity.  More than 1 billion adults are overweight; 300 million are clinically obese.  Mental disorders affect millions worldwide; about 14 percent of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders and psychosis.

Margy Heldring=s vision of establishing a senior-scientist/practitioner U.S. Public Health Service Corps is most timely.  As she points out, many of our colleagues are entering the twilight years of their careers.  They want to make a difference and are not yet ready to fully retire.  How can their considerable expertise be effectively utilized?  The vision expressed by President Lyndon Johnson at the University of Michigan comes to mind: AThe challenge of the next half century is whether we have the wisdom to use that wealth to enrich and elevate our national life, and to advance the quality of our American civilization....  This is the place where the Peace Corps was started....  Will you join in the battle to build the Great Society, to prove that our material progress is only the foundation on which we will build a richer life of mind and spirit?  There are those timid souls who say this battle cannot be won; that we are condemned to a soulless wealth.  I do not agree.  We have the power to shape the civilization that we want....  Those who came to this land sought to build more than just a new country.  They sought a new world.@  The following year Medicare became the law of the land.

Unlike the United States, in low- and middle-income countries, universities, science academics, and the research community are often absent from public policy engagement.  Our government, which is the largest funder of many international organizations and a significant donor of bilateral aid, carries considerable influence in shaping the global health environment and thus possesses the opportunity to be a good steward for health at both the national and global levels.  AHealth is a highly valued, visible, and concrete investment that has the power to both save lives and enhance the image of the United States in the eyes of the world....  Working with partners around the world and building on previous commitments, the United Stateshas the responsibility and chance to save and improve the lives of millions; this is an opportunity that the [IOM] committee hopes the United States will seize.@

Integrated/Co-located Care:  Retired Rear Admiral Chris Bruzek-Kohler recently shared her vision for the health care environment of the 21^st century.  AOne place to look to as an encouraging story of health care delivery transformation and a way forward for civilian mental health professionals is the Navy.  Navy Medicine has successfully implemented two programs providing mental health care in non-traditional settings: on the battlefield with Marines and in primary care practice.  A primary component of the Navy=s promotion of a >Culture of Fitness= is mental health.  Recognizing their responsibility to effectively prevent, identify, and treat all psychological health conditions and the ill effects of war, Navy Medicine mental health stationed with the Marines developed Operational Stress Control and Readiness (OSCAR) Teams, which embed psychologists, psychiatrists, psychiatric nurse practitioners and psychiatric technicians as organic assets in operational units.  The goal of the OSCAR teams is to be as far forward and to spend as much time as possible with the Marines to build the trust, cohesion, and understanding necessary to break the stigma of mental health care with military patients.

AThe concept of OSCAR is to demystify the whole process of psychiatric treatment.  The Marines often call the mental health provider >the wizard.=  The origins of this term were not only because the mental health provider could >make people disappear,= i.e., suddenly remove them from their units without warning, but it also provoked the image of the mysterious Wizard of Oz pulling the smoke levers behind the mirror.  This is not the case with OSCAR.  The mental health provider interacts with the Marines in the normal routine of the day.  In this way the mental health provider becomes a real person that the Marines can trust and get to know.  Being a full member of the Marine Corps unit, the Marines are more likely to ask questions about minor issues without the stigma of being seen as patients and before the>minor= issue becomes something major.  The OSCAR provider is also highly effective when they are a trusted advisor to mid-level leaders who can gain perspective from the provider, thereby helping them to become better leaders.  There is a heightened sense of trust and awareness on both sides and a profound improvement in communication among the warfighters, their leaders, and medical.

AThe power of having providers embedded is unmistakable.  Retired Navy Medical Corps Officer, Captain William P. Nash: >OSCAR builds a bridge across the cultural gap between the warfighter and the mental health professional the only way a bridge can be built B by drawing the mental health professional as fully as possible into the culture and life of the military unit to be supported.=  OSCAR=s success is evident in the enthusiasm surrounding the program in the Marine Corps and the desire of military commanders outside of the regimental level to expand it to air wings, logistics groups, and reserve forces for the benefit of their service members.

ANavy Medicine is also utilizing mental health professionals in innovative ways on the home front.  To improve quality and access to care, Navy Medicine has created integrated Medical Home Teams within its Internal Medicine and Primary Care clinics to provide personalized, coordinated, and proactive care to patients.  The Medical Home initiative is unique because it is an integrated care model where primary care services and behavioral health assets are together in the same clinic space.  The embedded behavioral health consultant provides health assessment and intervention expertise to primary care managers and their patients.  Clinical Psychologists are ideally suited for the Navy=s Medical Home Team model.

AA report from a 2007 DoD Task Force on Mental Health suggested that the integration of mental health providers within the Medical Home would improve access and decrease stigma by maximizing the number of interventions that can be conducted in a primary care setting.  Research supports the Task Force=s assertion and provides evidence of significant improvement in clinical outcomes and reduced psychological stress among service members served by behavioral health providers in primary care settings.  The Medical Home Model with integrated behavioral health specialists was first implemented at National Naval Medical Center (NNMC) in Bethesda, Maryland in2008, followed by Naval Medical Center inSan Diego and Naval Hospital Pensacola.  Building on early successes, the Navy will roll out the Medical Home Model at all remaining treatment sites this summer.@ 

Innovative Practices:  One of the more visionary provisions contained in the President=s Health Care Reform legislation (PPACA) authorized demonstration programs to train or employ alternative dental health providers in order to increase access to dental health care services in rural and other underserved communities.  This Fall the W. K. Kellogg Foundation released its report on the Alaska Dental Therapists program, which was strongly opposed by organized dentistry essentially proffering that these providers would be Apublic health hazards,@affirmatively harming their patients if allowed to practice.  The Kellogg Foundation found that: Adental therapists practicing in Alaskaprovide safe, competent and appropriate dental care.  The two-year, intensive evaluation is the first independent evaluation of its scale to assess care provided by dental therapists practicing in the United States.  It confirms for us what numerous prior studies of dental therapists practicing in other countries have already shown: that dental therapists provide safe care for underserved populations.@

Dental therapists have been providing preventive and basic dental care to children and families in remote Alaska Native villages since 2006.  Although new to the U.S., dental therapy has been well-established for decades in more than 50 countries, including those with advanced dental care systems similar to ours.  The evaluation assessed the work of dental therapists in five communities, as well as the experience of hundreds of patients.  They were directly observed performing sealant placement, composite and amalgam preparations, stainless steel crown placement, and oral health instruction.  The evaluation relied on examination standards used for assessing clinical competency for board certification of U.S. dental school graduates.  Alaskan dental therapists are technically competent to perform the procedures within their scope of work and do so safely and appropriately.  After graduating and completing a 400-hour externship under the direct supervision of a dentist, dental therapists are certified to provide a limited scope of dental services under the general supervision of a dentist.  They successfully treat cavities and help to relieve pain for people who often had to wait months or travel hours to seek treatment; patient satisfaction with their care is very high; and, they are will-accepted in tribal villages.  The report further noted that severe shortages of dentists disproportionately affect low-income communities and communities of color; that lack of affordable dental care is putting sorely needed dental services out of reach for nearly 50 million Americans, particularly those in rural and underserved areas.  Hawaii=s federally qualified community health centers have been particularly supportive of this (r)evolution as access to dental care and/or behavioral health care has continued to be their top priorities over the past decade.  The dental therapists are well respected in their communities.  Because many dental therapists return to practice in their home communities, they typically have the cultural skills and language fluency needed to educate and motivate people towards behavioral change.  As role models they serve as important oral health advocates.  ASimply training more dentists will not solve this problem.  TheAlaska model is a community-driven solution that can work in communities across the country.@  Aloha,

 

Pat DeLeon, former APA President BDivision 29 B November, 2010

PPACA -- THE IMPLEMENTATION STAGE

As our nation experiences the steady implementation of President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act (PPACA), over the next five to ten years, it is important to appreciate that the bill was crafted primarily with consumers (i.e., patients) in mind and not clinicians.  Perhaps as legislative modifications are made, based upon practical experiences, we will eventually see the enactment of the Single Payer System which the liberals so vocally championed.  There are a multitude of questions to be answered.  For example, how will the provision which requires health insurance plans to utilize at least 80% to 85% of the premium dollars collected to pay medical bills or otherwise improve their customers' health, ultimately be interpreted?  Will this allow insurance companies to pay clinicians for upgrading their office computers or attending continuing education (CE) courses?  The nonpartisan Congressional Budget Office (CBO) estimates that PPACA will reduce the federal deficit by $143 billion over the first ten years of enactment, ensure that 94% of Americans have health insurance, and effectively bend the ever-escalating cost curve.  Does this suggest that with 76% of Medicare spending currently being for patients with five or more chronic diseases, that we will see a special, national focus upon this growing population?  It is simply too early to predict with any sense of certainty.  Change is always unsettling and takes time, especially when important.

It is useful to view the enactment of PPACA within its historical context.  On May 22, 1964 President Lyndon Johnson laid out his vision for a Great Society at a Universityof Michigan commencement, which at that time was the most attended non-football event in campus history.  "I have come today from the turmoil of your Capitol to the tranquility of your campus to speak about the future of your country.  The purpose of protecting the life of our Nation and preserving the liberty of our citizens is to pursue the happiness of our people.  Our success in that pursuit is the test of our success as a Nation.  For a century we labored to settle and to subdue a continent.  For half a century we called upon unbounded invention and untiring industry to create an order of plenty for all of our people.  The challenge of the next half century is whether we have the wisdom to use that wealth to enrich and elevate our national life, and to advance the quality of our American civilization.…  Will you join in the battle to build the Great Society, to prove that our material progress is only the foundation on which we build a richer life of mind and spirit?  There are those timid souls who say this battle cannot be won; that we are condemned to a soulless wealth.  I do not agree.  We have the power to shape the civilization that we want.  But we need your will, your labor, your hearts, if we are to build that kind of society.  Those who came to this land sought to build more than just a new country.  They sought a new world."  On July 30, 1965 the President signed P.L. 89-97, the Social Security Amendments of 1965, and thus made Medicare [and Medicaid] the law of the land.

During his address before his first Joint Session of Congress, President Obama held out a similar vision and challenge.  "We will rebuild, we will recover, and the United States of America will emerge stronger than ever….  The costs of health care eats up more and more of our savings each year, yet we keep delaying reform….  Now is the time to jumpstart job creation, re-start lending, and invest in areas like energy, health care, and education that will grow our economy, even as we make hard choices to bring our deficits down.…  (T)his is America.  We don't do what's easy.  We do what is necessary to move this country forward….  (W)e can no longer afford to put health care reform on hold….  I suffer no illusions that this will be an easy process.  It will be hard.  But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of health care has weighed down our economy and the conscience of our Nation long enough.  So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year."  Compelling visions provide the context within which day-by-day experiences shape specific implementation strategies.

Six months after enactment of PPACA, the Chairmen of the two Senate Committees which were most involved in crafting the legislation stated:  Finance -- "Americans have reason to celebrate.  The new law put Americaon the road to a more sustainable consumer-friendly health care system.  The new law putAmerica on the road to a healthcare system in which all Americans have access to quality, affordable health insurance.  And the new law put America on the road to a health care system in which patients and their doctors – not insurance companies – control patient care.  These transformative changes will not happen overnight….  Today, with this 6-month mark, we pass a key milestone on our road to providing quality, affordable health care to all Americans.  This milestone is justone of many along the road.  But this milestone is one that signals an end to the insurance companies' worst abuses."

Health, Education, Labor, and Pensions (HELP) -- "On September 23, the law's six-month anniversary, six major reforms kicked in.  Now the law: * Bans insurance companies from dropping patients' coverage….  * Bans denial of coverage for children with pre-existing conditions….  * Cracks down on benefit payment limits.  Insurance companies are prohibited from imposing lifetime dollar limits on essential benefits….  * Provides for appeal of insurance company decisions….  * Guarantees free preventive care….  * Extends coverage for young adults.  Young adults are now allowed to stay on the parents' plan until 26….  [And, mental health parity is finally the law of the land.]  As many predicted, the law is increasingly popular as Americans get better acquainted with its broad range of benefits and consumer protections….  Mark my words: Americans will not allow their hard-earned benefits and protections to be taken away.  We will stay the course, defending the strong reforms in this new law and creating a reformed insurance and health care system that works not just for the healthy and the wealthy but for all Americans."  President Obama's vision will ultimately curtail the ever-escalating costs of health care; enhance the availability of high quality Primary Care; make Wellness and Preventive Care a national priority, as well as eliminating racial and geographical Health Disparities; and empower Educated Consumers to take responsibility fortheir health care, utilizing the most up-to-date advances in the communications and technology fields (i.e., Health Information Technology, Telehealth, and the utilization of data-based Gold Standards of care).  The next decade will be very "interesting," for consumers and practitioners alike – truly uncharted waters.

The health care environment of the 21^st century in which psychology will practice will be increasingly interdisciplinary in nature.  California nurse-psychologist Ann Carson, reflecting upon the Nurse Managed Health Clinic provision in PPACA: "This is an amazing document and gives me hope for the future of nursing and health care.  In many ways, a return to the earlier practice of nursing within the public health realm would be a huge step forward.  I was taught prevention (primary prevention) in my nursing program in the late 1960s.  The rest of the health care world, especially medicine, seems a bit delayed in recognizing the value."

In December, 2009 President Obama issued a Memorandum for the Secretary of Health and Human Services, calling for a Medicare demonstration to test Medical Homes in federally qualified health centers.  "My Administration is committed to building a high-quality, efficient health care system and improving access to health care for all Americans.  Health centers are a vital part of the health care delivery system.  For more than 40 years, health centers have served populations with limited access to health care, treating all patients regardless of ability to pay….  There are over 1,100 health centers across the country, delivering care at over 7,500 sites.  These centers served more than 17 million patients in 2008 and are estimated to serve more than 20 million in 2010….  Health centers use interdisciplinary teams to treat the 'whole patient' and focus on chronic disease management to reduce the use of costlier providers of care, such as emergency rooms and hospitals.  Federally qualified health centers provide an excellent environment to demonstrate the further improvements to health care that may be offered by the medical homes approach.  In general, this approach emphasizes the patient's relationship with a primary care provider who coordinates the patient's care and serves as the patient's principal point of contact for care….  (They) also emphasize activities related to quality improvement… and coordination….  Therefore, I direct you to implement a Medicare Federally Qualified Health Center Advanced Primary Care Practice demonstration."

We fully expect that those colleagues who possess psychopharmacological skills will be at a distinct advantage in the ever-evolving healthcare system.  Accordingly, we were pleased to learn from Steve Tulkin that this September, the Postdoctoral Master of Science Program in Clinical Psychopharmacology at the California School of Professional Psychology at Alliant International Universitybegan its fourth National Cohort with close to 60 students.  Students attend classes live over the Internet, and can ask questions and participate in class discussions utilizing this technology.  Psychologists in 23 states (fromHawaii to New York) are participating in the class, and one psychologist is participating live from South Africa.  He spoke briefly during the first meeting of the class to thank his U.S. colleagues, and express his hope thatSouth Africa will enact prescriptive authority legislation in the next couple of years.  Aloha,

Pat DeLeon, former APA President – National Register – October, 2010

AN EXCITING JOURNEY – AN INCREASING NEED FOR VISION

            With the enactment of President Obama's landmark health care reform legislation, the Patient Protection and Affordable Care Act [PPACA] [P.L. 111-148], nursing, as well as the rest of our nation's health care system, entered an era of exciting and totally unprecedented opportunity.  One of my fondest memories of that cold Christmas-eve morning was seeing Tine and our then-DoD Nurse Detailee, Jacqueline Rychnovsky, heading off to watch the historical Senate passage of the comprehensive bill.  Included at Senator Inouye's request and Jacqueline's perseverance was the new Nurse Managed Health Clinic provision which the AMA opposed.  This Fall, the Senate passed resolutions celebrating the 25^th Anniversary of the National Institute of Nursing Research (NINR) and designating the first week of October as "National Nurse-Managed Health Clinic Week."  Nursing has come a long way.

            One of the hallmarks of a maturing profession is its commitment to effectively addressing society's pressing needs.  Michelle Obama has generated a concerted focus on Childhood Obesity.  The White House Task Force on Childhood Obesity -- "The Childhood obesity epidemic in America is a national health crisis."  One in every three children ages 2-15 is overweight or obese.  Obesity is estimated to cause 112,000 deaths per year and one-third of all children born in 2000 are expected to develop diabetes during their lifetime.  The current generation may even be on track to have a shorter lifespan than their parents.  The Task Force proposed 70 policy recommendations for developing a national plan of action: * creating a healthy start on life for our children, from pregnancy through early childhood; * empowering parents and caregivers to make healthy choices for their families; * serving healthier food in schools; * ensuring access to healthy, affordable food; and, * increasing opportunities for physical activity.  Not surprisingly, their vision is highly consistent with PPACA's emphasis upon prevention, wellness, and encouraging healthy lifestyles.  The envisioned family-oriented services reflect the essence of nursing practice.

            The Task Force urged that developers of local school wellness policies be encouraged to include strong physical activity components, on par with nutrition components.  Further, that social skill development should be actively encouraged and there should be an age- and developmentally- appropriate focus.  The business community should be encouraged to consider which resources and physical assets (e.g., fields and gyms) can be used to increase students' access to outdoor and indoor recreational venues; while the entertainment and technology companies should be encouraged to develop new approaches for using technology to engage children in physical activity.  These are all excellent suggestions for making a difference in the lives of our nation's families.

The Task Force pointed out that obese adults have an increased risk for many diseases, including type 2 diabetes, heart disease, some forms of arthritis, and several cancers.  Overweight and obese children are more likely to become obese adults.  Obesity is a highly stigmatizing condition and in addition to the physical health consequences, severely obese children report a lower health-related quality of life (a measure of their physical, emotional, educational, and social well-being).  Childhood obesity is also associated with some psychiatric disorders, including depression and binge-eating disorders, which may both contribute to, and be adversely impacted by obesity.  U.S. Women's Olympic Soccer Team mental skills coach, Colleen Hacker reports that one in four high school girls reports that she does not like herself; 53 percent of 13-year old girls are unhappy with their bodies, while 78 percent of 12 grade girls are unhappy with their bodies; and, one in three adolescent girls will experience depression, anxiety, or eating disordered behavior.  Among girls, physical inactivity is associated with withdrawn, depressed symptoms; somatic complaints, social and attention problems, and rule-breaking behaviors.  While one in two boys participate in high school sports, only one in three high school girls participate.  Women of color are underrepresented in 20 of the top 25 participation sports.

            The Institute of Medicine (IOM) has recently called for developing a New Conceptual Framework to help obesity prevention researchers determine useful areas of study.  "The real world is a complex system, and the many influences on the energy-balance equation are all interacting simultaneously.  A systems perspective helps decision makers and researchers think broadly about this whole picture rather than merely studying the component parts in isolation.  Such a perspective can help to frame, explain, and resolve complex problems such as obesity.  It can lead to a better understanding of interactions, and highlights the importance of taking into account the context in which public health problems occur and how that context may affect the implementation and impact of interventions….  The United Kingdom Government Office of Science undertook an extensive evidence review that resulted in the characterization of obesity as a complex system involving seven major subsystems: individual psychology, biology, activity, food consumption, food production, activity environment, and societal influences.  This map was then used to assess links and interactions among influences; simulate and consider possible future scenarios; and ultimately justify a comprehensive, cross-government, national action plan on obesity."  "There is increasing recognition that overweight and obesity are not just problems of individuals, but also society wide problems that have serious health consequences and costs and affect some population groups more than others.  Acting on this recognition will require multifaceted, population-based changes in the social and environmental factors that influence energy intake and expenditure."

            We would rhetorically ask: Where is nursing's vision and collective voice in this evolving national agenda?  A careful review of the White House Task Force report does not find any express mention of the potential contributions of our nation's Schools of Nursing or their students or graduates.  And yet patient-centered, family-centered care is the hallmark of nursing care.  In its 25 years of outstanding accomplishments, the National Institute of Nursing Research (NINR) has clearly demonstrated that nursing research, and especially patient-centered research, makes a significant difference in the lives of our nation's citizens.  As healthcare continues to transform and the focus of care transitions from a disease and illness perspective to a health promotion and disease prevention strategy, Nurse Practitioners will play an increasingly important role in the provision of primary care.  Over 200 Nurse-Managed Health Clinics are providing high quality care to vulnerable populations in medically underserved rural, suburban, and urban communities throughout the country.  The challenge for Nurse-Managed Health Clinics will be to implement this knowledge and equally importantly, to ensure that those who shape our nation's health policies come to appreciate nursing's contributions.  Therefore Nurse Practitioners must continue to lobby for federal and state recognition of the central role the profession can play in a revamped health system.  Aloha,

 

Lt. Col. Corina Barrow, DoD Nurse Detailee

Natalie Bridgeman, Native Hawaiian Nurse Fellow

Pat DeLeon, former American Psychological Association President

 

National Nursing Centers Consortium (NNCC) – September, 2010

 

A MATURING VIEW OF COLLEAGUES

It is important to consider how those outside our field perceive psychology.  For some time, Chuck Faltz of the California Psychological Association (CPA) has emphasized that collectively, we must act to form new political alliances, and especially those which focus upon mutually shared agendas.  Our profession's advocacy agendas will increasingly have to be done collaboratively, taking into account the specific goals of each of the stakeholders who have formed the alliance.  To be successful, this new way of participating in the political process will take leaders who are collaborative in nature and who have strong negotiating and communications skills, as well as, most importantly, a vision of the future of professional psychology.

From time to time, however, a vocal subset of our membership has urged their State Association to aggressively oppose efforts by other professions to expand their scopes of practice, often proffering a "public health hazard" argument.  Perhaps we have forgotten our frustrations when organized medicine took this same approach with our clinicians.  At our San Diego convention, former APA President Bill McKeachiereflected upon how when he first came to theUniversity of Michigan, their medical school had sought to close the psychology clinic, allegedly for "practicing medicine."  Another former APA President Ron Fox has noted on a number of occasions, that these efforts to constrain other professions are expensive and in the long run, simply do not work.  In today's ever changing health care environment, we must have the vision to work collaboratively with others to expand psychology's clinical presence by affirmatively demonstrating how our services can benefit patients.

            A report submitted to the Congress by the Department of Defense (DoD) this Spring should be illustrative.  In response to a provision in the National Defense Authorization Act for Fiscal Year 2008 (P.L. 110-181), DoD was directed to contract with the Institute of Medicine (IOM) of the National Academy of Sciences or another similarly qualified independent academic medical organization to conduct an independent study of the credentials, preparation, and training of individuals practicing as "licensed mental health counselors" and to make recommendations regarding permitting members of this profession to practice independently under the TRICARE program.

            Subsequently, IOM made the following recommendations regarding training and licensure requirements:  * A master's or higher-level degree in counseling from a program in mental health counseling or clinical mental health counseling that is accredited by the Council for Accreditation of Counseling and Related Educational Programs.  * A state license in mental health counseling at the "clinical" or the higher or highest level available in states that have tiered licensing schemes.  * Passage of the National Clinical Mental Health Counseling Examination.  And, * A well-defined scope of practice for practitioners.  DoD found these recommendations to be in accordance with expectations for education, training, and supervised experience for other health care providers permitted independent practice in the TRICARE program.  The IOM's report was felt to be important in clarifying the components of professional education critical to safety and effectively assessing and treating Service members and their families.  DoD concluded: "We believe that the findings of this study provide solid guidance to the Department to propose changes to regulation and policy to allow for the independent practice of licensed mental health counselors in the TRICARE program."  Unprecedented change is definitely on the horizon.  Those who recall the past will see the similarities with psychology's initial recognition under the DoD CHAMPUS program.  Aloha,

 

Pat DeLeon, former APA President – Division31 – September, 2010

 

SAN DIEGO – “MY KIND OF TOWN”

            The 118^th APA annual convention, which was held this August in San Diego, was extremely pleasant.  At the APF/APA Awards ceremony, Hawaii's Kathy McNamara and Paul Pedersen were recognized for their decades of outstanding and distinguished service to the public, both nationally and internationally.  And, HPA Council Representative Craig Robinson was elected a Fellow of the APA.  Our sincerest congratulations to our colleagues.  These are well deserved honors and tributes.  These are special and "exciting times."

 

            Children and Youth – Programmatic Involvement:  A frequent visitor to Hawaii, and long time friend of Kathy from theirWright State University days, Rodney Hammond of the Centers for Disease Control and Prevention (CDC) presented his Nicholas Hobbs Award address entitled "Violence Prevention and the 'Futures of Children' Today."  Division 37 (the Society for Child and Family Policy and Practice) annually honors the psychologist who exemplifies the ideals and devotion to child advocacy/policy characterized by this outstanding scholar.  Over the past several years, Rodney has been on the forefront of addressing childhood violence from a public health perspective (i.e., emphasizing its healthcare, as well as its social policy relevance).  Last Fall, the newly appointed Director of CDC expressed his similar perspective: "(C)hild maltreatment is a serious public health problem with extensive short- and long-term health consequences….  (M)altreatment causes stress that can disrupt early brain development, and extreme stress can harm the development of the nervous and immune systems…  Fortunately, there is a growing body of evidence that documents the effectiveness of primary prevention strategies."

 

            Rodney emphasized that Nicholas Hobb's vision for the future of children held many insights for violence prevention and public health policy, stressing the importance of the ecological model, the need for coordination of services, and the value of early intervention.  Rodney proposed the strategy that: On the individual level, * strengthen the personal capacity of youth to resist violence.  On the relationship level, * build and support positive relationships between youth and adults.  On the community level, * promote thriving, safer, and more connected communities.  And, on society's level, * create a safer and healthier society.  In enacting his landmark Health Care Reform legislation, President Obama envisioned a national program supporting home visitation and provided $100 million in funding for this fiscal year, with the expectation that home visitation for high risk families could reduce child maltreatment by up to 40 percent.

 

            Rodney emphasized that there is a definite need for data-driven strategies to measure progress.  Under the leadership of Karen Saywitz, the APA has been working closely with CDC to identify a number of public health strategies and interventions which would promote positive parenting practices within the context of federally qualified community health centers, and particularly seeking opportunities for parenting interventions.  The CDC teen dating violence initiative is currently targeting 11-14 year olds in high-risk urban communities, again adapting evidence-based and promising prosocial skill programs.  Rodney further stressed that violence is preventable and that intervening early is critical.  Conceptualizing violence prevention programs within a public health model, provides the foundation for efforts to integrate parenting programs into primary healthcare which will ultimately be highly cost-effective and is consistent with the President's personal priority on enhancing wellness, prevention, and increasing access to primary healthcare.

 

            Children and Youth – Sports:  On a personal level, I truly enjoyed again having the opportunity to present with another frequent visitor to Hawaii, Colleen Hacker and her colleague Karen McConnell.  Colleen is the mental skills coach for the US Women's World Cup and Olympic Soccer Team and over the years has systematically addressed the importance of physical activity for girls.  Relevant statistics:  one in every six girls is obese or overweight; one in four girls grades 9-12 currently smokes; one in four high school girls reports that she does not like herself; 53 percent of 13-year old girls are unhappy with their bodies, while 78 percent of 12 grade girls are unhappy with their bodies; and, one in three adolescent girls will experience depression, anxiety, or eating disordered behavior.  Among girls, physical inactivity is associated with withdrawn, depressed symptoms; somatic complaints, social and attention problems, and rule-breaking behaviors.  While one in two boys participate in high school sports, only one in three high school girls participate.  Women of color are underrepresented in 20 of the top 25 participation sports.  Gender disparity in participation is even more pronounced when coupled with family income. 

 

            Research shows that involvement in sports can result in lifelong improvements to education, work, and health.  The increase in girls' athletic participation following passage of Title IX (Patsy T Mink Equal Opportunity in Education Act) was associated with a 7 percent lower risk of obesity 20-25 years later.  High school female athletes (compared to non-athletes) are less likely to experience unwanted pregnancy; more likely to get higher grades; more likely to graduate from high school; and more likely to have higher levels of self-confidence, self-esteem, and lower levels of depression.   They are also more likely to be physically active for life.  Those who are active have lower risks for breast cancer, osteoporosis, smoking, and illicit drug use.  Colleen emphasized the availability of mentors is extremely important.  Reflecting, a number of HPA's members pride themselves on being physically active, if not former athletes.  Perhaps HPA could play a catalytic role in facilitating mentorship opportunities, especially through our state's federally qualified community health centers.  These centers (and our Native Hawaiian health centers) are society's "safety net."  Their beneficiary populations represent the underserved that psychology and President Obama seek to serve.

 

            A Maturing Presence (EBTs):  An evolving priority within the Obama Administration is to ensure that our nation's health care practitioners embrace evidence-based practices and treatments (EBTs).  The Institute of Medicine (IOM) has consistently reported that: "The lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of about 15 to 20 years.  Even then, adherence of clinical practice to the evidence is highly uneven."  And, that: "(T)he critical importance of evidence-based decision making does not yet seem to be on the radar screen of the majority of physician and hospital leaders, although the tipping point may be near."

 

            The Department of Veterans Affairs (VA) has been in the forefront of this evolution.  Joan Zweben, however, has recently raised several fundamental concerns regarding the implementation process.  * The selection process was neither collaborative nor transparent as the decisions were being made.  Treatments with weak evidence were selected while others with strong evidence were omitted.  Without transparent criteria and an open process, the rationale is mysterious and there is too much room for personal preferences of the decision makers.  * A commitment to a scientific process means that interventions shown to produce good results in efficacy trials (rigorous, tightly controlled) are then studied in effectiveness trials to see if they bring benefit in real world settings.  There appear to be few if any multi-site effectiveness studies conducted on VA populations for the designated treatments, so we don't know much about the level of improved outcomes that can be expected.  * How was it determined that the effect sizes were worth the transition costs?  In general, effectiveness is reduced when treatments are implemented in real world situations, and in many cases the effect sizes in the random assignment studies are modest.  * The "pick from this list" approach stifles innovation and rigidifies the treatment system.  It can promote a return to "cookie-cutter" treatment, rather than individualized treatment.  In the VA, this would also have impact on recruiting and training students, narrowing their range of skills.  * It appears that no attention has been given to the consistent research finding that the therapeutic relationship has a more powerful influence than any specific intervention in determining outcomes.  Multi-site effectiveness trials show variability of outcomes among the clinicians, despite the presence of fidelity checks.  Interventions such as Motivational Enhancement Strategies that strengthen the therapeutic alliance were omitted from the approved list.

 

The VA should seek to: * Establish the baseline.  Look at our current outcomes, determine which programs have the best outcomes, (excluding the possibility of significant differences in patient characteristics), and which need improvement.  * Examine what they are doing that is working or not working.  * Don't freeze the list.  There are usually multiple pathways to the goal.  And, * Include outside experts.  The VA Health Administration operates the largest federal medical care delivery system in the country, with 153 hospitals, 90 VA residential rehabilitation treatment programs, 135 nursing homes, and 1,031 outpatient clinics.  VA's experience and policies with EBTs will have a dramatic impact upon the rest of the nation, including the private sector.  These are "exciting times."  Aloha,

 

 

Pat DeLeon, former APA President – Hawaii Psychological Association – September, 2010