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

A GLIMPSE AT AN EVOLVING PRACTICE ENVIRONMENT

            The Institute of Medicine (IOM) Roundtable on Evidence-Based Medicine recently conducted a workshop, "Leadership Commitments to Improve Value in Health Care: Finding Common Ground."  The IOM established the Roundtable in 2006 "as a unique and neutral venue where the key stakeholders could work cooperatively to help transform the way in which evidence on clinical effectiveness is generated and used to improve health and health care and to drive improvements in the effectiveness and efficacy of medical care in the United States."  Central to the IOM vision is the notion that collectively, the healthcare sectors possess the knowledge, expertise, and leadership necessary to transform the healthcare system and that what is most acutely needed is a shared commitment to improving the development and use of information about the efficacy, safety, effectiveness, value, and appropriateness of the health care delivered.  The underlying objective is to develop a "learning healthcare system" in which, by the year 2020, 90% of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence.  The three stated goals were: (1) To consider stakeholder capacity for stronger progress toward a "learning healthcare system;" (2) To explore transformational opportunities; and, (3) To identify possibilities for collective initiatives that might be considered by Roundtable sectors.  The participants included high level officers from the Mayo Clinic, Blue Shield of California, National Business Group on Health, Consumers Union, AMA, SEIU, CMS, VA, and a number of other impressive organizations.

            Common Concerns and Themes:  *  Rising costs and limited resources.  System inefficiencies.  Increasing complexity.  Expanding evidence gap.  Limited system capacity and flexibility.  And, Entrenched cultures.  *  Build trust and collaboration. Foster agreement on "value" in health care.  Improve public understanding of evidence.  Characterize the impact of shortfalls in the evidence.  Identify the priorities for evidence development.  Improve the level, quality, and efficiency of the research.  Clarify and promote transparency.  Establish principles for the interpretation and use of evidence.  Improve engagement in the full life cycle of interventions.  Focus on frontline providers.  Foster a trusted intermediary for evidence.  Build the capacity to meet the demand.  Create incentives for change.  And, Accelerate advances in health information technology (HIT).   The envisioned "learning healthcare system" is one that maintains a constant focus on the health and economic value returned by care delivered and continuously improves in its performance.

The workshop participants felt that broad culture change is especially needed to enable the evolution of the learning environment as a common partnership of patients, providers, and researchers alike.  Currently, health care has various customs and practices which often are not conducive to reform.  Caregiving and caregivers are often "siloed," with inadequate communications among the various functional areas of the healthcare system.  Information is not shared as widely as it should be within specific healthcare systems, let alone between systems, contributing to inefficiency and distrust in the system.  In general, providers, patients, and other sectors do not yet believe that the development of evidence is an activity relevant to their experience in the routine delivery of care.  Accordingly, the point of care must be the central focus for this continuous learning process – a major point, which Steve Ragusea has been making to psychology's leadership for over a decade.

Intriguing Notions:  Accelerating the potential for better development and application of evidence requires improved communication between patients and clinicians about the nature of the evidence base and the need for partnership in its development and use.  Leadership is required from every quarter – strong, visible, and multifaceted leadership from all involved sectors to marshal the vision, nurture the strategy, and motivate the actions necessary to create the "learning healthcare system" desired.  "Workshop discussions were largely predicated on a central belief that evidence-based care should be delivered by interdisciplinary teams, an approach that requires a significant shift in the culture of health care, including embracing the patient as part of the team.  To make team-driven care the norm, attention is needed on retooling practices in the areas of clinical education, ongoing training, testing, and credentialing for front-line healthcare providers.  The development of decision tools and prompts for use in the practice setting and the establishment of infrastructures to improve the focus, accessibility, use, and generation of the best evidence by providers would also help make evidence-based, team-driven care the norm.  Similarly, practices could be designed and implemented to ensure that existing data from patient care loops back to inform the generation of new evidence.  Other levers noted to promote broader uptake of the use of evidence in clinical practice include education, payments, measurement and assessment, enhanced patient engagement, and reporting requirements."

This overarching vision is proposed within the context that 89% of physicians work in solo practices or small-group practices (less than 10 physicians, with 50% working with four colleagues or fewer); a similar situation probably exists for psychologists.  Because information in the healthcare system is presently partitioned into "silos" without connectivity, a clinical data and analytic infrastructure must be created to enable evidence-based medicine, especially since physicians spend 60% of their time seeking data.  The importance of developing trust among the various stakeholders, as well as encouraging interdisciplinary collaboration, are major reoccurring themes.

Yet, during the recent Congressional deliberations on President Obama's healthcare reform legislation, in their December 1, 2009 letter to the Senate Majority Leader, the AMA shared its view: "In lieu of the proposed nurse-managed health clinics, the AMA supports fully integrated multidisciplinary health care teams that are comprised of nurses and other health care professionals, which are led by physicians to ensure that patients get the best possible care" [highlighted in the actual letter].  The nurse-managed clinic provision was retained in the final version of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148), notwithstanding the AMA's expressed concern.  Today, pharmacists make up the third largest group of healthcare professionals.  Having matured to requiring the doctor of pharmacy or clinical pharmacy degree as their educational standard, their members are providing an increasingly wide range of health services (including behavioral health) to their patients.

Change Is Coming:  It has consistently been reported that not only does care vary significantly for reasons unrelated to appropriateness, but that even when the available evidence strongly supports a regimen of care – i.e., identified best practices exist – such care is received, on average, only half of the time.  It should not be surprising, therefore, that in general, the public is not aware of the concept of evidence-based medicine, nor does the current terminology used to describe the concept resonate with consumers when presented to them.  We have a long way to go in developing the necessary level of "health literacy" among the general population.  The IOM estimates, for example, that more than 47% of adults have difficulty locating, matching, and integrating information in texts.  In fact, studies indicate that a majority of Americans get their health information from the media.  Today's consumers are largely unaware of the variability in healthcare quality and do not have adequate information with which to make informed healthcare decisions that are based on evidence and that reflect their values and preferences.  Currently, the results of 10,000 randomized control trials (RCTs) are published each year.  "The complexity of modern medicine exceeds the inherent limitations of the unaided human mind."  "(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."  A major challenge --  "(T)he United States devotes less than one-tenth of a percent of its total healthcare expenditures to understanding how well health care works and how to improve it, an amount that is small compared with the amounts invested to understand other major segments of the economy."

Russell Lemle points out that "The VA has been in the forefront of promoting the use of evidence based psychotherapies (EBPs) for mental health problems.  However, they have instituted a narrow subset of EBPs (without transparent selection criteria) in a manner that limits VA clinicians' use of the broader array of best available evidence-based interventions."  Reflecting the concerns of many clinicians, Morgan Sammons cautions that: "What is eminently clear is that the effect size of EBTs often does not differ substantially from the effect size of treatment as usual.  There is often an .05 or better statistical difference between EBTs and a wait list or sham condition, but the difference becomes much smaller when you compare two active treatments.  It's quite disconcerting to the developers of evidence based treatments but there it is.  This is likely an expression of the 'Wampold factor' – all active credible treatments are about as good as any other active credible treatment.  So rather than focusing on a narrow subset of EBTs, we should look at those components of active credible treatments that make them in general somewhat, although not terribly, effective.  Perhaps it would be more efficacious and ecologically valid to focus on disease management strategies, rather than overly focusing upon a specific intervention that may not be applicable to many patients outside the confines of randomized trials.  We live in a world of nonspecificity of effect – and it doesn't make a lot of sense to devise highly elaborate, specific treatments for a range of conditions that don't respond to highly elaborate, specific treatments any better than they do nonspecific ones.  This isn't antiscientific – indeed, it's quite a scientific opportunity – but it defies the probability based analyses that the real 'scientific' psychology has become endeared of."

The Commonwealth Fund:  "Using Pharmacists, Social Workers, and Nurses to Improve the Reach and Quality of Primary Care.  As the landmark health reform law goes into effect, bringing millions of uninsured Americans onto insurance rolls over the next five years, demand for primary care services will increase.  So, too, will demand for more accessible, effective, and efficient models of primary care.  Rather than hiring more primary care physicians, many medical practices, health centers, and other primary care settings have been experimenting with innovative models of care that both extend the reach of primary care physicians and increase the quality of ambulatory services...  [bringing] pharmacists, social workers, nurses, and nurse practitioners to primary care practices.  With them comes a new set of skills that can improve care and lower costs for patients with depression, physical disabilities, and other conditions that have proven difficult to treat in primary care settings….

"The Commonwealth Care Alliance invested heavily in the model – spending approximately $4 million on 25 practices, many of which are located in low-income, safety net clinics.  The investment, which covers the cost of hiring the nurse practitioners by the primary care practices and investing in infrastructure such as electronic medical records, is more than offset in reductions in hospitalizations for preventable conditions as well as delays in nursing home placements…."

Dramatic Change Is Coming:  Over the next five years, we will witness the systematic implementation of what is perhaps the most significant social legislation enacted by the Congress since the Great Society programs of President Lyndon Johnson.  Change is definitely coming.  This could well be an extremely exciting era for our profession's prescribing psychologists.  Those with vision and perseverance will thrive and flourish.  Aloha,

 

Pat DeLeon, former APA President – Division 55 – September, 2010

A GLIMPSE AT AN EVOLVING PRACTICE ENVIRONMENT

A GLIMPSE AT AN EVOLVING PRACTICE ENVIRONMENT

            The Institute of Medicine (IOM) Roundtable on Evidence-Based Medicine recently conducted a workshop, "Leadership Commitments to Improve Value in Health Care: Finding Common Ground."  The IOM established the Roundtable in 2006 "as a unique and neutral venue where the key stakeholders could work cooperatively to help transform the way in which evidence on clinical effectiveness is generated and used to improve health and health care and to drive improvements in the effectiveness and efficacy of medical care in the United States."  Central to the IOM vision is the notion that collectively, the healthcare sectors possess the knowledge, expertise, and leadership necessary to transform the healthcare system and that what is most acutely needed is a shared commitment to improving the development and use of information about the efficacy, safety, effectiveness, value, and appropriateness of the health care delivered.  The underlying objective is to develop a "learning healthcare system" in which, by the year 2020, 90% of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence.  The three stated goals were: (1) To consider stakeholder capacity for stronger progress toward a "learning healthcare system;" (2) To explore transformational opportunities; and, (3) To identify possibilities for collective initiatives that might be considered by Roundtable sectors.  The participants included high level officers from the Mayo Clinic, Blue Shield of California, National Business Group on Health, Consumers Union, AMA, SEIU, CMS, VA, and a number of other impressive organizations.

            Common Concerns and Themes:  *  Rising costs and limited resources.  System inefficiencies.  Increasing complexity.  Expanding evidence gap.  Limited system capacity and flexibility.  And, Entrenched cultures.  *  Build trust and collaboration. Foster agreement on "value" in health care.  Improve public understanding of evidence.  Characterize the impact of shortfalls in the evidence.  Identify the priorities for evidence development.  Improve the level, quality, and efficiency of the research.  Clarify and promote transparency.  Establish principles for the interpretation and use of evidence.  Improve engagement in the full life cycle of interventions.  Focus on frontline providers.  Foster a trusted intermediary for evidence.  Build the capacity to meet the demand.  Create incentives for change.  And, Accelerate advances in health information technology (HIT).   The envisioned "learning healthcare system" is one that maintains a constant focus on the health and economic value returned by care delivered and continuously improves in its performance.

The workshop participants felt that broad culture change is especially needed to enable the evolution of the learning environment as a common partnership of patients, providers, and researchers alike.  Currently, health care has various customs and practices which often are not conducive to reform.  Caregiving and caregivers are often "siloed," with inadequate communications among the various functional areas of the healthcare system.  Information is not shared as widely as it should be within specific healthcare systems, let alone between systems, contributing to inefficiency and distrust in the system.  In general, providers, patients, and other sectors do not yet believe that the development of evidence is an activity relevant to their experience in the routine delivery of care.  Accordingly, the point of care must be the central focus for this continuous learning process – a major point, which Steve Ragusea has been making to psychology's leadership for over a decade.

Intriguing Notions:  Accelerating the potential for better development and application of evidence requires improved communication between patients and clinicians about the nature of the evidence base and the need for partnership in its development and use.  Leadership is required from every quarter – strong, visible, and multifaceted leadership from all involved sectors to marshal the vision, nurture the strategy, and motivate the actions necessary to create the "learning healthcare system" desired.  "Workshop discussions were largely predicated on a central belief that evidence-based care should be delivered by interdisciplinary teams, an approach that requires a significant shift in the culture of health care, including embracing the patient as part of the team.  To make team-driven care the norm, attention is needed on retooling practices in the areas of clinical education, ongoing training, testing, and credentialing for front-line healthcare providers.  The development of decision tools and prompts for use in the practice setting and the establishment of infrastructures to improve the focus, accessibility, use, and generation of the best evidence by providers would also help make evidence-based, team-driven care the norm.  Similarly, practices could be designed and implemented to ensure that existing data from patient care loops back to inform the generation of new evidence.  Other levers noted to promote broader uptake of the use of evidence in clinical practice include education, payments, measurement and assessment, enhanced patient engagement, and reporting requirements."

This overarching vision is proposed within the context that 89% of physicians work in solo practices or small-group practices (less than 10 physicians, with 50% working with four colleagues or fewer); a similar situation probably exists for psychologists.  Because information in the healthcare system is presently partitioned into "silos" without connectivity, a clinical data and analytic infrastructure must be created to enable evidence-based medicine, especially since physicians spend 60% of their time seeking data.  The importance of developing trust among the various stakeholders, as well as encouraging interdisciplinary collaboration, are major reoccurring themes.

Yet, during the recent Congressional deliberations on President Obama's healthcare reform legislation, in their December 1, 2009 letter to the Senate Majority Leader, the AMA shared its view: "In lieu of the proposed nurse-managed health clinics, the AMA supports fully integrated multidisciplinary health care teams that are comprised of nurses and other health care professionals, which are led by physicians to ensure that patients get the best possible care" [highlighted in the actual letter].  The nurse-managed clinic provision was retained in the final version of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148), notwithstanding the AMA's expressed concern.  Today, pharmacists make up the third largest group of healthcare professionals.  Having matured to requiring the doctor of pharmacy or clinical pharmacy degree as their educational standard, their members are providing an increasingly wide range of health services (including behavioral health) to their patients.

Change Is Coming:  It has consistently been reported that not only does care vary significantly for reasons unrelated to appropriateness, but that even when the available evidence strongly supports a regimen of care – i.e., identified best practices exist – such care is received, on average, only half of the time.  It should not be surprising, therefore, that in general, the public is not aware of the concept of evidence-based medicine, nor does the current terminology used to describe the concept resonate with consumers when presented to them.  We have a long way to go in developing the necessary level of "health literacy" among the general population.  The IOM estimates, for example, that more than 47% of adults have difficulty locating, matching, and integrating information in texts.  In fact, studies indicate that a majority of Americans get their health information from the media.  Today's consumers are largely unaware of the variability in healthcare quality and do not have adequate information with which to make informed healthcare decisions that are based on evidence and that reflect their values and preferences.  Currently, the results of 10,000 randomized control trials (RCTs) are published each year.  "The complexity of modern medicine exceeds the inherent limitations of the unaided human mind."  "(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."  A major challenge --  "(T)he United States devotes less than one-tenth of a percent of its total healthcare expenditures to understanding how well health care works and how to improve it, an amount that is small compared with the amounts invested to understand other major segments of the economy."

Russell Lemle points out that "The VA has been in the forefront of promoting the use of evidence based psychotherapies (EBPs) for mental health problems.  However, they have instituted a narrow subset of EBPs (without transparent selection criteria) in a manner that limits VA clinicians' use of the broader array of best available evidence-based interventions."  Reflecting the concerns of many clinicians, Morgan Sammons cautions that: "What is eminently clear is that the effect size of EBTs often does not differ substantially from the effect size of treatment as usual.  There is often an .05 or better statistical difference between EBTs and a wait list or sham condition, but the difference becomes much smaller when you compare two active treatments.  It's quite disconcerting to the developers of evidence based treatments but there it is.  This is likely an expression of the 'Wampold factor' – all active credible treatments are about as good as any other active credible treatment.  So rather than focusing on a narrow subset of EBTs, we should look at those components of active credible treatments that make them in general somewhat, although not terribly, effective.  Perhaps it would be more efficacious and ecologically valid to focus on disease management strategies, rather than overly focusing upon a specific intervention that may not be applicable to many patients outside the confines of randomized trials.  We live in a world of nonspecificity of effect – and it doesn't make a lot of sense to devise highly elaborate, specific treatments for a range of conditions that don't respond to highly elaborate, specific treatments any better than they do nonspecific ones.  This isn't antiscientific – indeed, it's quite a scientific opportunity – but it defies the probability based analyses that the real 'scientific' psychology has become endeared of."

The Commonwealth Fund:  "Using Pharmacists, Social Workers, and Nurses to Improve the Reach and Quality of Primary Care.  As the landmark health reform law goes into effect, bringing millions of uninsured Americans onto insurance rolls over the next five years, demand for primary care services will increase.  So, too, will demand for more accessible, effective, and efficient models of primary care.  Rather than hiring more primary care physicians, many medical practices, health centers, and other primary care settings have been experimenting with innovative models of care that both extend the reach of primary care physicians and increase the quality of ambulatory services...  [bringing] pharmacists, social workers, nurses, and nurse practitioners to primary care practices.  With them comes a new set of skills that can improve care and lower costs for patients with depression, physical disabilities, and other conditions that have proven difficult to treat in primary care settings….

"The Commonwealth Care Alliance invested heavily in the model – spending approximately $4 million on 25 practices, many of which are located in low-income, safety net clinics.  The investment, which covers the cost of hiring the nurse practitioners by the primary care practices and investing in infrastructure such as electronic medical records, is more than offset in reductions in hospitalizations for preventable conditions as well as delays in nursing home placements…."

Dramatic Change Is Coming:  Over the next five years, we will witness the systematic implementation of what is perhaps the most significant social legislation enacted by the Congress since the Great Society programs of President Lyndon Johnson.  Change is definitely coming.  This could well be an extremely exciting era for our profession's prescribing psychologists.  Those with vision and perseverance will thrive and flourish.  Aloha,

 

Pat DeLeon, former APA President – Division 55 – September, 2010