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