LICENSURE MOBILITY

            Over the years, psychology's elected leadership has increasingly called for focused attention upon the importance of facilitating licensure mobility.  Stan Moldawsky obtained the endorsement of the APA Council of Representatives slightly over a decade ago and mobility was a significant topic at James Bray's 2009 Presidential Summit on the Future of Psychology.  James notes: "Australia implemented national licensure in 2010 – it was a challenge to get it started, but initial reports indicate that it has helped psychologists practice across the vast country and better serve the broadly dispersed population from the cities to the outback.  The Australia Psychological Society was the key mover of this legislative change."  This Spring, HRSA submitted its report to Congress on licensure portability, assessing the level of cooperation among the various licensing boards and evolving models.  "Licensure portability is seen as one element in the panoply of strategies needed to improve access to quality health care services through the deployment of telehealth and other electronic practice services (e-care or e-health services) in this country….  Overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals in order to address workforce needs and improve access…."

            Steve DeMers, Association of State and Provincial Psychology Boards (ASPPB): "In addition to our Credentials Bank, Disciplinary Data System and Certificate of Professional Qualification programs that promote mobility, we are also pilot testing in two jurisdictions a Uniform Application for Psychology Licensure system.  In these two jurisdictions, applicants for licensure will actually apply through ASPPB and we will both primary source verify and store the applicant's licensure related information before transmitting it to the jurisdiction for a licensure decision.  We are largely following the Federation of State Medical Boards (FSMB) model of expedited licensure rather than the Nursing Compact approach.  ASPPB is planning on seeking a federal (HRSA) grant to support model programs to expedite licensure as a means of promoting telepractice."

Examples of the magnitude of change just over the horizon: HHS has proposed regulations to assist rural patients, under which practitioners credentialed at one hospital would be allowed to utilize telemedicine – interacting with a patient over interactive video devices – even if they are not credentialed at the hospital where the patient is receiving care.  The House of Representatives Department of Defense (DoD) authorization act includes a provision expanding the state licensure exception to include qualified and credentialed contractor and civilian health care professionals, in order to allow the National Guard, reserves, veterans, and retirees quicker and more efficient access to care.  "This amendment will allow for new technologies in telephone and Internet communications to expand into the [DoD], which will greatly expand access, especially in rural America.  It will also allow more specialists to be involved in providing care….  (Quoting the Vice Chief of Staff of the Army): 'The Army, like the larger American society, is suffering from a shortage of behavioral health specialists, and that is, in fact, a national crisis.  Efforts in tele-behavioral health – allowing specialists to meet with patients through teleconferencing technology, for instance – could increase the effectiveness and reach of a limited number of providers….  There are challenges regarding the credentialing and licensing of specialists to work across State lines.'"

We would rhetorically ask: Have our State Association members engaged in discussions with their own licensure board in order to ensure that licensure mobility becomes a significant priority?  Currently, 24 States have adopted the Nursing Compact approach; 37 States are in some phase of implementation of the FSMB Uniform Licensure Application approach.  Where are your State Association and Licensing Board in this important discussion?  Aloha,

 

Pat DeLeon, former APA President – Division31 – June, 2011

 

 

AN EXCITING VISION FOR THE FUTURE

The Department of Veterans Affairs:  I recently had the opportunity to attend the 14^th annual VA Psychology Leadership Conference, "Innovation through Leadership, Research, Service, and Advocacy."  This was the largest gathering in their history with over 200 excited colleagues attending, many for the first time.  Maui'sKathy McNamara and Kathleen Piercerepresented Hawaii.  APA President Melba Vasquez gave a truly inspiration report on the Association's efforts on behalf of our nation's veterans, as well as her Presidential initiatives; for example, carefully addressing the needs of our increasing immigrant population. Katherine Nordal and Randy Phelps from the Practice Directorate highlighted the importance of psychology seeing itself as a bona fide health care profession and working hard to ensure that our nation's health policy experts (including those in the White House) appreciate all that we can bring to their vision.  VA Central Office was well represented.  I was very pleased with the extent to which Bob Zeiss has been systematically expanding our post-doctoral presence; this year funding 267 positions at 58 sites in 31 states and the District of Columbiaand Puerto Rico.

Over half of our profession's clinicians have had some VA training experience.  Many of us grew up in families in which loved ones served in the military.  VA is working hard to transform itself into a veteran-centric, highly responsive integrated health care system utilizing the most up-to-date technology to provide state-of-the-art care.  Historically practitioner-comfortable "silos" must give way to interdisciplinary, coordinated care.  VA will attract retiring DoD colleagues with their unique veteran's perspective.  And, with the military already authorizing prescriptive authority, VA will eventually follow suit.  The federal sector has a unique opportunity, with its considerable resources and national presence, to bring the rest of the health care world into the 21^st century capitalizing upon the unprecedented developments occurring within the health information technology (HIT) environment.  Is there, for example, any meaningful difference between on-site supervision and that conducted via telehealth?  At the highest level, VA and DoD are committed to integrating their electronic health records.  This will allow seamless care from active duty to retirement, and across-patient and family comparisons of effectiveness and need.  VA visionaries Toni Zeiss and Lisa Kearney truly did an outstanding job.

            "Telepsychology is knocking:  The key to responsible use in our clinical work is the training of psychologists regarding the existing legal, ethical, and clinical issues involved with not only e-mail but video-chat such as Skype, Facebook, text messaging, iPhone apps, as well as a number of other technologies.  Handling the barrage of new electronic services promising to make practice 'easier' is fraught with nuances that are difficult for the average clinician to detect.  Privacy and confidentiality; licensure and other regulatory issues; patient and practitioner authentication; HIPPA requirements; appropriate online professionalism, including boundaries in social media sites; treatment ramifications of searching for patient information online; reputation management and reacting to negative reviews in online rating websites; mandated reporting of abuse or suicide and homicide intent; what to include in the informed consent discussion and document; what to include in the patient record; how online technology is likely to evolve, including the electronic health records and what they mean for psychologists – all these issues are at our doorstep.  When the patient floats from one to another technology and asks that the psychologist accommodate him or her, what is the responsible psychologist to do?" (Marlene Maheu, a visionary leader in telehealth).

            An Interdisciplinary Perspective:  Sandy Harding, MSW, with the AmericanAcademy of Physician Assistants: "The physician assistant (PA) profession was created over 40 years ago in response to a shortage of primary care physicians.  In 1970, there were approximately 250 PAs.  Today, over 75,000 PAs provide high quality, cost effective care in virtually all health care settings and in every medical and surgical specialty.  PAs are one of three health care professionals providing primary medical care in the U.S.  By design, PAs always practice in teams with physicians, extending the reach of medicine and the promise of health care to the most remote and in need-communities.  PAs often provide autonomous medical care, have their own patient panels, and are granted prescribing authority in all 50 states.  In 2009, nearly 300 million patient visits were made to PAs.  By all accounts, the primary health care workforce must grow in order to provide care to the individuals and families who will receive access to covered medical care as a result of the implementations of President Obama's Patient Protection and Affordable Care Act.  PAs are a key part of the solution to today's and tomorrow's health care workforce shortage.  However, to fully utilize PAs in the nation's primary care workforce, Congress must: * Eliminate unnecessary federal barriers to the quality medical care provided by PAs; and, * Integrate PAs into all federal programs designed to promote growth in the primary care workforce.  Currently, for example, Medicare imposes a barrier to hospice care and the Federal Employees' Compensation Act will not honor a clinic-based claim where the PA is the only health care worker on site, but will provide for reimbursement in a hospital emergency room."

            A Historical Perspective:  Jerry Michael, former Dean of the University of Hawaii School of Public Health and Assistant Surgeon General of the U.S. Public Health Service, prophetically observed in 1968: "For broad planning purposes, we can project long-range trends in health manpower supply and demand.  In contrast to our scientific and economic successes and people's expectations based upon them, we see gross inadequacies in trained manpower.  I cannot emphasize too strongly that the value of any auxiliary health worker is directly proportional to the quality of his training and the quality of his supervision.  Quality training and quality supervision are essential.  It is also essential to determine just what jobs the workers are to do – and where – and to train them for the specific jobs.  These precepts are so elementary that it is almost redundant to state them, yet we see all too many instances in which these obvious first steps have been forgotten or overlooked.  The keystone in better utilization of health care facilities is improved planning, training, and education.  Thus it would follow that these elements are equally crucial in the utilization of health personnel.  In addition, planning aimed at the most effective use of health manpower must also be responsive to changing knowledge and social changes and to the increasing expectations of health service consumers.  The scarcity of health manpower must be viewed as both a national and a local problem, and the approach to its solution must be systematic, based on sound knowledge of the makeup of the health system and with the needs of the patient identified and kept paramount."  VA, DoD, and increasinglyHawaii's political leadership appreciate this vision.  Above all else, our system must be patient-centered and no longer concerned with being highly provider comfortable.  Aloha,

Pat DeLeon, former APA President – HPA – June, 2011