THE ERA OF TRANSFORMATION

 When The Moon Is In The Seventh House.  And Jupiter Aligns With Mars.  As our nation's health care costs continue to rise faster than almost any other segment of our economy -- expenditures of $2.6 trillion in 2010, or over 10 times the $256 billion in 1980 -- the health care environment is undergoing unprecedented transformation.  In many ways, "bending the cost curve" has become the rationale for instituting substantive changes which health policy experts, particularly those at the Institute of Medicine (IOM), have recommended for decades.  A key element of President Obama's landmark Patient Protection and Affordable Care Act (PPACA) is dramatically increasing the availability of quality primary care, with an emphasis upon patient-centered (definitely not provider-centric) services.  It is estimated that chronic disease treatment currently accounts for over 75% of expenditures, with obesity being a major contributor.  Chronic pain, for example, affects at least 116 million American adults – more than the total for heart disease, cancer, and diabetes combined.  Pain costs the nation $635 billion each year in treatment and lost productivity.  Accordingly, prevention, public health strategies, effective utilization of technology (e.g., telehealth, informatics, and virtual treatment modalities), as well as behavioral expertise will become of increasing clinical and policy importance.  Change is always unsettling.  This movement away from traditional fee-for-service, small (often solo) practice models towards accountability, reimbursing for demonstrated outcomes, and large systems of care (e.g., Accountable Care Organizations (ACOs)) is definitely difficult for our senior practitioners and educators.  Interdisciplinary collaboration and integrated care are the future.  To achieve this laudatory goal, practice and education must increasingly work together.

This past Summer, six major professional educational organizations released the report Core Competencies for Interprofessional Collaborative Practice.  This visionary effort by the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges (AAMC), and the Association of Schools of Public Health lays out a strategic plan for implementing a number of recommendations made by the IOM over the past 40 years.  The underlying objective is to ensure safe, high quality, accessible, patient-centered care.  It will not be easy to establish a culture of interprofessional learning and genuine respect for the competence of others.  There is a long history of "turf wars" under the banner of "patient safety."   Nevertheless, it is important to appreciate that How care is delivered is steadily becoming appreciated as being as important as What care is delivered.  Developing effective teams and redesigned systems is critical.  These underlying concepts are reflected in PPACA's ACO and medical home provisions.  On a personal level, having retired from the U.S. Senate staff after 38+ years, I look forward to working on these intriguing issues from a university perspective.

The underlying purpose of interprofessional learning is to prepare health professional students for deliberately working together with the common goal of building a safer and better health care system.  To be successful, one must appreciate that educational institutions have a responsibility to both produce a health care workforce that is responsive to the nation's evolving health care needs and also to ensure that their graduates are able to practice to the full extent of their expertise.  Practice and education can no long be viewed as separate entities.  The optimal use of the workforce requires a cooperative effort in the form of teams sharing common goals and incorporating the patient, family, and/or community as active members.  This is particularly important for addressing the complex needs of chronic conditions where the psychosocial-economic-cultural gradient of care is so significant.  Examples of exciting interprofessional education exist but are rare.  For example, the Accreditation Council on Graduate Medical Education multispecialty resident survey data showed that formal team training experiences with non-physicians was significantly related to greater resident satisfaction with learning and overall training experiences, as well as to less depression, anxiety, and sleepiness, and to fewer reports by residents of having made a serious medical error.

Core competencies are needed to:  * Create a coordinated effort across the health professions to embed essential content in all health professions education curricula.  * Guide professional and institutional curricular development of learning approaches and assessment strategies to achieve productive outcomes.  * Provide the foundation for a learning continuum in interprofessional competency development across the professions and the lifelong learning trajectory.  * Acknowledge that evaluation and research will strengthen the scholarship in this area.  * Prompt dialogue to evaluate the "fit" between educationally identified core competencies and practice needs/demands.  And, * Actively involve accreditation agencies and licensing and credentialing bodies in the process.

The report notes: "It may be more helpful to think in terms of competencies that are common or overlapping more than one health profession but not necessarily all health professions.  This can be the source of interprofessional tensions, such as in the debate about overlapping competencies between primary care physicians and nurse practitioners.  The overlap may be a strategy to extend the reach of a health profession whose practitioners are inaccessible for various reasons….  'Complementary' competencies enhance the qualities of other professions in providing care….  "Collaborative' competencies are those that each profession needs to work together with others, such as other specialties within a profession, between professions, with patients and families, with non-professionals and volunteers, within and between organizations, within communities, and at a broader policy level."

Perhaps the heart of this transformation: "Provision of patient-centered care is the goal of interprofessional teamwork.  The nature of the relationship between the patient and the team of health professionals is central to competency development for interprofessional collaborative practice.  Without this kind of centeredness, interprofessional teamwork has little rationale."  Mutual respect and trust are foundational to effective interprofessional relationships.  Collaborative care honors the diversity that is reflected in the individual expertise each profession brings.  All team members must place the interests of patients and populations at the center of health care delivery. Today, too many health professions students have little knowledge about or experience with interprofessional communication.  Working in teams involves sharing one's expertise and being willing to relinquish some professional autonomy to work closely with others, including the patient and his/her family.  "The challenges to bringing about transformational change in health professions education, which includes much stronger emphasis on 'learning together to work together,' are real and will require creativity and commitment to overcome.  However, positive changes… indicate that many of the elements requiring change are 'unfreezing'….  Every indication is that the time is now indeed right for transformational changes and, collectively, we are ready for action."  We would rhetorically ask: Should not those pursuing psychology's psychopharmacology (RxP) agenda rightfully see themselves as being on the forefront of their profession's evolution into the 21^stcentury?

A Refreshing Vision:  Reflecting upon the experiences of retired colleagues, Vickie Mays has insightfully proposed intergenerational collaboration: "I have seen some wonderful transformations in retirement.  What I love is the executive group that sends retired executives to work free with community organizations.  I wish there was a community service mandate at all high schools and universities as that is the time to have those executives get a sense of community.  What would make psychology a transformed profession is if, like our law colleagues, we had to do pro bono work.  I have thought on a couple of occasions of trying to move this through APA by having people indicate their willingness and then having APA put it on a website as a start.  We at UCLA now have a volunteer center and it has made a big difference in the tackling of community needs.  We bus the students into a school and in one day we renovate a school, rehab a facility, any number of things!"  If such an approach were systematically implemented in federally qualified community health centers, we would expect that our senior and new career colleagues would work together to develop that necessary comfort level to effectively integrate psychological expertise with primary care needs.

Changing Times:  * The Substance Abuse and Mental Health Services Administration (SAMHSA) recently announced the availability of $35.7 million for up to 32 Primary and Behavioral Health Care Integration grants for community behavioral health organizations to establish coordinated and integrated services through the collocation of primary and specialty care medical services.  The goal is to improve the physical health status of adults with serious mental illnesses who have, or are at risk for, co-occurring physical health conditions and chronic diseases, with the objective of supporting the "triple aim" of improving their health, enhancing consumers' experience of care, and reducing the cost of care.  * Pharmacy students are now eligible for the National Health Service Corps State Loan Repayment Program.  Through program guidance, the Health Resources and Services Administration has provided states with the flexibility to include additional healthcare professionals, including pharmacists, in the state loan repayment program.  Thirty-one states currently participate in this initiative.  Only states that are seeking new or continued funding are eligible to include the expanded health professionals during this funding cycle.  A state agency must be responsible for the grant management – health care reform is, indeed, local.

Federal Trade Commission (FTC):  Under the Carter Administration, the FTC aggressively addressed the issue of competition in health care.  Recently, under the Chairmanship of Jon Leibowitz, the FTC has again focused upon health care and particularly the findings of the IOM report The Future of Nursing: Leading Change, Advancing Health.  In response to a request by a Kentucky Statelegislator regarding pending legislation: "Recent reports by the Institute of Medicine (IOM) have identified a key role for advanced practice nurses in improving the delivery of health care….  Among other things, the IOM found that advanced practice nurses play a key role in improving access to health care and 'restrictions on scope of practice… have undermined [nurses'] ability to provide and improve both general and advanced care.'  You have advised that the currently required collaborative prescribing agreement provides no physician supervision and can be costly to APRNs.  As a result, the requirement is likely to limit the availability of APRN care….  Given the potential benefits of eliminating unwarranted impediments to APRN practice, we recommend that the Kentucky legislature seek to ensure that statutory limits on APRNs are no stricter than patient protection requires….  Absent a finding there are countervailing safety concerns regarding APRN prescribing practices for nonscheduled substances, SB187 appears to be a precompetitive improvement in the law that would benefit Kentucky health care consumers….

"The FTC is charged under the FTC Act with preventing unfair methods of competition and unfair or deceptive acts or practices in or affecting commerce.  Competition is at the core of America's economy, and vigorous competition among sellers in an open marketplace gives consumers the benefits of lower prices, higher quality products and services, more choices, and greater innovation.  Because of the importance of health care competition to the economy and consumer welfare, anticompetitive conduct in health care markets has long been a key target of FTC law enforcement, research, and advocacy.  Recently, FTC staff have analyzed the likely competitive effects of proposed APRN regulations in other states."  This Is The Dawning Of The Age Of Aquarius.  Aloha,

Pat DeLeon, former APA President – Division 55 – May, 2012

 

CALIFORNIA, HERE I COME:

     I recently had the refreshing experience of participating in the California Psychological Association 2012 convention Enhancing Today – Preparing for Tomorrow in historicMonterey.  CPA President Craig Lareau and Convention Chair Mark Kamena provided a tantalizing glimpse into psychology's exciting future.  There were fascinating sessions addressing the unique needs and strengths of our nation's children, telehealth/telepsychology, virtual realities, and the extraordinary implications for all of the health care professions inherent in President Obama's landmark Patient Protection and Affordable Care Act, with its emphasis upon dramatically increasing access to primary care, effectively utilizing the most up-to-date technology in daily practice; and developing patient-centered, integrated approaches to health care.  Former Department of Defense (DoD) prescribing psychologist Morgan Sammons and I participated in Sallie Hildebrandt's symposium on psychology's potential role in Psychopharmacology Treatment, along with former U.S. Navy Surgeon General Harold Koenig.  The increasingly emerging needs of our nation's active duty personnel, their families, and our veterans (e.g., PTSD, acute and chronic brain trauma, as well as related social-employment-housing issues) were graphically highlighted.  No longer can psychology (or any other discipline) practice in isolated silos.  Interdisciplinary collaboration and provider accountability are the future.  The opportunities for those with vision are unprecedented.  Those who ignore society's pressing needs will be left behind.

            The Ever Evolving Health Care Environment:  This Spring, the Surgeon General of the U.S. Army testified before the Senate Appropriations Committee.  Lt. GeneralPatricia Horoho is the first female (and first nurse) to serve in that position.  "Since 1775, Army Medicine has been there.  In every conflict the U.S. Army has fought, Army Medicine stood shoulder to shoulder with our fighting forces in the deployed environment and received them here at home when they returned….  The survival rate for the conflict in Afghanistan is 90.1%.  This ability to rapidly transport our wounded Service Members coupled with the world-class trauma care delivered on the battlefield has resulted in achievement of the highest survival rate of all previous conflicts.  The survival rate in WWII was about 70%; in Korea and Vietnam it rose to slightly more than 75%....  Army Medicine is committed to accountable care – where our clinical processes facilitate best practice patterns and support our health care team in delivering competent, compassionate care.  In everything we do, there is a need for accountability – to our patients, our team members, and ourselves….

            "The collective healthcare experience is driven by a team of professionals, partnering with the patient, focused on health promotion and disease prevention to enhance wellness.  Essential to integrated health care delivery is a high-performing primary care provider/team that can effectively manage the delivery of seamless, well-coordinated care and serve as the patient's medical home.  Much of the future of military medicine will be practiced at the Patient-Centered Medical Home (PCMH).  We have made Patient Centered Medical Homes and Community Based Medical Homes a priority.  The Army's 2011 investment in patient centered care is $50M.  Patient Centered Medical Home (PCMH) is a primary care model that is being adopted throughout the Military Health System (MHS) and in many civilian practices throughout the nation.  Army PCMH is the foundation for the Army's transition from a 'health care system to a system for health' that improves Soldier Readiness, Family wellness and overall patient satisfaction through a collaborative team based system of comprehensive care that is ultimately more efficient and cost effective.  The PCMH will strengthen the provider-patient relationship by replacing episodic care with readily available care with one's personal clinician and care team emphasizing the continuous relationship while providing proactive, fully integrated and coordinated care focusing on the patient, his or her Family, and their long term health needs.  The Army is transforming all of its 157 primary care practices to PCMH practices….  Our MHS is not simply a health plan for the military it is amilitary health system….

            "An area in which the Army and our Sister Services have innovated to address a growing problem is in concussion care.  The establishment of a mild Traumatic Brain Injury (TBI)/concussive system of care and implementation of treatment protocols has transformed our management of all battlefield health trauma.  Traumatic Brain Injury (TBI) is one of the invisible injuries resulting from not only the signature weapons of this war, improvised explosive devices and rocket propelled grenades, but also from blows to the head during training activities or contact sports.  Since 2000, 220,430 Service Members have been diagnosed with TBI worldwide….  Currently, there are almost 350 studies funded by DoD to look at all aspects of TBI….  We have partnered with the Department of Veterans Affairs, the Defense and VeteransBrain Injury Center, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, academia, civilian hospitals and the National Football League, to improve our ability to diagnose, treat, and care for those affected by TBI.

            "There are significant health related consequences of over ten years of war, including behavioral health needs, post-traumatic stress, burn or disfiguring injuries, chronic pain or loss of limb.  Our Soldiers and their Families need to trust we will be there to partner with them in their healing journey, a journey focused on ability vice disability.  A decade of war in Afghanistan and Iraq has led to tremendous advances in the knowledge and care of combat-related physical and psychological problems.  Ongoing research has guided health policy, and multiple programs have been implemented in theater and post-deployment to enhance resiliency, address combat operational stress reactions and behavioral health concerns.  Similar to our approach to concussive injuries, Army Medicine harvested the lessons of almost a decade of war and has approached the strengthening of our Soldiers and Families' behavioral health and emotional resiliency through a campaign plan to align the various Behavioral Health programs with the human dimension of the ARFORGEN cycle [deployment cycle], a process we call the Comprehensive Behavioral Health System of Care (CBHSOC)….

            "Near-term goals of the CBHSOC are implementation of routine behavioral health screening points across ARFORGEN and standardization of screening instruments….  Long-term goals of the CBHSOC are the protection and restoration of the psychological health of our Soldiers and Families and the prevention of adverse psychological and social outcomes like Family violence, driving under intoxication violations, drug and alcohol addiction, and suicide.  This is through the development of a common behavioral health data system; development and implementation of surveillance and data tracking capabilities to coordinate behavioral health clinical efforts; full synchronization of Tele-behavioral health activities; complete integration of the Reserve Components; and the inclusion of other Army Medicine efforts including TBI, patient centered medical home, and pain management….  (T)he possible overreliance on medication-only pain treatment has other unintended consequences, such as prescription medication use.  The goal is to achieve a comprehensive pain management strategy that is holistic, multi-disciplinary and multi-modal in its approach…."  The challenges and opportunities for psychology over the next decade are extraordinary – for those with vision, dedication, and compassion.  As was evident at CPA, and subsequently at the Wright Institute, psychology's next generation is ready and poised to effectively address society's most pressing needs.

The Continuing Journey:  A number of colleagues have shared with us their fascinating personal stories surrounding retirement.  Ruth Ullmann Paige, former APA Board of Directors:  "Retirement.  I closed my practice in December, 2010, for the most part.  A few patients were just not ready to stop therapy or to start with someone else.  So I continue to see very few people.  A friend of mine calls it 'retirement light.'  I have maintained my license and my liability insurance.  I am very behind in obtaining CE credits, and I might close my practice altogether when I need to present CE credits to the Licensing Board.  Not renewing my psychology license will surely trigger a huge psychological crisis for me; at least it seems that way right now.  Perhaps it won't feel that way when the credits are due.  It is often surprising to me that which was once 'unthinkable,' becomes 'acceptable' at times.

            "The most startling, meaningful, and wonderful outcome of retirement from APA has been my having much stronger and frequent contacts with my children.  I, along with many women of my age, struggled with work-family balance.  In my day, though, that is not how the issue was framed.  Almost all of my psychologist and other professional women friends felt non-stop guilt for years and years.  In my heart I always believed I short changed my children, and that my priorities were upside down.  Those feelings never changed during the decades I was working.  So, when I 'retired' from APA, and then a few years later, from practice, I was thrilled and humbled to find that my children (no longer actual children) totally, easily, completely, and with so much love, welcomed me back into their lives.  All of my children live in WashingtonState and I see them and my grandchildren often.  We all take a wonderful and special annual family vacation together, and we get together for holidays as well as at other times.  Family has become the most meaningful highlight of my life.  I am so very grateful to have been given another chance.

            "On a more intrapersonal level, I find still challenging, a year after I closed most of my practice, deciding which activities, other than family, are most personally meaningful.  Opportunities to be involved in activities and tasks are unending.  When I retired, I wanted for the first time in my life to do what I really wanted to do, and I learned that is difficult for me.  I am embarrassed to admit that I have spent much of my life with an external focus.  While I have long loved psychology and governance involvement, part of the joy was the response I received from others.  Years and years ago, it was praise that I was able to both complete the Ph.D. and to have three children.  (I reached a higher level of education, and had more children than anyone else in my family).  Later, it was praise from a Dean and colleagues and then very positive feedback as a result of WSPA and APA involvement.  It was my good fortune to receive much, much praise as I lived my life.  While I felt really good about my activities, I was also driven by praise to do more – I often did too much, worked too long, was away from home too much, missed too many family events, and rarely had time for myself.  So on January 1, 2011, I thought this is now my time.  Whoops!!  My time for What?  I learned I had no idea what I wanted to do when I wasn't working and achieving in some venue.  I had never in my life had primarily an internal focus.  During my first retirement year I realized I needed to stop doing, and to hear myself.  That is not so easy in what is still an overly busy life (I managed to do it again!) and one in which I have been unaccustomed to paying attention to what I wanted to do.  I know more now about what I do not want to do.

            "To this day, the external/internal dimension remains challenging.  I walk outdoors regularly now in the forested Northwest.  Even though it rains sometimes, it is always wonderful and calming and uplifting.  I am less inclined to spend time with those I don't want to – for whatever the reason.  I read a bit more – still not as much as I'd like to.  I spend too much time on print and online newspapers.  Al and I go to the theatre and films a whole lot.  We have subscriptions to three theatre companies, and participate in a play reading group monthly.  This is an activity I love.

            "I am more involved now with the local Democratic Party, my legislators, candidates, etc.  It has been great to learn about local issues that affect us on a day-to-day basis, and to be able to discuss these with our legislators, who thankfully are Democrats.  This is a highly significant year politically both at the local and national levels.  Given the disastrous national and international policies of the Republicans and the Tea Party, for the sake of all Americans and, for sure, my family, I hope the Democrats will win the House and Senate in both Washingtons, and the Presidency in DC and the Governor's mansion in thisWashington.  The mood in the USA toward those who need social supports, toward immigrants, toward education, toward science is often scary.  I hope we pass through this stage and reemerge as a good and decent country.

            "The changes so far, as you can see, have been more subtle than dramatic.  It is mostly a matter of paying attention and noticing.  Still, I am searching for what else feels personally meaningful.  Maybe I am trying too hard.  Life is good, and as I said, still too over full.  I guess that has been, and continues to be me."

            Ruth's experience is not an isolated one.  A former Senate Chief of Staff:  "HeyPat!  How is life in the post-Senate world??  How has the adjustment gone?  For me, it took a while to exhale.  I didn't even realize how burned out I was until I left.  I didn't read the front section of the Washington Post for a month – had no interest!  I hope you have enjoyed it so far and given yourself a chance to just relax and breathe for a while.  Whenever you are up for it, I'd love to have coffee and check in and see what you are up to."  Don Freedheim (former Division 29 President):  "I agree that there is life after retirement and have continued to edit, etc.  Many people said to me: 'What are you going to do?'  That's not the issue in retirement.  There are so many things to do that I've barely time to get to the books I want to read, etc.  The issue is one of 'identity.'  After so long in a 'position' (middle child in a family, different grades in school, rank and role in a profession, etc. – all part of an institution), there is no 'institution' of retirement and one finds oneself with no role or business or career identity.  It took me about three years to adjust to having no such identity, but I finally accepted writing 'retired' on the forms that called for 'occupation.'  Now I'm content not to have a 'position' with an institution and free to do what I like, when I like….  Welcome to the non-institution of retirement!"

            Additional Reflections:  "I still haven't written 'retired' anyplace yet.  Most of us don't do active parenting anymore, as in parenting young children.  That's another institution we're not part of in the same way.  While Al and I are, fortunately, very involved in our children's and grandchildren's lives, we're not 'doing' very much.  We listen often and share our thoughts (lightly), and we participate in the good, fun activities and help a bit.  Being at this stage of life is facing another retirement, of sorts.  Retirement, itself, is actually another 'institution,' but it's complicated, partly because the underlying values, beliefs and meanings are not openly discussed in our culture.  In fact, we avoid focusing upon them.  All of our lives we've been busy achieving and meeting responsibilities and expectations to – do well in school, raise children, earn a living, be socially and culturally engaged, and then, we finally retire.  For just about the first time since we've been alive, it's our time, to do what we really want to.  It's a new and unfamiliar 'institution.'  We haven't been trained for it at all.  And what makes it so urgent and scary for some, for me, is that when we are in that 'institution,' we also have the awareness that life is moving along very rapidly and that this period is the last time ever to live in a way that is personally important and meaningful" [Ruth].  The opportunities for psychology and for all of us are there.  Open up that Golden Gate.  California here I come.  Aloha,

 

Pat DeLeon, former APA President – Division29 – May, 2012

 

 

INTEGRATED PRIMARY CARE

 The enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA) represents the culmination of decades of thoughtful discussion among health policy visionaries, notwithstanding the U.S. Supreme Court's ultimate decision.  During the Congressional deliberations, the President proclaimed: "(N)early 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."  ACA will provide needed health care to an additional 32+ million Americans; the priority being patient-centeredprimary care with an emphasis upon preventive-oriented, interdisciplinary, and integrated health services.  The Institute of Medicine (IOM) has stressed that the health care needs of older Americans will be particularly difficult to meet given the current severe shortage of geriatric specialists, as will be the case with an increased demand for chronic care management.

Those fortunate to live in rural America(e.g., your Delta areas) have long appreciated the special "challenges" and "opportunities" involved.  Diana Shaw, CEO of the Lana'i Community Health Center: "Lana'i has only one real town and only 3,000 residents.  There are no chain stores or shopping malls.  There is no movie theatre or night life to speak of, no public transportation, and rental cars cost about $150 a day.  There is no pharmacy, and career options are extremely limited due to the focus on tourism.  There are no stop lights, only one gas station (with gas last year close to $6.00 a gallon), and only about 30 miles of paved road.  Everything on the island has to be flown in or brought in on the barge (which only comes once a week – weather permitting), and this can lead at times to prices which approach double what is seen elsewhere – even in rural communities on the Mainland.  From a health care perspective, we have significant gaps in the area of women's health (among other issues, Lana'i does not have mammography capabilities on island), oral health (only one dentist serves the island, flying in on Monday and out on Thursday), behavioral health (no psychiatry, no inpatient substance abuse facilities, no domestic violence shelters on island), and limited on-island case management, prevention, and continuity of primary care.  Babies are not born on the island, and mothers-to-be must relocate to Oahu or Maui at 36 weeks to avoid endangering the mother or baby.  What in most other communities is a joyous family occasion, on Lana'i is a stressful, expensive occasion, with mothers-to-be separated from their 'ohana.'

            "We have focused recruitment efforts on the young clinician – but found that they have their choice of places to live and work, and most have young families and want schooling options and activities for their children or work for their spouse.  Also isolation presents a challenge to the young clinician who is used to being able to refer to specialists and having a host of colleagues at hand to discuss a case.  Advanced Nurse Practitioners (APNs) remain the best option for our health center – and, actually, the most suitable option for our patients.  The skills and mindset learned during their many years of nursing fit well with the needs and language challenges of our patients.  APNs are more affordable.  We have been lucky to be part of several training programs and especially helpful, when one considers our top diagnoses include stress and other behavioral health disorders, to be part of a clinical psychology training program.  We recently resolved our problem of not having a psychiatrist on our island by using videoconferencing (VTC) technology.  Our patients have been very pleased with this VTC option, but it took us over a year to find a provider on Oahu who would work with us due to their hesitance to use VTC as a medium.  The challenges are many – but many hands make light work.  Why are we doing this?  Our greatest resource are the people of Lana'i – they are hard-working, sweet and friendly once they know you've come to stay.  Our island is a gem."

            Psychopharmacology (RxP) is an integral component of primary care.  Although involved in the RxP movement from the beginning, it is impossible to predict the next state to enact prescriptive authority.  WillHawaii and Oregon overcome their vetoed bills?  The numbers of colleagues completing advanced training continues to grow.  As of the Fall of 2010, 276 graduates had been admitted to take the APA PEP (Psychopharmacology Examination for Psychologists), developed by the APAPO Practice Organization's College ofProfessional Psychology.  With the advances in educational technology, those on their clinical internships should soon have ready access to medication decision protocols.  Over the years, slightly more than one third of our State Associations have established task forces to coordinate RxP activities, with nearly a quarter having introduced relevant legislation.  Today, several of the States pursuing this, such as Arizona and New Jersey, were initially expected by their leaders to be the "last in the nation."  Guam has finally issued regulations for their 1998 legislation.  Nursing, in collaboration with AARP, is systematically addressing practice barriers restricting their Doctor of Nursing Practice (DNP) scope of practice, pursuant to another IOM recommendation.  Fundamental change always takes time; oftentimes, longer than one might expect.

A concluding reflection: Having recently retired from the U.S. Senate staff after 38+ years, I am intrigued by the experiences of other senior colleagues.  Former VA psychologist Rod Baker: "My definition of a 'good retirement' -- Doing what you want, as much as you want, and whenever you want.  And, if you are not doing that, you only have one person to talk to."  Aloha,

 

Pat DeLeon, former APA President – Arkansas Psychological Association – April, 2012

 

 

THE IMPORTANCE OF COMMITMENT

    Lessons From The Past:  Recognizing the importance of addressing the federal government in its role as a "payer of care," in the mid-1970s psychology's visionary "dirty dozen" (Rog Wright, Nick Cummings, Herb Dorken, Gene Shapiro, Jack Wiggins, etc.) focused upon the necessity of having psychology recognized under the Department of Defense (DoD) Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).  CHAMPUS provided reimbursement for the health care expenses of 7.9 million military dependents and retirees for those services they were not able to receive at military health care facilities.  In FY'1985, the CHAMPUS budget request was $1.4 billion.  Since Fiscal Year 1976, clinical psychologists have been expressly enumerated as autonomous providers with "medical or psychological" necessity being the recognized criteria for reimbursement.  Those actively involved in expanding psychology's legislative presence over the years, at the state and federal level, are well aware of how helpful this precedent has been.

            CHAMPUS has now evolved into TRICARE which currently provides necessary health care to over 9 million eligible beneficiaries, including active duty uniformed personnel and their dependents, eligible members of the Reserve Component and their dependents, and uniformed services retirees and their dependents and survivors.  It provides care through both military and nonmilitary hospitals, clinics, and other providers.  It is administered on a regional basis utilizing managed care support contractor networks of civilian providers in each of its North, South, and West regions.  There are three basic options for non-Medicare eligible beneficiaries.  Having worked closely with the leadership of TriWest (which is responsible for serving Hawaii), we are personally aware of how supportive they have been to psychology and other non-physician providers, as well as working closely with their community partners.  The FY'2013 budget request for TRICARE is $48.7 billion, a 300% increase over FY'2001.

A Vision of National Health Care:  During the Congressional deliberations on President Obama's landmark Patient Protection and Affordable Care Act (commonly known as the Affordable Care Act (ACA)), the military retiree community vocally resisted its programs being impacted by this new initiative.  However since ACA has become public law, strategic modifications have been evolving; for example, extending dependent coverage up to the age of 26.  And, as the decades-long efforts to revamp the military health care system into an integrated Defense Health Agency continue, as well as discussions regarding DoD and VA health initiatives becoming increasingly coordinated -- for example in the telehealth and electronic medical records areas -- psychology mustcontinue its efforts to systematically expand its presence in each of these critical federal initiatives.  Fundamental change as envisioned under ACA always takes time; however, especially with the unprecedented advances occurring within the communications and technology fields (i.e., Health Information Technology), the ultimate vision of an integrated federal health care delivery system is becoming increasingly robust.

A Very Real and Pressing Need:  The armed conflicts that our nation has been involved with over the past decade should highlight the need for psychology's active involvement with military personnel and their families.  Testifying before the Senate Armed Services Committee in June, 2010 the then-Vice Chief of Staff of the Army noted: "Our nation has asked a lot of our Soldiers and they have exceeded expectations by a long shot.  However, the prolonged demand on them –and on their families – continues to put a significant strain on our Force.  Many individuals have deployed multiple times.  They are tired.  A significant number of them suffer physical injuries….  Many more suffer from behavioral health issues, such as depression, anxiety, traumatic brain injury and post-traumatic stress – often referred to as the 'invisible wounds of war'….  Our overarching goals are to improve individuals' resiliency; eliminate the long-standing, negative stigma associated with seeking and receiving help; and, ensure Soldiers, Army Civilians and Family Members who may be struggling get the help that they need."

Experts report that since the start of the Iraq War in 2003, the rate of suicide among U.S. Army soldiers has soared, with an 80% increase between 2004 and 2008, paralleling increasing rates of depression, anxiety, and other mental health conditions.  Prior to 2003, their suicide rate closely matched the rate of suicide in the civilian population and was even on a downward trend.  Nurse researchers at theUniformed Services University of the Health Sciences (USUHS) report that deployment separation is definitely stressful on military families, with one fourth of military spouses reporting not being able to manage daily stress during deployment separation.  During the first Gulf War, spouses of deployed soldiers had stress scores nearly twice as high as spouses of nondeployed soldiers.  Eighty-five percent of Army wives listed deployment as the most stressful situation they had experienced in the past 5 years, with 70% of these spouses being symptomatic for depression and anxiety.  Unintended weight gain or loss is a problem to a large extent for 30% of Army spouses during deployment.  One of the major challenges of post 9/11 military life is repeated deployment separation and frequent extensions.

Being Present – Being Heard:  We have recently been informed that a number of our colleagues are experiencing significant difficulty in becoming recognized providers under TRICARE, with some even being informally led to believe that since sufficient numbers of psychologists have already been enrolled in the various panels, there is little contractor interest in accessing new providers.  Clearly, this stance is inappropriate from both a beneficiary and provider frame of reference.  We would suggest that it is psychology's responsibility to affirmatively address this issue and further, that those providers who feel that unrealistic barriers are being imposed upon them should bring this to the attention of DoD, probably most effectively through their own elected officials in the U.S. House of Representatives or U.S. Senate.  Members of Congress are extraordinarily responsive to concerns brought to their attention by theirconstituents.  If psychology does not collectively ensure that our practitioners are valued under TRICARE, why should we expect that other federal initiatives, especially in these extraordinarily tight budgetary times, will appropriately recognize our clinical expertise?  Given the demonstrated psychological needs of those serving our nation today and their families, we would also urge that serious consideration be given to working with (i.e., volunteering for) "Give an Hour."  Psychologist Barbara Van Dahlen has done a wonderful job in providing behavioral health care services to military personnel and their families, as well as systematically addressing the historical stigma noted by the former Army Vice Chief of Staff in his Congressional testimony.  A major responsibility of every learned profession is to provide proactive and visionary leadership in addressing society's needs.  Aloha,

 

Pat DeLeon, former APA President – National Register – March, 2012