INTERESTING PERSPECTIVE AT THE FEDERAL LEVEL

  DoD/VA Challenges and Exciting Opportunities:  Although I am no longer on the U.S. Senate staff, it is intriguing to reflect upon how psychology and the other health professions are viewed on Capitol Hill.  During her recent Senate testimony, the U.S. Army Surgeon General Patricia Horoho pointed out: "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….  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 theatre and post-deployment to enhance resiliency, address combat operational stress reactions and behavioral health concerns….  For those who do suffer from PTSD, Army Medicine has made significant gains in the treatment and management of PTSD as well.  The DoD and VA jointly developed the three evidenced based Clinical Practice Guidelines for the treatment of PTSD, on which nearly 2,000 behavioral health providers have received training….  (Our) researchers develop strategies and advise policy makers to enhance and sustain mental fitness throughout a service member's career.  Psychological health problems are the second leading cause of evacuation during prolonged or repeated deployments.  (DoD) psychological health and resilience research focuses on prevention, treatment, and recovery of Soldiers and Families behavioral health problems, which are critical to force health and readiness.  Current psychological health research topic areas include behavioral health, resiliency building, substance use and related problems, and risk-taking behaviors."  Her considerable sensitivity to the critical importance of the behavioral sciences, including the psychosocial-cultural-economic gradient of care, undoubtedly reflects the fact that she is the first female and first non-physician Surgeon General in the history of the U.S. Army.

            In considering the Fiscal Year 2013 funding for the Department of Veterans Affairs (VA), the Senate Appropriations Committee voted 30-0 to recommend a $135.6 billion budget.  As of last Fall there were an estimated 22.2 million living veterans and their 34 million dependents (spouses and dependent children).  The VA Health Administration (VHA) operates a national healthcare delivery system consisting of 153 hospitals, 1,102 outpatient clinics and Vet Centers, 133 nursing homes, and 107 VA residential rehabilitation treatment programs.  VHA is the largest federal medical care delivery system in the nation.  The unemployment rate of male veterans between ages 18-24 is 29%; almost double that of their civilian peers with over 847,000 unemployed veterans.  A tragedy which strongly suggests that psychology has much to contribute.

The underlying vision for President Obama's Patient Protection and Affordable Care Act (P.L. 111-148) is the importance of providing high quality primary care through an interdisciplinary team approach, emphasizing integrated care.  It is anticipated that the various health care professions will ultimately learn to work collaboratively, in a cost-effective manner.  The Accountable Care Organization (ACO) and Medical Home provisions of the law are clear examples.  For many of psychology's practitioners this approach represents a fundamental change in their role and clinical orientation.  It will also require our educational systems to significantly modify their programs and expectations.  In many ways, over the years, VHA has championed this approach.  Accordingly, the Senate Appropriations Committee's expressed Interests/Concerns should be of considerable interest to those contemplating the future.

*  Licensing Requirements at DoD/VA Collocated Facilities:  In fiscal year 2012, the Committee directed the Department of Veterans Affairs and the Department of Defense to examine ways in which duplicative licensing requirements at collocated medical facilities might be eliminated.  The findings of this examination were required to be reported to the Committees on Appropriations of both Houses of Congress.  The Committee reiterates the expectation and importance that the VA submit this report.  Upon receipt of the report, the Department is directed to provide regular reports on progress made in implementing any recommendations to streamline duplicative licensing requirements.  An astute colleague working for VHA feels that the more DoD/VA operates like a business, the better off we will be.  Very few in either Department understand "cash flow" or have ever had to live month to month, week to week, and day to day having to make a payroll.  Those who have only worked in the public sector think they understand the "business model," but they have never had to make payroll.  Payroll is always assured and never something they have to concern themselves with.  The bottom line:  They care deeply about patients and each other, but they never really worry if an action they take or don't take might influence whether they will or won't get their next pay check.  Thus, they are comfortable allowing themselves the luxury of not doing what would be most cost-effective in the long run, especially if that would require fundamental change.  For example, embracing prescriptive authority for well trained non-physicians and eliminating bureaucratic hassles such as duplicative credentialing.

*  VA Nursing Academy:  The Committee commends the VA for addressing the nursing shortage through the VeteransAffairs Nursing Academy.  This pilot program established partnerships with competitively selected nursing schools to expand the number of teaching faculty in VA facilities and affiliated nursing schools in order to increase student enrollment in baccalaureate nursing programs.  The Committee notes the VA's realization of a net-positive value for the pilot overall and urges VA to continue its collaboration with the Department of Defense through the Uniformed Services University of the Health Sciences by providing nurse faculty and nursing students in the graduate nursing education programs through the external evaluation period.  Advanced Nursing Education:  The Committee urges the VA, in conjunction with accredited schools of nursing, to explore the development of a fast-track doctoral training program which would facilitate completion of a doctorate in nursing by qualified nurses employed within the VA network who possess a bachelor of science in nursing.  Nursing Research Program:  The Committee supports the Veterans Affairs Nursing Research Program, which facilitates research on the specific nursing needs of combat veterans and aging veterans.  The Committee strongly supports continuation of this program.  The Committee also encourages collaboration between VA nurses and recipients of Tri-Service Nursing Research Program awards in the exploration of research proposals that improve the health and well-being of their shared beneficiary population.

*  Rural America:  The Committee recognizes that the demand for VA services in rural areas will only increase and believes that the VA must do more to plan for and provide quality healthcare to veterans living in rural and highly rural areas.  Travel barriers, including long distances to VA medical facilities and lack of public transportation, make it difficult for the VA to serve rural veterans.  Also, lack of specialized care in rural areas, including mental healthcare, make it difficult for veterans to obtain quality care at home.  The VA is working to address these problems through a number of initiatives, including expanding the use and variety of telemedicine techniques, such as video consultations with practitioners, telephone healthcare monitoring and management, and audio-visual telemedicine diagnostic techniques.  The Committee encourages the VA to pursue leading-edge telemedicine technology and innovative rural health demonstration projects, and to incorporate promising advances into its rural health delivery system.  The Committee recognizes the ongoing challenges to recruit and retain highly qualified healthcare professionals, particularly mental health professionals, in rural areas.  Staffing shortages ultimately lead to higher out-of-pocket costs for veterans as well as decreased quality of care.  The Committee directs VHA to more thoroughly and aggressively evaluate and deploy innovative approaches to recruiting and retaining quality physicians, surgeons, mental health professionals, and other healthcare professionals in rural areas.  These potential approaches should include additional flexibility for rural facilities to enhance salary offers and to offer contract incentives to qualified applicants.  VA should investigate using innovative ways to rotate practitioners through rural areas, such as medical "circuit riders," fully staffed mobile clinics, and cooperative ventures using community hospitals or clinics as platforms for providing VA healthcare services.

*  Mental Health:  Access to VA's mental health services is imperative given the number of Iraq and Afghanistan war veterans suffering from combat related mental health problems.  The Committee remains very concerned about the ability of veterans suffering from combat related mental health conditions to access clinical care in a timely manner.  The Inspector General review found that first-time patients have not uniformly been provided timely mental health evaluations and existing patients often must wait beyond the desired date for appointments.  The Department recently announced that it would add an additional 1,600 mental health clinicians and 300 support staff as part of an ongoing review of mental health operations.  The Committee supports this effort.

There is clear Congressional recognition of the importance of providing high quality mental health and behavioral health care for DoD and VA beneficiaries.  There is demonstrable interest in developing highly innovative approaches for delivering care, especially in remote and rural areas.  We would ask: Whether the Congress or the Administration understands how psychology might meaningfully contribute to the underlying mission of DoD and the VA?

            The Patient-Centered Outcomes Research Institute (PCORI):  The Patient Protection and Affordable Care Act also established PCORI to conduct or commission research to provide information about the best available evidence to help patients and their health care providers make more informed decisions.  The intent is to give patients a better understanding of the prevention, treatment, and care options available, and the science that supports them.  The Institute Mission Statement: "PCORI helps people make informed health care decisions, and improves health care delivery and outcomes, by producing and promoting high integrity, evidence-based information that comes from research guided by patients, caregivers and the broader health care community."  It is an independent, non-profit organization governed by a 21-member Board of Governors.  During his APA Presidency, James Bray testified before the Institute of Medicine as to the importance of Comparative Clinical Effectiveness Research and psychology's potential contributions.  "Comparative effectiveness research is a critically important tool for advancing an evidence-based approach to health care decision-making.  However, the full public health benefits of such research will only be realized if behavioral, psychosocial, and medical interventions for the prevention and treatment of mental and physical health conditions are evaluated individually and in combination.  Even when strictly medical treatments are compared, it is important to expand the range of outcome measures to include behavioral and psychological outcomes, such as quality of life and adherence to treatment protocols."  In its initial research effort, PCORI proposed $120 million for these types of initiatives.  This Summer, $96 million will be made available for those engaged in patient-centered outcomes research.  PCORI maintains a broad scope of interest, rather than addressing specific disorders or conditions.  The underlying research agenda contemplates five broad areas: Assessment of prevention, diagnosis, and treatment options; Improving healthcare systems; Communication and dissemination research; Addressing disparities; and, Accelerating patient-centered outcomes research and methodological research.  Aloha,

 

Pat DeLeon, former APA President – Division 42 – June, 2012

 

PROACTIVITY IS INCREASINGLY CRITICAL

APA State Leadership Conference:  At this year's exciting event, Bringing Psychology to the Table: State Leadership in Health Care Reform, Katherine Nordalhighlighted the critical role of President Obama's Accountable Care Act (ACA) in furthering health care reform and the importance of action by psychology at the state level.  "We're facing unchartered territory with proposed new models of care delivery.  Again, different kinds of care delivery models than we've been used to working in before.  We're facing new financing mechanisms that we're going to have to understand and appreciate, and the ways that they are going to impact practice, whether it's private practice or institutional practice….  (W)e know that the states are in the drivers' seat and most of what happens about health care reform is going to happen back home….  There is also marketplace uncertainty for us….  (I)f you think you won't be affected by Medicare and Medicaid because you've opted out of those systems or you don't want to participate in those systems, you really need to think again.  Medicare and Medicaid contribute over 50% of all the funding for hospitals in this country.  I'm not talking about just mental health care; I'm talking about health care in this country.  Medicare and Medicaid and other public funds pay for about 58% of all mental health and substance abuse care in this country.  And we know that commercial carriers often times peg their rates to the Medicare rates.  So Medicare rates not only affect the income of private practitioners; they affect the income of agencies, they affect the income of hospitals, they affect incomes in federally qualified health centers [FQCHCs], community mental health centers and community health centers….  (D)espite all of this uncertainty, change is here.  And change is fairly inevitable….  So we have to be ready to claim our place at the table.  We need to be involved at the ground level….  If we don't participate, then we abdicate our responsibility there and we let other people… define what our future is going to be as a profession.  And that's just not an option for us."

            Health Care Reform:  The newly established Accountable Care Organization (ACO) provision of ACA reflects the Administration's commitment to ensuring that all Americans will have ready access to necessary high quality primary care services.  For many health policy experts, ACOs are functionally equivalent to the HMOs of President Nixon and the Managed Care efforts of President Clinton.  Sandra Wilkniss, former APA Congressional Fellow and currently on the staff of U.S. Senator Jeff Bingaman, reviewed the statutory language and implementing regulations for ACOs.  In neither were psychologists expressly enumerated.  Clinical management and oversight must be managed by a senior-level medical director who is a physician and is one of the ACO providers/suppliers; is physically present on a regular basis in any clinic, office, or other location participating in the ACO; and is board-certified and licensed in the State in which the ACO operates.  Public response: "A number of commenters recommended CMS include measures that are more inclusive of specialty care, pediatric care, and non-physician professionals, such as nurse practitioners and registered nurses.  Many of these commentaters noted that the proposed measures were heavily focused on primary care….  Response:  We believe that the final set of measures is appropriately focused and measures care furnished by a variety of providers including specialists, nurses, and nurse practitioners."  As Kathleen so eloquently urged, our practitioners mustbecome actively involved, especially at the local level, for the future of the profession.

            Addressing Society's Needs:  Over the years, we have been impressed by the extent to which our nation's elected officials actively support those who serve society.  Sallie Hildebrandt reports that more than 110,000 active-duty Army troops last year took antidepressants, sedatives and other prescription medications.  In 2008 the Rand Corporation's comprehensive study of the mental health and cognitive needs of returning service members and veterans found that nearly one-third of returning service members reported symptoms of a mental health or cognitive condition.  Approximately 18.5% of those who have returned from Afghanistan andIraq have PSTD or depression, with 19.5% experiencing a traumatic brain injury during deployment.  Half of those needing treatment seek it, but only slightly more than half who receive treatment receive minimally adequate (i.e., scientifically based) care.

Without question, as the U.S. Army Surgeon General Patricia Horoho testified: "For those who do suffer from PTSD, Army Medicine has made significant gains in the treatment and management of PTSD….  The DoD and VA jointly developed the three Evidenced based Clinical Practice Guidelines… on which nearly 2,000 behavioral health providers have received training.  (Our) researchers develop strategies and advise policy makers to enhance and sustain mental fitness throughout a service member's career.  Psychological health problems are the second leading cause of evacuation during prolonged or repeated deployments….  (Our) psychological health and resilience research focuses on prevention, treatment, and recovery of Soldiers and Families behavioral health problems, which are critical to force health and readiness."  General Horoho is the first female (and nurse) Surgeon General in the Army's history.  We would rhetorically ask: How is Hawaii Psychological Association reaching out to our military and veteran community, many of whom are being served by Hawaii's FQCHCs, in order to provide pro bono care and expertise?  From personal discussions, we know that our State's health centers are very interested in collaborating.

            An Interesting Evolution:  Elaine Rodino, while in full-time private practice, is exploring new frontiers.  "You asked that I send you some information about my new business venture.  This isSeniorPremierDating.com.  Our senior dating website is for people 50+ to connect with others for dating, companionship and house sharing.  As you know, the senior population is growing rapidly with the aging of baby boomers and the increasing longevity of existing seniors – all of whom are increasingly computer savvy.  Our site is different from existing sites in two specific ways, Humor and Psychology.  We will have short videos depicting senior dating scenarios that will be created and performed by Renee Taylor and Joseph Bologna.  Taylor and Bologna are Emmy Award winning writers and performers in theatre, film and TV.  Their work has always been about the foibles of relationships.  The psychological aspects of issues facing seniors dating will be presented by myself and by contributing psychologists.  Each contributor will write short articles on topics in their specialty areas such as aging issues, weight and sex, and also include a short statement about their practice and a link to their website.

            "At this point the site has a simple questionnaire for subscribers to complete.  Profiles of potential subscribers will be gathered beginning in June through email blasts to those potentially interested.  In August we will activate the site to accept subscribers and do matching.  We've done a lot of research and consultation for this project.  We have an extensive business plan and a hopeful financial projection for the next five years.  Colleagues interested in contributing articles or in learning more about our venture should contact us atERodino@aol.com."  Fundamental change is upon us.  Aloha,

Pat DeLeon, former APA President – HPA – June, 2012

 

WHEN I WAS A LITTLE BITTY BABY:

Reflecting with senior colleagues upon retirement, we heard personal stories of profound joy, sadness, complexity, and relief accompanying this new state for most of us.  Retirement for some is a delight.  Finally an opportunity to do what we want to, when we want to, where we want to, and how we want to!  Psychologists are highly conscientious, productive, high achieving, hard working folk.  Many of the shared "reflections" described having worked, almost excessively, for most of their lives.  What a relief when there are no bosses, systems, or organizations that dictate and limit how we spend our time.  On the other hand, that very absence of structure can trigger anxiety and doubt.  So for some, retirement is also like being in a room without walls.  Don Freedheim referred to being retired as being without an institution that frames our activities and guides how we spend our time.  Previously, as we went to grade school, attended universities, worked, met partners, had children and hobbies, and became grandparents we had rules of the institution to follow.  While we lived and worked in many different settings, all had rules, procedures, customs.  We are now on our own in retirement.  We finally have control of personal time.  There are no rules regarding what we should be doing.  What should rule-followers be doing when there are no rules to follow?  That is the question.  If we are not psychologists, who are we?  Just about all of us deal, though in individual fashions, with identity issues.

For some, deciding which activities are most personally meaningful is a huge challenge.  Many report not having enough time.  Opportunities to be involved in activities and tasks eventually become unending.  When Ruth 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 thought this is now my time.  Whoops!!  My time for what?  I needed to stop doing and to hear myself… to pay attention to what I really wanted to do.  I know now more about what I do not want to do."  Visionary sage Gene Shapiro:  "If you possibly can, never retire!"

That is not to say that retired or mostly retired colleagues in their individually creative way aren't living full and varied lives.  Many (Jay Benedict) truly love being psychologists and don't really want to stop working.  Shortly after retiring from the U.S. Senate staff, Patnoticed he was no longer in the once all-important information loop and missed the action affecting psychology practice, education, and research.  Integral to his identity was being creative, innovative, and trail blazing.  Accordingly, he enthusiastically accepted the intriguing opportunity to mentor the next generation of practitioners (nursing, law, pharmacy, and psychology) in engaging in interdisciplinary (e.g., integrated), patient-centered practice from a university base.  Having "practiced" health policy for nearly four decades, he will now engage in shaping its theoretical/philosophical application.

            How our senior colleagues relate their experiences, reflects their activities and orientations while working.  Their look at retirement parallels work perspectives.  Ed Sheridan, an educational administrator (Dean and Provost) thoughtfully considers the many realistic and practical issues that require attention in preretirement and retirement, namely the need for collaboration and in-depth discussion with a partner about a multitude of life style preferences, health care concerns likely to arise, realistic appraisal of financial needs, etc.  Rod Baker, former VA chief psychologist, accustomed to employment in a large organization known for structure and "red tape" now follows his own path in retirement: "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."

            Choices made by our colleagues regarding their retirement activities are varied, and naturally consistent with preretirement beliefs and values.  How important is it to continue working in some fashion as a psychologist?  Many in the field just loved being psychologists.  It is difficult to give up that identity completely, especially for those who have been leaders in the field and have devoted countless hours.  Time devoted to the profession may be inversely related to one's number of hobbies.  Almost everyone, including those no longer working as psychologists, very much wants to continue being productive, in the sense that work and doing things to promote better communities bring meaning and vitality to life.  APA State Association guru Mike Sullivan: "I have a very different take on retiring, meaning having productive goals to accomplish.  For me it's meant a whole new horizon of productivity in direct community service (volunteering)!"  Many, like Ruth and Linda Garcia-Shelton, feel blessed to finally find themselves reconnecting with family and friends, having previously felt somewhat guilty about perhaps placing their budding careers a bit higher than their families.  Many women of their era struggled with work-family balance, although at that time society did not quite frame the underlying pressures so delicately and distinctly.

            An evolving, although still almost unspoken theme, is the undercurrent of existential urgency – realization of the mortality of ourselves and those we love.  Reflecting upon the impact of mortality is complicated, partly because the underlying values, beliefs, and meanings are typically not discussed in our culture.  In fact, we actively avoid focusing upon them.  But they are there.  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.  We haven't been trained for this.  And what makes it so urgent and scary for some, is that 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.  In Them Old Cotton Fields Back Home.  Aloha,

 

Ruth Ullmann Paige, former APA Board of Directors; & Pat DeLeon, former APA President

California Psychological Association – May, 2012