TECHNOLOGICAL IMPERATIVE

 One direct consequence of the advent and steadily increasing presence of technology within the health care arena will be the need for psychology to finally seriously address the issue of licensure mobility.  The Department of Veterans Affairs (VA) recently announced its plan to increase veterans' access to mental health care by conducting more than 200,000 clinic-based, telemental health consultations by mental health specialties this fiscal year.  Earlier the VA indicated that it would no longer charge a copayment when veterans receive care in their homes from VA health professionals using video conferencing.  The Secretary: "Telemental health provides Veterans quicker and more efficient access to the types of care they seek.  We are leveraging technology to reduce the distance they have to travel, increase the flexibility of the system they use, and improve their overall quality of life.  We are expanding the reach of our mental health services beyond our major medical centers and treating Veterans closer to their homes."  Since the start of the VA Telemental Health Program, VA has conducted over 550,000 patient encounters. 

            The Fiscal Year 2013 budget request for the Office of Rural Health Policy, which is located within the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services, notes that there has been a significant Departmental focus on rural activities for over two decades.  Historically, rural communities have struggled with issues related to access to care, recruitment and retention of health care providers, and maintaining the economic viability of hospitals and other health care providers in isolated rural communities.  There are nearly 50 million people living in ruralAmerica who face ongoing challenges in accessing rural health care.  Rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than their urban counterparts.  Rural areas also continue to suffer from a shortage of diverse providers for their communities' health care needs and face workforce shortages at a greater rate than their urban counterparts.  Of the 2,052 rural counties in the nation, 77 percent are primary care health professional shortage areas (HPSAs), where APA's Nina Levitt reports that psychologists are eligible for the National Health Service Corps Loan Repayment Program which places health professionals in underserved rural communities.

HRSA's Telehealth Grants initiative is designed to expand the use of telecommunications technologies within rural areas, seeking to link rural health practitioners with specialists in urban areas, thereby increasing access and the quality of healthcare provided.  Telehealth offers important opportunities to improve the coordination of care in rural communities by linking its providers with specialists and other experts not available locally.  The strengthening of a viable rural health infrastructure is viewed as critical for long-term success, including facilitating distance education experiences.  The budget request for the office of rural health office once again proposed $11.5 million, which has subsequently been approved by the Senate Appropriation Committee, and thus allows the continuation of the Licensure Portability Grant initiative, in order to assist states in improving clinical licensure coordination across state lines.  This particular initiative builds on HRSA's 2011 Report to Congress indicating: "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 to health care services, particularly in light of increasing shortages of health professionals. "

            For some colleagues, and particularly for those who are not comfortable with fundamental change, the relationship between telemental health and licensure mobility might seem to be a tenuous one.  And yet, we would suggest that they are intimately linked.  The public policy rationale for professional licensure is to protect the public from untrained and/or unethical practitioners, not to enhance the status or economic well-being of the profession.  Historically, and we would expect for the foreseeable future, licensure decisions and qualification criteria have been made at the individual state level, where each of the professions plays a major role in determining its requirements for membership and its scope of practice, albeit through the political process.  Within the federal system the governing statutes and implementing regulations generally require licensure in at least one state (regardless of practitioner geographical location) and facility approval (i.e., being credentialed).  As improvements in technology allow for increasingly higher quality utilization, the congressional committees with jurisdiction have been systematically "cleaning up" potential lingering statutory restrictions.  And, at both the state and federal level, expanding reimbursement paradigms are evolving.  APA estimates that 13 states now require private sector insurance companies to pay for telehealth services.  Over the years, we have not been aware of any objective evidence which suggests that the quality of care being provided via telehealth is in any way compromised.  To the contrary, as the VA, the Department of Defense (DoD), and the federal criminal justice system are demonstrating, access has been significantly enhanced and new state-of-the-art clinical protocols have been developed and implemented.

            A First Hand View -- From TriplerArmy Medical Center:  "I joined the Telebehavioral and Surge Support (TBHSS) Clinic in February, 2011 during its infancy.  At that time, the program was fully staffed with providers and support staff, making us 24 strong.  TBHSS provides healthcare access by connecting eligible beneficiaries to providers who are able to indentify and treat their clinical needs.  These services are provided through secured video technology which allows accessibility from remote locations worldwide.  I was very excited to have the opportunity to work in a clinic that has the ability to reach out to those off island, typically in areas where the demand for services is far greater than that of the availability.  To date, the clinic has been able to support Alaska,Texas, Korea, Japan, Okinawa, and American Samoa, as well as various sites on the island ofOahu and in the Continental United States.  As a provider, it was refreshing to be able to provide multiple services such as therapy, consultation, administrative evaluations, and both neuropsychological and psychological assessments. In addition, we provided surge support during different points within the ARFORGEN cycle whenever there was a need for augmented behavioral health resources.  In February, 2012 I was fortunate to be commissioned in the USPHS as a Lieutenant (0-3) and detailed to Tripler.  As a clinical psychologist, I was able to utilize all the skills within the Department of Psychology that I acquired from my time at TBHSS.  Recently, I had the honor to be promoted to the position of Clinical Director of TBHSS.  Returning back to my roots has been exciting as I get to work with individuals who have a passion and commitment to serve service members and their families.  My journey as a clinical psychologist civilian contractor to active duty clinical director has just begun and I am looking forward to the ongoing relationships that the TBHSS team forges with the different regions" [Sherry Gracey, Lt. USPHS].

            ASPPB:  We were very pleased to learn from Steve DeMers that the Association of State and Provincial Psychology Boards (ASPPB) was successful in its application this year for one of the licensure portability grants issued by HRSA.  ASPPB will receive approximately $1 million over the next three years to provide support for state psychology licensing boards addressing statutory and regulatory barriers to telehealth, focusing upon continuing the development and implementation of its Psychology Licensure Universal System (PLUS) initiative.  As an integral means of addressing the present barriers associated with telepsychology, ASPPB has developed an on-line application system, the PLUS, that can be used by any applicant who is seeking licensure, certification, or registration in any state, province, or territory in the United States or Canada that participates in the PLUS program.  This also enables concurrent application for the ASPPB Certificate of Professional Qualification in Psychology (CPQ) which is currently accepted by 44 jurisdictions and the ASPPB Interjurisdictional Practice Certificate (IPC).  All information collected by the PLUS is deposited and saved in the ASPPB Credentials Bank, a Credentials Verification & Storage Program (The Bank).  This information can then be subsequently shared with various licensure boards and other relevant organizations.  Therefore, streamlining future licensing processes.

            ASPPB is an active participant in the APA/ASPPB/APAIT Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, established by former APA President Melba Vasquez and co-chaired byLinda Campbell (APA) and Fred Millan (ASPPB).  The members have backgrounds, knowledge, and experience reflecting expertise in the broad issues that practitioners must address each day in the use of technology -- ethical considerations, mobility, and scope of practice.  Several of the meta-issues discussed to date center on the need to reflect broadness of concepts when incorporating telecommunications technologies and to provide guidance on confidentiality and maintaining security of data and information.  In addition, a number of meta-issues focus on the critical issue of interjurisdictional practice.  The underlying intent behind the proposed guidelines is to offer the best guidance to psychologists when they incorporate telecommunication technologies in the provision of psychological services, rather than be prescriptive. The Task Force met twice in 2011, June of 2012, and plans to meet once more this Fall.  Feedback on their recommendations will be sought at the Orlandoconvention, throughout the APA governance, and continuously from the membership at large.  Their goal is to have the guidelines adopted by APA as policy and approved by ASPPB and APAIT sometime in 2013.

            The U.S. Supreme Court:  As we all must be aware, this summer the U.S. Supreme Court upheld the underlying constitutionality of the President's landmark Patient Protection and Affordable Care Act of 2010 (ACA), including it's far reaching individual mandate provision, by a 5-4 vote.  For legal scholars, the most critical issue was probably the Court's deliberations regarding the federal government's power to regulate Commerce vs. its power to raise Taxes, as a government of limited and enumerated powers.  "We do not consider whether the Act embodies sound policies.  That judgment is entrusted to the Nation's elected leaders.  We ask only whether Congress has the power under the Constitution to enact the challenged provisions."

For health policy experts and practitioners, the Court's musings on our nation's health care system makes for particularly intriguing reading.  * "Everyone will eventually need health care at a time and to an extent they cannot predict, but if they do not have insurance, they often will not be able to pay for it.  Because state and federal laws nonetheless require hospitals to provide a certain degree of care to individuals without regard to their ability to pay, hospitals end up receiving compensation for only a portion of the services they provide.  To recoup the losses, hospitals pass on the cost to insurers through higher rates, and insurers, in turn, pass on the cost to policy holders in the form of higher premiums.  Congress estimated that the cost of uncompensated care raises family health insurance premiums, on average, by over $1,000 per year."  * "Indeed, the Government's logic would justify a mandatory purchase to solve almost any problem….  (M)any Americans do not eat a balanced diet.  That group makes up a larger percentage of the total population than those without health insurance.  The failure of that group to have a healthy diet increases health care costs, to a greater extent than the failure of the uninsured to purchase insurance….  (T)he annual medical burden of obesity has risen to almost 10 percent of all medical spending and could amount to $147 billion per year in 2008.  Those increased costs are born in part by other Americans who must pay more, just as the uninsured shift costs to the insured."  * "In enacting [ACA], Congress comprehensively reformed the national market for health-care products and services.  By any measure, that market is immense.  Collectively, Americans spent $2.5 trillion on health care in 2009, accounting for 17.6% of our Nation's economy.  Within the next decade, it is anticipated, spending on health care will nearly double.  The health-care market's size is not its only distinctive feature.  Unlike the market for almost any other product or services, the market for medical care is one in which all individuals inevitably participate."  * "Not allU.S. residents, however, have health insurance.  In 2009, approximately 50 million people were uninsured, either by choice or, more likely, because they could not afford private insurance and did not qualify for government aid."

            Bringing Psychology To The Table – State Leadership In Health Care Reform:  At this year's impressive State Leadership conference, Katherine Nordal exhorted our state association leaders to appreciate that: "We're facing uncharted territory with proposed new models of care delivery.  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.  We know that the states are in the drivers' seat, and most of what happens about health care reform is going to happen back home.  We know that we can't do it alone.  Our advocacy depends on effective collaborations and effective partnerships.  We have to be ready to claim our place at the table.  We need to be involved at the ground level.  You've got to get involved in coalitions.  If we don't participate, then we abdicate our responsibility there and we let other people – physicians, nurses, social workers, MFTs, whoever – define what our future is going to be as a profession.  And that's just not an option for us.  If we're not at the table, it's because we're on the menu….  When you get home and you turn your focus to health care reform, I want you to remember that other groups don't automatically think about psychology and invite us to the table when they're having these discussions.  We have to identify health care reform initiatives that impact psychological practice and our patients and get involved in those in a proactive way.  If you wait…."  Aloha,

 

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

 

EXCITING TIMES FOR THE PUBLIC SECTOR

  During this year's Senate Appropriations Committee hearings on the Fiscal Year 2013 budget, the three Department of Defense (DoD) Surgeon Generals and the Chiefs of the Service Nursing Corps noted the importance of quality mental health care, advances in technology (e.g., telehealth), and the critical psychosocial-cultural-economic gradient of care to the military and to its families.  Having personally observed these hearings over the years, the change in focus from previously almost exclusively acute care and "medical" issues, to the recognition of the importance of systems, holistic approaches, and patient-centered care represents a very nice evolution/maturation for which psychology and nursing can be justifiably proud.  Many of the underlying concepts, such as coordinated and integrated care, not to mention fundamental interdisciplinary respect, are at the foundation of President Obama's landmarkPatient Protection and Affordable Care Act.  I have come to particularly appreciate how critical the public sector's inherent emphasis upon systems of care --  in contrast to the private sector's often isolated (or silo-oriented) care -- is in fostering cost-effective, state-of-the-art, high quality care for beneficiaries.  This is the future and fortunately our training programs are becoming increasing responsive.  At lunch the other day, for example, I learned that Uniformed Services University of the Health Sciences (USUHS)  clinical psychology graduate student LT Chantal Meloscia, USN is enrolled/embedded in a Graduate School of Nursing advanced physiology course.  This core course for advanced nurse practitioners provides an in-depth understanding of the function and regulation of the body system to maintain homeostasis, with an emphasis on the integration of the structure and functional systems within the human body.  The course content ranges from cellular mechanisms to the major body organ systems, providing the basis for understanding physiologic derangements.  On average, nine USUHS psychology students will take this required course annually, serving as a foundation for a pharmacology class the following year taken through the medical school.

            United States Air Force (USAF):  National health care costs continue to rise at rates above general inflation and the DoD is not insulated from this growth as we purchase over 60% of our care from the private sector.   In times of war there are always significant advances in the field of medicine.  Today we are applying these lessons to shape future readiness and care.  Build patient-centered care.  At home, we continue to advance thePatient-Centered Medical Home (PCMH) to improve the delivery of peacetime healthcare.  The foundation of patient-centered care is trust, and we have enrolled 920,000 beneficiaries into team-based, patient-centered care.  Continuity of care has more than doubled with patients now seeing their assigned physician 80% of the time and allowing patients to become more active participants in their health care.  PCMH will be in place at all Air Force Medical Treatment Facilities (MTFs) by June of this year.  The implementation of PCMH is decreasing emergency room visits and improving health indicators.  We have also implemented pediatric PCMH, focusing on improving well child care, immunizations, reducing childhood obesity, and better serving special needs patients.

            Our personalized medicine project,Patient Centered Precision Care (PC2), which builds on technological and evidence-based genomic association, received final Institutional Review Board approval.  We enrolled the first 80 patients this year with a goal of enrolling 2,000 patients in this research.  It will allow us to deliver state-of-the-art, evidence-based, personalized health care incorporating all available patient information – the advancement of genome-informed personalized medicine.  We are also testing incorporation of smart-phones into our clinics to link case managers directly to patients.  Linking wireless and medical devices into smart phones allows the patient to transmit weight, blood pressure, or glucometer readings that are in high risk parameters, directly to their health team for advice and consultation.

            Safeguarding the well-being and mental health of our people while improving resilience is a critical Air Force priority.  We remain vigilant with our mental health assessments and consistently have Post-Deployment Health Reassessment completion rates at 80% or higher for Active Duty, Guard, and Reserve personnel.  We have implemented the Congressionally directed two-phased approach requiring members to complete an automated questionnaire, followed by a person-to-person dialogue with a trained privileged provider.  Whenever possible, these are combined with other health assessments to maximize access and minimize inconvenience for deployers.  Each deployer is screened for post-traumatic stress disorder (PTSD) four times per deployment including a person-to-person meeting with a provider.  Although our PTSD rates are rising, the current rate remains low at 0.8% across the Service.  Our mental health providers, including those in internships and residencies, are trained in evidence-based PTSD treatments to include Prolonged Exposure, Cognitive Processing Therapy, and Cognitive Behavioral Couples Therapy for PTSD.  Virtual Iraq/Afghanistan uses computer-based virtual reality to supplement Prolonged Exposure Therapy at 10 Air Force sites.  Diagnosis is still done through an interview, supported by screening tools and other psychological testing as clinically indicated.

            We are working closely with Air Force leadership to inculcate healthy behaviors.  Comprehensive Airmen Fitness focuses on building strength across physical, mental, and social domains.  While we experienced a drop in the active duty suicide rate in 2011, we remain concerned.  Guard and Reserve suicide levels have remained steady and low.  The major risk factors continue to be relationship, financial and legal problems.  No deployment or history of deployment associations has been found.  By summer of this year, we will embed behavioral health providers in primary care clinics at every MTF.  The Behavioral Health Optimization Program reduces stigma by providing limited behavioral health interventions outside the context of the mental health clinic, offering a first stop for those who may need counseling or treatment.  We are increasing our mental health provider manning over the next 5 years.

            This past year, the Air Force field-tested a new Electronic Health Record (EHR) during Aeromedical Evacuation (AE) missions.  Air Force nursing priority for 2011 was to further advanced research and evidence-based practice initiatives to improve patient safety and pain management during AE transport.  Our Informatics Fellowship is critical to prepare nurses to participate in the development and fielding of computer based information systems, such as the EHR.  Patient centered care is at the core of all we do; it is our highest priority.  Care for our patients crosses into both inpatient and outpatient arenas, and has been redefined with a more focused emphasis on providing healthcare to promoting health.  Embedded in our patient-centered care is an emphasis on resilience.  The Air Force is committed to strengthening the physical, emotional, and mental health of our Airmen and their families.  "You will know you're a military nurse when you visit the National Mall in Washington  D.C., and the Vietnam Veterans visiting The Wall tell you their stories of how nurses saved their lives, and then they thank you for serving.  Then you swallow the lump in your throat and blink back the tears in your eyes and continue doing what you were doing without missing a beat.…  You will know you're a military nurse when at the end of the day, at the end of the tour, or the career, you say, 'I'd do it all over again.'"

            U.S. Army Surgeon General Patricia Horoho noted: "Psychological health problems are the second leading cause of evacuation during prolonged or repeated deployments."  Division member Ray Folen and Becky Porter were with the Surgeon General at TriplerArmy Medical Center when she addressed 5,000 Army behavioral health providers throughout the world, utilizing video-conferencing.  "It was an impressive event, the first of its kind in my 28 years with the Army.  She is a most impressive visionary."  SG Horoho is the first non-physician and first woman selected for this leadership position in the history of the U.S. Army, dating back to 1775.

            A Wonderful Role Model:  "When I turned 70, I retired officially, but since I like to teach, I taught one course a term for free until I had to have my hips and right shoulder replaced at age 85 (the penalty for 50 years of pitching softball).  Now I come to my office every morning to do e-mail and play MURDER at noon.  Then I go home to have lunch with my wife and read the New York Times which is delivered to us, daily.  I still subscribe to 50 journals, including theChronicle of Higher Education and Sciencemagazine which come weekly; so I always have plenty to read.  We also go on Tuesday evenings to hear the Easy Street Jazz Band, which plays some of the same music I played when I played piano in bars weekends during my college years.  We have sung in the FirstBaptist Church for 65 years and enjoy that.  We have an excellent Korean woman organist and a fine choir director.  Our daughters and their husbands live nearby; so we get together with them frequently.  For Christmas, Karen gives us a scroll for one year of free computer consultation and Linda and Larry give us a scroll promising one year of free household maintenance.  (I'm no good at practical things).  One of my friends retired from Harvard and can only go in to hear lectures because he doesn't have an office.  So, at age 91, we feel lucky to be healthy and well cared for.  Best wishes!"  [Bill McKeachie, former APA President.  Regularly attending APA conventions since 1947].

Pat DeLeon, former APA President – Division 18 – July, 2012

 

THE TIMES THEY ARE A-CHANGIN’

The U.S. Army Surgeon General Patricia Horoho recently testified before the Senate Appropriations Committee: "Psychological health problems are the second leading cause of evacuation during prolonged or repeated deployments." The popular media reports that suicides among military members, on average of one per day, are the highest rate so far during a decade of war in Iraq andAfghanistan – and this year higher than the number of troops killed in combat. This clearly demonstrates an appreciation for the need for psychological services in a timely fashion. Reflecting upon my tenure on the U.S. Senate staff, I recall an August 2, 1978 memo from the then-Principal Deputy Assistant Secretary of the Department of Defense titled: Utilization of Psychologists in the Military Health Care System. VernonMcKenzie: "I have had my staff explore this question in some detail. We have concluded that there are utilization problems with respect to this group that require further consideration. We have tentatively concluded that there are several steps which might be taken which would improve the utilization of this professional group. Among these are the following…. Grant psychology departmental autonomy where the size and staffing of the hospital would justify…. Allow a psychologist, when he is senior and capable, to be the head of a mental health department…. Improve the promotion opportunities for senior psychologists…." SG Horoho is the first female and first nurse to be appointed to that critical position since the creation of Army Medicine in 1775.
Bob McGrath, a staunch supporter of psychology obtaining prescriptive authority from the beginning, estimates that currently there are 1600-1700 colleagues who have completed their advanced psychopharmacology training. This is an impressive figure. What I consider even more so, however, is the increasing interdisciplinary training efforts being developed by our academic colleagues as the nation evolves towards integrated care. For example, clinical psychology graduate student LT Chantal Meloscia, USN is enrolled/embedded in a Graduate School of Nursing Advanced Physiology course. This core course for advanced nurse practitioners provides an in-depth understanding of the function and regulation of the body system to maintain homeostasis, with an emphasis on the integration of the structure and functional systems within the human body. The course content ranges from cellular mechanisms to the major body organ systems, providing the basis for understanding physiologic derangements. On average, nine USUHS psychology students will take the required course annually serving as a foundation for a Pharmacology class the following year taken through the MedicalSchool.
Visionary Cynthia Belar announced a new APA Primary Care Fellowship which will develop an overall framework and strategy for promoting the engagement of psychologists in providing integrated mental and behavioral health services in primary care settings. This will involve outreach to physician specialty associations, interdisciplinary primary care organizations, and disease-specific groups to enhance collaboration and partnerships on programmatic and policy initiatives related to integrated health care. Exciting opportunities. For the times they are a-changin'. Aloha,

Pat DeLeon, former APA President – Division 31 – June, 2012

THE STEADY EVOLUTION

  As our nation's business leaders and elected officials seek to address the escalating cost of health care, there will undoubtedly be increasing emphasis upon utilizing the unprecedented advances occurring in computer technology to ensure that necessary, cost-effective care becomes readily available.  Chronic disease treatments account for over 75% of expenditures, with obesity being a major contributor.  Chronic pain affects 116 million adults; more than heart disease, cancer, and diabetes combined.  No single profession can reasonably claim exclusive clinical expertise for these conditions, for which the psychosocial-economic-cultural gradient of care is so critical.  To control costs and increase access, the economic incentives must be transitioned from our traditional fee-for-service and often isolated small practices, to an integrated, multi-disciplinary system, comprehensive enough to capitalize upon multi-provider and multi-discipline strengths, prevention opportunities, and cross patient-diagnosis comparisons.  Change is always unsettling.  Yet, future health delivery models will have much in common with the HMOs proposed by President Nixon and the Managed Care efforts of President Clinton.

            Within the past decade, nearly every health profession has enhanced the education of their graduates, their scope of clinical practice, and their numbers.  There are over 150,000 Advanced Nurse Practitioners (Doctors of Nursing Practice) and Physician Assistants providing quality primary care.  Notwithstanding medicine's historically expressed concerns, objective evaluations of these non-physicians consistently report extraordinary competence and satisfaction by patients.  Similar results exist for optometrists, physical therapists, psychologists, and clinical pharmacists.  With our aging population and expanding ability to quantify health care outcomes, we must embrace a health care delivery system that is dedicated to providing the highest possible quality of patient-centered care in a cost-effective manner.  The critical implementation decisions will be made at the local level.  Aloha,

 

PatDeLeon

 

The Council for Ohio Health Care Advocacy – June, 2012