LOOKING TO THE FUTURE – PERHAPS THROUGH THE LOOKING GLASS?

Over the coming decade professional psychology will increasingly embrace its generic health psychology expertise.  As Education Directorate visionary Cynthia Belar has noted: "There is nothing new about interprofessional education, team based care, or integrated care.  What is new is the national recognition of its importance for 'Crossing the Quality Chasm' (Institute of Medicine (IOM)) and the increasing calls for such by leaders in medical education.  Psychologists in health settings have often provided team based care, but training for such has usually begun at the internship or postdoctoral levels.  With the focus on interprofessional competencies there are increased demands for interprofessional education in the earliest stages of training, where students can learn with and from each other and before stereotypes get rigidified.  Early involvement in interprofessional education provides a challenge for doctoral programs housed in colleges of arts and sciences or universities without other health professions students, but one not impossible to meet.  In fact the Graduate Psychology Education (GPE) program of HRSA, of which APA was the architect, has since its inception required the training of psychologists with at least two other health professions for receipt of grant funds.  We have said before how federally qualified health centers (FQHCs) and departments of internal medicine, pediatrics, and family practice can provide invaluable experiences in training for team-based primary care.  Programs that want to prepare health service providers should run, not walk, to these settings and work to establish collaborative opportunities for training."  President Obama's landmark Patient Protection and Affordable Care Act (ACA), with its distinct emphasis upon increasing access to patient-centeredprimary health care, provides a number of incentives for interdisciplinary care and interdisciplinary training.  We would suggest that this (re)volution provides the public sector with an unprecedented opportunity to demonstrate critical clinical leadership while developing truly innovative partnerships with psychology's (and professional nursing's) training institutions, in order to effectively deliver gold standard care for its beneficiaries.

            The IOM recently issued another futuristic report "Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation." Two-thirds of adults and almost one-third of children in our nation today are overweight or obese.  This epidemic of excess weight is associated with major causes of chronic disease, disability, and death.  Its annual cost is estimated at $190.2 billion.  After reviewing hundreds of prior strategies for their promise in accelerating obesity prevention, the IOM mapped out how the most promising interacted with, reinforced, or slowed each other's progress.  This "systems approach" resulted in several specific recommendations including: * Make physical activity an integral and routine part of life.  * Create food and beverage environments that ensure that healthy food and beverage options are the routine, easy choice.  * Transform messages about physical activity and nutrition.  * Expand the roles of health care providers, insurers, and employers.  And, * Make schools a national focal point.  The IOM stressed that because obesity is such a complex and stubborn problem, a bold, sustained, and comprehensive approach is needed.  Action must occur at all levels – individual, family, community, and the broader society – with ongoing assessment of progress being key as efforts move forward.  Obesity risks are often disproportionate among minority, low-income, less educated, and rural populations, due to inequitable distribution of health promotion resources and community risk factors that contribute to disparities in obesity prevalence.  We would suggest that those individuals and their families who primarily rely upon the services of the public sector would be particularly at risk and that the psychosocial and behavioral skills of advanced practice nurses and psychologists could be extraordinarily cost-effective.  University of Hawaii President MRC Greenwood served as vice chair of the IOM committee.

Those in attendance at the APA Orlando Opening Ceremonies could clearly appreciate that addressing obesity was an extremely high priority for President Suzanne Bennett Johnson.  Suzanne bestowed well deserved Lifetime Recognition awards on Kelly Brownell and Rena Wing for their decades of pioneering, standard-setting work.  And yet, we are also aware of significant emotional "push back" she has received from a vocal subset of the membership.  Perhaps this contingent, which does not believe that obesity should be of serious concern to psychology, feels that it is a "medical" problem and that we only deal with "mental health" issues.  Or, perhaps they feel that talking about obesity "stigmatizes" individuals and therefore by addressing psychology's potential contribution, one is being discriminatory.  A smaller subset apparently even believes that "obesity is a myth," notwithstanding considerable scientific and clinical evidence to the contrary.  Thankfully, our next generation continues to expand their horizons.  Lia Billington, who is a prescribing psychologist in New Mexico, is currently conducting a fellowship with the Society of Teachers of Family Medicine.  As part of this experience, she is working on a "scholarly project" to be presented at their national meeting this summer.  Her hypothesis is that there are a number of prescribing/medical psychologists who are significantly contributing to Medical Education (formally or informally) and is attempting to track them down [lia.billington@gmail.com].

            Impressive Learning Opportunities in the Public Sector:  "After the War – The Uniformed Services University of the Health Sciences (USUHS) Medical and Clinical Psychology Department provided a recent seminar from the perspective of a Wounded Warrior's family member.  Stacy Fidler is the mother of Marine Lance Corporal Mark Fidler, who was severely wounded in Afghanistan on the 3^rd of October, 2011, while on foot patrol, after being in country less than two weeks.  While the initial blast took off one leg below the knee and the other leg above the knee, the extensive and complicated injuries to his entire body required that the surgeons amputate from the pelvis down.  Considered a miracle by many in the medical community, Mark was not expected to survive.  Stacy's unflagging support and advocacy are, no doubt, an integral part of his survival and her continued dedication to her son ensures that he receives the best care available.

            "Stacy is not a professional speaker, but she has a way of relating her story to an audience.  She sat on a chair in the middle of the stage and easily, but passionately, told the story of how her life has changed in the last year and a half.  She discussed the initial shock and confusion she felt upon hearing the news that her son was seriously wounded in a blast.  She recalled hastily packing a bag to travel to Walter Reed and the excruciatingly slow hours until she could see her son.  She discussed the many painful surgeries that he has undergone, and the effects on him and those around him.  Stacy shared how her son feels phantom pain in his missing legs every day, but how he fears the pain going away because then he won't feel his legs at all.  Stacy discussed the need for healthcare providers to build rapport with the Wounded Warriors, and to never forget that they are still people, and not just a name on a round.

            "Stacy also shared amusing stories about how Mark was in such pain that he could not see President Obama when he came to visit the Walter Reed hospital.  This 'refusal' led to Mark being investigated and out on a watch list.  Stacy discussed how her son had learned to adapt to his situation with his internal fortitude.  For instance, he has surfed by standing on his hands.  He also claims that push-ups are much easier now.  It has been Mark's sense of humor that helps him through the toughest times.  For instance, he likes to occasionally bark at people just to see what their reactions will be.  Stacy was honest about the difficulties they have faced with coordinating care and finding resources.  She discussed how the family and caretaker community help one another, both emotionally and also with information on programs, drug interaction, providers, and medical procedures.  Stacy related the great need to never forget that a Wounded Warrior is not their injury.  They have an injury, but they are still the person they were before.  Mental health professionals working with these young men and women must keep in mind aspects that go beyond the direct injury.  For instance, she shared the story of one 19-year-old Wounded Warrior who will never be able to have sex with his wife again, and the effects on that relationship and his own self-esteem.

            "There were many more stories, each presented with candor, wit, and the bitter taste that only comes from experience.  Yet, she also related humor, and the sweet feeling of hope that comes from strength.  Stacy presented on the day that Mark was being prepped for another surgery, a skin graft for the severely burned areas of his back.  The next day Mark had the surgery and he is recovering well.  After a year and a half, Stacy and Mark's journey is still far from over, but it is obvious from whom Mark received his great strength and determination to continue.  Even as a Wounded Warrior, Mark continues to exemplify the greatest characteristics of the Marine Corps and the military in general.  And so does his mother, Stacy.  To you both I say, 'Semper Fi' [Steven Brewer]."  We would remind the readership that this is at a time when the media reports that more troops were lost to suicide in 2012 than in combat.  "Knowing is not enough; we must apply.  Willing is not enough; we must do" (IOM/Goethe).

            The 113^th Congress:  On January 24, 2013 Pamela Hyde, Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), testified before the U.S. Senate that SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.  SAMHSA envisions a Nation that acts on the knowledge that:  * Behavioral health is essential for health.  * Prevention works.  * Treatment is effective.  And, * People recover from mental and substance disorders.  In order to fulfill this mission, SAMHSA has identified eight Strategic Initiatives to focus the Agency's work on improving lives and capitalizing on emerging opportunities.  SAMHSA's top Strategic Initiatives are: Prevention; Trauma and Justice; Health Reform; Military Families; Recovery Supports; Health Information Technology; Data, Outcomes and Quality; and Public Awareness and Support.

            Acutely aware of the Newtown tragedy and citing the work of psychologist John Monahan, the Administrator noted that behavioral health research and practice over the last 20 years reveal that most people who are violent do not have a mental disorder and that most people with a mental disorder are not violent.  In fact, those with mental illness are more likely to be the victims of violent attacks than the general population.  Demographical variables such as age, gender, and socioeconomic status are more reliable predictors of violence than mental illness.  She further testified that almost half of all Americans will experience symptoms of a mental health condition at some point in their lives.  Yet today, less than one in five children and adolescents with diagnosable mental health problems receive the treatment they need.  And, only 38% of adults with diagnosable mental health problems – and only 11% of those with diagnosable substance use disorders – receive needed treatment.

            Integration -- Given that behavioral health is essential to an individual's overall health, SAMHSA administers the Primary and Behavioral Health Care Integration (PBHCI) program.  The purpose of this program is to improve the physical health status of people with serious mental illnesses (SMI) by supporting communities to coordinate and integrate primary care services into publicly funded community mental health and other community-based behavioral health settings.  It is focused on increasing the health status of individuals based on physical or behavioral health need, encouraging structural changes in existing systems to accomplish its goals.  To date, the program has awarded 94 grants and 55% of awardees are partnering with at least one Federally Qualified Health Center (FQHC).  [Recall Cynthia Belar's vision].  This integration has resulted in significant physical and behavioral health gains.

            In concluding, the Administrator reaffirmed that President Obama's ACA advances the field of behavioral health by expanding access to behavioral health care; growing the country's behavioral health workforce; reducing behavioral health disparities; and implementing the science of behavioral health promotion.  The most recent data indicates that the national expenditure on mental health care was $113 billion and for substance abuse $22 billion in 2005.  With Medicaid already being the largest payer of mental health services, the ACA will extend Medicaid coverage to as many as 17 million hardworking Americans.  SAMHSA's number one strategic initiative is Prevention of Substance Abuse and Mental Illness, including fulfilling the public health promotion component of ACA.  Aloha,

Pat DeLeon, former APA President – Division 18 – February, 2013

TIMELY EVOLUTION

     With the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA), APA established its Center for Psychology and Health, with CEO Norman Anderson at the helm.  The Center's mission is to aggressively expand psychology's presence within the evolving health care delivery models being adopted across the nation.  Former Practice Directorate Deputy Executive Director Randy Phelps heads up the Center's Office for Healthcare Financing with the pressing challenge of ensuring that emerging and current healthcare financing policies treat psychology's practitioners equitably and fairly.  He will direct APA's participation in the American Medical Association (AMA) Relative Value Update (RUC) and Current Procedural Terminology (CPT) processes, and will coordinate advocacy with the APA Practice Organization and APA involving the commercial carrier market and the Centers for Medicare and Medicaid Services (CMS).  A decade ago, APA had the foresight to establish the Health and Behavior CPT codes.  These codes provide an immediately available and critical vehicle for reimbursement ofhealthcare psychology services (beyond mental health services) within fee-for-service integrated care mechanisms in support of team-based care, which is a hallmark of the ACA.  There can be no question that physical health and mental health are intimately intertwined.  However, perhaps psychology's biggest challenge within the new healthcare environment is that the profession is being defined by marketplace and national health policymakers as primarily (if not exclusively) as a mental health profession, rather than a more generic healthcare profession.  For example, as former APA President Suzanne Bennett Johnson passionately emphasized during her Orlando Opening Ceremony, even though psychology has created a number of very effective treatment strategies for addressing the nation's epidemic of obesity -- with two-thirds of adults and almost one-third of children being overweight or obese -- our practitioners cannot be reimbursed in primary care for these services which must be provided by physicians or nurse practitioners.

            Randy's challenge is very real on two accounts.  The Institute of Medicine (IOM) has observed that health care in America has experienced an explosion in knowledge, innovation, and capacity to manage previously fatal consequences.  Yet, paradoxically, it falls short on such fundamentals as quality, outcomes, cost and equity.  Each action that could improve quality – developing knowledge, translating new information into medical evidence, applying new evidence to patient care – is marred by significant shortcomings and inefficiencies that result in missed opportunities, waste, and harm to patients.  Americans would be better served by a more nimble health care system that is consistently reliable and that constantly, systematically, and seamlessly improves.  In short, the country needs health care that learns by avoiding past mistakes and adopting newfound successes.  Thus whether psychology's critical expertise will ultimately be embraced is an "open question."  Another major barrier is having our members appreciate that unprecedented change is occurring.  APA has been successful in having psychologists deemed eligible to bill under three types of CPT codes, mental health (including therapy and diagnosis), testing (including neuropsychology), and health and behavior.  The 2011 Medicare data indicate that nationwide our practitioners have submitted less than 400,000 bills under the health and behavior code; in sharp contrast, we have submitted several million under "mental health."  Simply stated, psychology is not billing (nor acting) as if we are a healthcareprofession.  This must change.  Aloha,

 

Pat DeLeon, former APA President -- West Virginia Psychological Association – February, 2013

 

THE LAND OF VISIONARIES

  Making A Difference:  One of the most fulfilling aspects of working within Nursing at the Uniformed Services University of the Health Sciences (USUHS) and the University of Hawaii (with Law and Pharmacy) is the opportunity to pursue interdisciplinary collaboration, which is one of the hallmarks of President Obama's landmark Patient Protection and Affordable Care Act (ACA).  One of the very last events of my APA Presidential term was to travel to the State of Washington in December, 2000 to present a well-deserved Presidential Citation to your colleague Colleen Hacker for her outstanding work with the U.S. Women's Olympic Soccer Team, which in my judgment, revolutionized the expectations of our nation's female youth for what they could accomplish in sports, science, and education.  They made a lasting impression on my daughter Kate.  That evening, I reflected upon the many national accomplishments of WSPA's leaders; for example, Ruth Paige whom I have had the pleasure of serving with on the APA Board of Directors, Barry Anton, and Andy Benjamin.  I recalled Al Paige inviting me to Ocean Shores in May, 1981 to talk about the importance of your maintaining the doctoral level standard, notwithstanding internal "political pressures."  Former APA Congressional Science Fellow Margy Heldring and Elizabeth Robinson were catalysts for a number of important APA policy issues, including attracting more women into APA's governance.

            Recently I had the opportunity to address the leadership of several national pharmacy organizations and learned, once again, that their members from your state have been on the cutting edge of pharmacy's maturation.  Today the Doctor of Pharmacy (PharmD) degree is the educational standard and their practitioners are providing comprehensive, patient-centered primary care (comparable to what health psychologists envision), including such preventive services as relaxation techniques, blood pressure evaluations, and anti-smoking educational efforts.  Our College of Pharmacy in Hilo conducts well attended community health fairs and is training Hawaii's psychologists in psychopharmacology.  The profession of pharmacy has obtained "collaborative practice" medication authority in almost all states and throughout the federal services (i.e., VA, DoD, USPHS, and Bureau of Prisons), often including the ability to initiate, modify, and terminate drug protocols.  While pharmacists have been involved with vaccines dating back to the mid-1800s and the distribution of smallpox vaccine, approximately two decades ago pharmacists began routinely immunizing patients in their communities as a standard practice activity.  The Washington State Pharmacists Association initiated the first ongoing formalized training of pharmacists in vaccine management in 1994, leading to the American Pharmacists Association's (APhA) nationally recognized training program for their members, in conjunction with the CDC.  Today (in contrast to psychology's orientation) organized pharmacy has embraced the utilization of pharmacy technicians, especially with the advent of the impressive advances occurring within the communications and technology fields.  Psychology should learn from pharmacy's experiences, including working closely with the pharmaceutical industry to sponsor innovative service delivery models.  Within the nursing profession, which also has been steadily expanding its scope of clinical practice over the past several decades, their national leaders have often been from your state.  And, various Washington State educational institutions have long maintained an impressive presence throughout Rural America; including on Indian reservations, the Pacific Basin, and the State of Alaska.  Providing patient-centered, cost-effective, and demonstrably accountable care has been paramount throughout these efforts.  I would love to hear of WSPA's efforts to work collaboratively with your state's federally qualified community health centers (FQHCs).

            Novel Models:  Former APA President Alan Kazdin recently addressed the need for our nation to develop novel models for delivering quality mental health services.  There can no longer be any question that there are significant economic and personal burdens of untreated "mental illness" throughout the nation and the world.  Mental health and physical health are inextricably intertwined.  Within the U.S. approximately 50% of our population meets the criteria for at least one psychiatric disorder during their lifetime.  Many of the barriers for delivering care for physical health issues to large swaths of individuals in need, particularly in developing countries, are recognized to be similar to the barriers of providing mental health care.  Alan points out that within the mental health professions the current model of delivering care is expanding; many involve the use of technology and online-versions of treatment drawing upon the Internet and other social media.  Similar to pharmacy's recognition, our former President has seriously proposed exploring "task shifting" which is a method of redistributing the tasks of delivering services to a broad range of individuals with less training and fewer academic qualifications than traditional health care workers possess in order to scale up the scope of providing services.  The underlying concept is not new having emerged from global health initiatives, particularly in developing countries where the majority of task-shifting applications have focused upon physical health where shortages of human resources and the burden of illness are acute.  This approach has recently been expanded to mental health concerns because of its ability to be scaled up to provide services to individuals who otherwise do not have access to care, as well as its adaptability to diverse countries, cultures, and local conditions.  Standardized treatments, decentralized delivery models, and simplified treatment protocols are systematically evolving.  Perhaps "lessons learned" from the business community's experience with "disruptive technology and disruptive innovations" will become the key.  To appreciate the true potential of this approach, psychology's training models of the future must become interdisciplinary in nature and we would suggest, moving beyond those of the traditional health professions.

            An Interesting Example of Alan's Vision -- Behavioral Health Technicians:  "Recently those of us at USUHS were fortunate to have five enlisted behavioral health technicians (BHTs) speak with the students, faculty, and staff of the Medical and Clinical Psychology Department.  The group consisted of Army and Navy personnel, with various assignment and deployment experiences.  The main speaker for the group was Army Sergeant First Class (SFC) Jonathan Colon, the Senior Enlisted Leader for the Directorate of Behavioral Health and the senior 68X (Army Behavioral Health Technician) for the Walter Reed National Military Medical Center of Bethesda.

            "SFC Colon discussed the primary duties of the BHT within the Army, Navy, and Air Force.  For example, the Army BHT assists in providing treatment for patients with behavioral health problems such as substance abuse, sexual assault and domestic violence, social issues, and posttraumatic stress disorder (PTSD).  They collect the required data from clients and are responsible for unit training on various behavioral health topics.  Under the supervision of a licensed provider (including psychological nurse), the enlisted BHT can conduct initial interviews, perform assessments, provide follow-up care, administer psychological tests, assess patient response to rehabilitation or treatment, co-facilitate group therapy sessions, and perform Combat and Operational Stress Control (COSC) functions.

            "The Navy and Air Force BHTs perform very similar functions, but with some distinct differences.  For instance, Navy BHTs are initially trained as corpsmen, which means they also have extensive medical training and can assist with emergency patient care if necessary.  The Navy is responsible for overseeing the needs of the Marine Corps, as that group is designated under the Department of the Navy.  The Air Force BHT job duties include on-call consultation to the Command and clinic management, though the Air Force BHT has a smaller role in conducting therapy sessions.

            "Perhaps the most shocking bit of information for the audience was the discovery of how much independent work the BHTs perform while deployed.  Due to the lack of licensed mental healthcare providers, these BHTs are left to work alone for weeks or months at a deployed site.  They will conduct the initial assessment, create a treatment plan, conduct individual or group therapy, and even make medication recommendations.  They work under the auspice of the behavioral health provider assigned to that camp or region through a precept method.  The BHT will conduct the work and create the recommendations, then contact the provider by phone for approval or changes, and then implement the finalized plan.

            "Another key piece of BHT duty is to act as the liaison between the troops and the commanders, and between the licensed provider and the troops.  All licensed providers are military officers, and all BHTs are enlisted.  The difference can sometimes be a gulf that is difficult to traverse, and the BHTs are the bridge that connects both sides.  Many times, troops will not want to see a licensed provider, but they have an issue they want to discuss.  An enlisted BHT, who is in the ranks working, eating, and bunking with these troops, is more likely to find out about the issue and offer assistance.  Their presence also reinforces the strength and trust between the troops and the Command structure, as well as helping to eliminate the stigma of being treated in behavioral health.  Obviously, the skills and experiences of these BHTs cannot be overemphasized, nor should they be underestimated.  They are skills that need to be utilized by the licensed providers of all the military branches, lest we lose them [Steven Brewer]."  Interesting times as always.  Aloha,

Pat DeLeon, former APA President – WSPA – January, 2013