With the enactment of President Obama's Patient Protection and Affordable Care Act (ACA), our nation's health care environment has truly entered uncharted waters. Unprecedented change is inevitable. Yet, from a health policy perspective, a discernible foundation has been evolving over the past decade. Increasing access to patient-centered primary care; an emphasis upon prevention and wellness; interdisciplinary collaboration across the health professions; integrating physical and mental health; and data-driven accountability (i.e., "gold standard" care) is what is being demanded. The extraordinary advances occurring within the communications and technology fields provide exciting opportunities (e.g., telehealth, virtual realities, and personalized health apps). Health care, like education, is fundamentally locally based. As Katherine Nordal has made abundantly clear during her State Leadership Conferences (SLC), psychology must get personally involved at the state and local level if we expect our clinical expertise to be appropriately recognized. As she has graphically emphasized: "If we're not at the table, it's because we're on the menu." The Institute of Medicine: "Health care in America has experienced an explosion in knowledge, innovation, and capacity to manage previously fatal conditions. 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 the new evidence to patient care – is marred by significant shortcomings and inefficiencies that result in missed opportunities, waste, and harm to patients." Psychology must not be so naïve as to assume that our potential clinical contributions will be appreciated by those shaping our nation's health policies. The States today have an extraordinary opportunity to shape their own health care destiny.
Oregon – "She Flies With Her Own Wings": In 2011 the State of Oregon projected a $2 billion deficit in its Medicaid budget. The Governor (a former emergency room physician) negotiated an agreement with the Obama Administration to address the deficit if the program would grow at a rate that is two percent slower than the rest of the country, and thereby ultimately generate an $11 billion savings over the next decade. Oregon would pursue the Holy Grail in healthcare policy -- slower cost growth. A major provision of ACA allows the states to significantly expand their Medicaid program to cover everyone below 133 percent of the federal poverty line. In Oregon, Medicaid is expected to enroll 400,000 new patients by 2022, nearly doubling its current numbers. "In terms of cost-control experiments, this likes of this are something we have never seen in health care."
Robin Henderson, a regular attendee at SLC, is executive director of the Central Oregon Health Council and works within the St. Charles Health System. "Many places around the country are waiting for health reform, integration, and other changes to happen to them. They wait for 'the answer' that will bend the cost curve, and look outside for guidance, ideas, leadership, and motivation. Central Oregon isn't that place. Long considered Oregon's playground, we have been on the bleeding edge of health reform efforts in Oregon for years. Our recent efforts have centered on the creation of 'Coordinated Care Organizations,' heralded by the Centers for Medicare and Medicaid Services as the Medicaid corollary to the Accountable Care Organizations (ACOs) in the ACA. Before the federal legislation was even crafted, health leaders in this scenic part of the country knew things had to change. They knew their health system – comprised of St. Charles Health System, three community mental health centers, three public health agencies, Mosaic Medical Center (the region's largest federally qualified health center (FQHC) serving all three counties); the Central Oregon Independent Practice Association representing more than 600 independent practitioners; and even PacificSource Health Plans, the Medicaid payer serving the region – had the potential to lead the way.
"In early 2009, community members gathered together and decided to take on three areas of escalating healthcare costs – over utilization of the region's emergency departments, increases in high risk pregnancies that resulted in increased births in the region's neonatal intensive care unit (NICU), and a lack of resources and care coordination for children and youth with special healthcare needs. These three areas shared common threads – the lack of care coordination, especially in relation to the increased need for services to combat the social disparities of health that drive up healthcare costs and reduce patient engagement; and the lack of any fiscal or agency collaboration between physical and mental health needs. Patients would come to the region's emergency departments with complex needs, but there was no mechanism to coordinate with community mental health agencies for their care. Babies born in the neonatal intensive care unit with known indicators for future developmental problems had no coordinated resource for early identification until problems were highly noticeable. Children with complex physical and behavioral disorders could only receive comprehensive diagnostic evaluations after enduring a nearly year long wait list for the one clinic in Oregon – more than 180 miles away from the region. This was unacceptable to health leaders in the region and needed to change.
"The envisioned projects were called the Health Integration Projects, and for the next two years, the region's health leaders brought them to fruition without added funding, grants, or increased payments. The results have been highlighted in the national media and are now being studied by the academic community thanks to the efforts of Ben Miller at the University of Colorado School of Medicine, who has shared his experiences with SLC attendees. They formed the basis for what is now known as the 'Central Oregon Health Council' – a non-profit public/private partnership of health and community leaders dedicated to improving the health of the region, with the goal of fulfilling the Triple Aim – Better Health, Better Care, and Better Cost for their community. Under the direction of myself as Executive Director, this collaborative serves as the governance entity for the region's only Coordinated Care Organization.
"This year's goals are focused on continuing efforts to double the number of regional primary care homes with Behavioral Health Consultants and start a pre- and post-doctoral internship/residency program for training the next cadre of psychologists to serve this community and others, expanding nursing care coordination in pediatric settings, and expanding the Title V population currently served by the region's Program for the Evaluation of Development and Learning – a monthly multi-disciplinary clinic led by neuropsychologist Sondra Marshall that is the hub for children and youth with special healthcare needs and the region's NICU follow-up clinic. Efforts to integrate public health and primary care have focused on expansion of Maternal/Child Health initiatives placing WIC screening and other nursing care coordination services directly in regional obstetrics practices to identify high risk prenatal mothers and wrap-around services as early as possible. We also focus on expanding the successful integrated School Based Health Centers in high-risk neighborhoods to serve families that otherwise would not seek healthcare services. One of the biggest pushes is the expansion of multi-disciplinary healthcare teams targeting the region's highest-cost, most complex patients and wrapping services around them to improve their health outcomes and engagement in their own care – and reducing costs by doing so. These are just a few of our goals – for a complete picture, visit our website at www.cohealthcouncil.org.
"It is noteworthy to emphasize that the region does all of this work without grants, foundation support, increased state spending, or assistance of any kind. We committed our own resources to improve the lives of our friends and neighbors, and reconnect the mind and body once and for all because we know we are blessed to live in one of the most beautiful places on Earth. Considering the primary economic driver of this region is tourism, come for a visit and see what we do. Just don't forget your skis or your golf clubs."
Division President in 1990 – A Colleague With Vision: "A Brief Biography – I started my professional life by joining a primary care practice and purchasing a part of a medical office building on the grounds of a small rural hospital in Wyoming in the late 1970s. I have worked closely with physicians and other medical professionals throughout my career. I began consulting with my medical colleagues on the appropriate medication for the treatment of psychiatric disorders in the early 1980s. Because I have a fully integrated practice and that practice needed expert providers we began hiring Nurse Practitioners (APNs) in the early 1990s in a primary care role. These APNs had full Rx authority but would frequently ask my opinion regarding the best choice for psychiatric medications for their patients. In the mid-1990s I cosponsored a motion in the Council of Representatives to create Division 55. The purpose of this new division was to promote psychologists' direct involvement with Rx authority. Having worked with APNs in my practice and with psychologist colleagues nationally to promote Rx authority for our profession – I was committed to securing Rx authority for myself.
"Unfortunately, the Wyoming Psychological Association has had no strong center of gravity for the advancement of Rx authority and has, in fact, had a number of members in leadership positions who have worked to defeat colleagues' efforts in this regard. During my APA advocacy work for Rural Health I worked with a number of leaders in the nursing community on national boards and committees including Dr. Colleen Conway Welch, the Dean of the College of Nursing at Vanderbilt University. Over time my nursing colleagues convinced me to enter a program of training in nursing with the goal of becoming an advanced practice nurse with prescriptive authority. Although there is not a direct route in academia for psychologists to add advanced nurse training, the more I studied the possibility, the more I liked it.
"With the guidance of my nursing mentors in 1998 I completed an ASN degree and passed the NCLEX (the national RN examination). I completed the academic course work for this degree 'on line' and the clinical training at my local hospital where I have been a part of the medical staff since 1978. You may remember some of my missives at that time filed as the 'True life adventures of a Boy Nurse.' A term my clinical instructors gave me after making up a hospital identification badge that said: 'Dr. Enright – student nurse.' I learned a lot from the nurses on PCU, ICCU, and in surgery. I had a good deal of fun changing roles, soaking up all the expertise I could from these talented professionals.
"In 2000 I completed a MS in Nursing at the University of Wyoming and was licensed as an APRN with full prescriptive authority. The State of Wyoming has one of the best licensing laws for APRNs in the country. I have a fully independent license with no oversight by other health care professionals. My prescriptive authority is the same as an MD. There is no limitation on my formulary. I have the authority from the DEA to prescribe the full schedule of controlled substances. This means I can prescribe Schedule II Stimulants to my ADHD patients, Narcotics for pain patients, or whatever is appropriate. My authority is limited in the same way a physician's authority is limited. I am required to show that I am qualified to prescribe the medications I chose to use in my practice. Just as a primary care doctor does not prescribe cancer drugs without special training, I only prescribe medications that I am trained to administer – which are, of course, primarily psychotropic drugs. This makes a lot more sense to me than having a limited formulary – with Schedule II drugs under the review of another profession (language in at least one of the current state psychologist Rxing laws).
"I have been licensed as an APRN and prescribing for 12 years. I have never once regretted my decision to complete my nurse training. My conviction is reinforced by the fact that psychologists in the State of Wyoming still do not have Rx authority. In the last 12 years I have not had to call a doctor one time to ask if he/she might write an Rx for my patient. I have instead had a number of physicians refer patients to me for medication management.
"I have what I consider to be an ideal work setting. On a daily basis I prescribe medications for my patients. I have physician colleagues in my office to consult with regarding the potential adverse side effects on the combination of psychotropic and other medications. You would likely not be surprised by the number of people I see who are taking a homeopathic dose of their antidepression/anxiolytic medication or are having significant side effects to the 'cocktail' of drugs they are prescribed – this is particularly true of patients over the age of 65. It is a pleasure to directly intervene and provide competent care to these people.
"The APRN credential is particularly good for day-to-day practice because I can follow my patients when they travel or move to other states. This happens quite often; especially since I live quite close to the Idaho border. My DEA number is on file with most corporate pharmacies and it is easy to call prescriptions anywhere from Alaska to New York. I don't know what the psychologists in the two states who have Rx authority do when their patients find themselves in another state and in need of a prescription refill. It would seem to be at least potentially problematic.
"As an APRN I share a nurse (RN) with one of my physician colleagues. I am not sure if psychologists with Rx authority are allowed to extend their agency to nurses or other professionals. The reality of this convenience is that the nurse in my office can call my Rx refills if I am in session or away. As I mentioned, I have been on the medical staff of my local hospital since 1978. Having credentials in both psychology and advanced practice nursing the medical staff at my local hospital consolidated my privileges. I believe I am the only psychologist in the State of Wyoming to ever have Rx privileges granted by the medical staff.
"Upon completion of my nurse training I was approached by my mentors regarding my willingness to join the faculty at my College of Nursing. Unfortunately, the University of Wyoming is at some distance from my home in northwest Wyoming, so a tenure track position was not tenable for me. I have accepted a position on the adjunct faculty of the College of Health Sciences allowing for teaching opportunities and giving me many new colleagues.
"Upon reflection, my only regret taking this course of action to add a credential as an APRN is that I have not been able to help facilitate other colleagues taking this course of action to enrich their professional practice and, in the end, obtain Rx authority. Obviously, a number of psychologists across the country have committed their whole careers to the training of psychologists for Rx authority. Consequently, a good deal of financial resources has been committed to enrolling students in these programs. No similar financial incentive is in place for psychologists extending their training to include advanced practice nursing. The other slight regret I have is that I wish I had undertaken the training sooner!
"I do need to thank a number of people who supported me throughout this quite amazing journey. I would not have been able to complete the process without the support and guidance of the leaders in nursing education who steered me to the proper resources and training programs, while giving me invaluable advice on how to deal with the college of nursing and the licensing board. I also have to thank those psychology colleagues who think 'outside the box,' for without that approach I never would have even begun this process let alone come out successfully on the other side. For all that you have done for me and all of my colleagues who have asked not 'Why?' but 'Why not?' – you have my gratitude.
"An additional reflection – I have always thought my Advanced Nurse training was a more comprehensive education than earning a MS in psychopharmacology because of the 'hands on' requirements of the training. It seems to me that it is important for a person who has prescriptive authority to have experience actually administering medication through multiple routes rather than assuming that you will only be prescribing medication taken by mouth in pill form. As a nurse I have given IM injections, started IVs – you name it. If you have prescription privileges at a hospital you need to know how to do these procedures – especially if you are expected to 'order' other support staff to do it. I still participate in giving flu shots at our office just to keep my skills up!! – Ranger Mike [Mike Enright]." You got to make the morning last…. Feeling groovy. Aloha,
Pat DeLeon, former APA President – Division 42 – March, 2013
