The 30th Annual APA State Leadership Conference (SLC): "Countdown to Health Care Reform," as always, was a truly outstanding event. From my public policy/political perspective, I was particularly pleased with the extent to which those fortunate to attend the conference learned firsthand the intricacies of working with the media at both the local and national level. Former Hawaii Psychological Association (HPA) President June Ching, for example, described her impressive efforts over the years to be "helpful" to our local print, radio, and television colleagues, while always being mindful of her unique expertise. Arthur Evans, Jr., Commissioner of the Department of Behavioral Health and Intellectual disAbility Services for the City of Philadelphia, and Robin Henderson of the Central Oregon Health Council described their visionary efforts to "bend the cost curve," while ensuring that beneficiaries received gold-standard care; i.e., demonstrating that psychology's involvement would bring "added value" to the overall quality of life of their neighbors. David Ballard's exemplary Psychologically Healthy Workplace Awards Ceremony once again highlighted the broad impact of psychology in improving daily lives throughout America.
The presentation on the APA/ASPPB/APIT joint Telepsychology Taskforce demonstrated our profession's responsiveness to the unprecedented challenges occurring within the nation's health care environment. "The Task Force for the Development of Telepsychology Guidelines has completed its work on the "Guidelines for the Practice of Telepsychology." The APA Board of Directors will be asked at their June 2013 meeting to recommend that the APA Council of Representatives at its meeting in August 2013 adopt as APA policy these Guidelines. This joint effort has been funded for one additional year (2013) to allow the Task Force to continue its collaborative work to advance model regulatory language and provide guidance on risk management practices (Joan Freud)." On a related note, ASPPB is circulating its draft "E.Passport proposal" for public comment. This will be a mechanism developed by ASPPB (concurrent to the Telepsychology Task Force work) to facilitate interjurisdictional practice for those providing telepsychology services. Each of the 500-plus state psychology leaders present at SLC will undoubtedly have his/her own highlight. SLC is a one-of-a-kind leadership and advocacy training event, which in my judgment is only surpassed by our annual convention (this year being held in Honolulu) in its importance to our professional community.
A former APA Congressional Science Fellow and now Executive Director of the Practice Directorate, Katherine Nordal in her Keynote Address passionately laid out for the audience the importance of being personally involved and actively engaged in the public policy/political process over the long haul. "At this time last year, the future of the Affordable Care Act (ACA) seemed uncertain. Since then, we've had a Supreme Court decision that upheld the ACA and the November reelection of President Barack Obama. The Affordable Care Act has survived, and implementation of the largest expansion of the health care safety net will proceed. The clock is ticking toward full implementation of the law and January 1, 2014 is coming quickly. But January 1st is really just a mile maker in this marathon we call health care reform. We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us. The details of ACA implementation vary from state to state, and so do the key players.
"All of you are painfully aware of the difficult health care environment in which we find ourselves these days: * Ever increasing demands for cost containment, declining levels of reimbursement and limits on service delivery. * Greater regulatory requirements. And, * Increasing competition in the psychotherapy marketplace, particularly due to growing numbers of masters-trained mental health providers. Fee-for-service is being replaced by alternative reimbursement mechanisms and marketplace and regulatory developments are encouraging more collaborative and integrated practice models. I see professional psychology facing challenges on three levels: First, there are challenges on the federal level where for starters, there are plenty of unfamiliar faces on Capitol Hill – a total of 94 new House and Senate members in the 113th Congress. There are challenges for the states. A principle example is expansion of Medicaid. Millions of consumers are expected to move into the Medicaid system as the ACA is fully implemented. Medicaid programs in 16 states do not recognize private sector psychologists as providers. For those that do, many place conditions and restrictions on psychologists' participation. For example, requiring physician referral for psychological services. As of 2010, only 25 state Medicaid programs utilized health and behavior codes. In addition to challenges at the federal and state levels, there are challenges for individual practitioners, regardless of practice setting. One of the major ongoing challenges facing many practitioners is the need to adapt to new and emerging systems of care. Looking to the future, viable practice options will vary from one psychologist to another.
"Let's focus on what's happening to address the challenges – beginning with what psychology brings to the table. One of the first steps in positioning for reform is for practitioners to recognize that they bring numerous professional skills and strengths to integrated care settings, including: * Conducting thorough psychological assessments. * Understanding environmental factors such as family and community systems. * Designing, monitoring and evaluating interventions. * Promoting patient responsibility, resilience and recovery. * Applying behavioral principles to modify health-risk behaviors and attending to interpersonal barriers to behavior change. And, * Understanding group dynamics and facilitating teamwork. These are factors that create 'value-add' for psychologists on health care teams and in integrated, interdisciplinary systems of care. And that's what many of our practitioners increasingly will need to promote: the value and quality they can contribute to emerging models of care. We are a highly educated and talented discipline, and we need to identify and create opportunities to make others aware of the skills and strengths we can contribute to health care. I believe that if we are not valued as a health profession, it will detract from our value in other practice arenas as well. So regardless of how we feel about the current state of our health care system, psychology must take its seat at the table and contribute to the solutions needed to fix our ailing system. Psychology will be valued to the extent that we bring our knowledge to bear on the grand challenges of our society. And believe you me, health care is a grand challenge.
"I can sum up in two words what we encourage state leaders to focus on as the countdown to health care reform proceeds: Advocacy and Education. On the advocacy front, we must step up to the plate and insist that psychologists and the psychological and behavioral services we deliver be included in emerging models of care and payment mechanisms. No one else is fighting the battles for psychology… and don't expect them to. We need to look at our advocacy broadly as taking advantage of any opportunity to help others understand and appreciate the value of psychology and psychological services. It's not enough to have a good message. We also need good messengers. Education involves both public education and outreach, along with psychologist education and training needed to prepare the profession for the new practice models that will evolve with health care reform. The skill sets needed for a psychology practice that predominately involves psychotherapy are not necessarily sufficient for practice in integrated care settings. Yes, the clock is ticking towardJanuary 1, 2014. But remember, we're not running a sprint. Health care reform is a marathon – we're in it for the long haul. New models of care and changes in health care financing won't take shape overnight. We can't afford to be left out of health care again (i.e., Medicare) and then have to spend decades playing catch-up. We can't hope to finish the marathon called health care reform if we're not at the starting line. Fortunately, many psychology leaders have embraced our call to action."
Advances Within Professional Nursing: This Spring I had the opportunity to attend two national/international nursing conferences addressing how their profession is responding to our ever-changing health care environment. The American Association of Colleges of Nursing (AACN) 2013 Spring Annual Meeting was entitled "Guiding Change: Technology in Nursing Higher Education." Not surprisingly, there was a focus on exploring challenges inherent in the increasingly technology-dependent environment of nursing higher education, as well as the utility and effectiveness of simulation in nursing education and research-based suggestions for the future. The importance of public policy/political advocacy remained a consistent theme. The Hawai'i State Center for Nursing held its annual Pacific Institute of Nursing conference, "Partnership with Parity: The New Paradigm." Two of their speakers described particularly interesting developments for non-physician clinical practice, within the policy context of the 2010 Institute of Medicine (IOM) report "The Future of Nursing: Leading Change, Advancing Health." The IOM noted that with more than three million members, the nursing profession is the largest segment of the nation's health care workforce. And recommended that * Nurses should practice to the fullest extent of their education and training. * Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. * Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States. And, * Effective workforce planning and policy making require better data collection and information infrastructure.
The first recommendation of the IOM was to "Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training." Perhaps most intriguing was the call for the Federal Trade Commission and the Antitrust Division of the Department of Justice to review existing and proposed state regulations concerning advanced practice registered nurses (APRNs) to identify those that have anticompetitive effects without contributing to the health and safety of the public. States with unduly restrictive regulations should be urged to amend them to allow APRNs to provide care to patients in all circumstances in which they are qualified to do so.
Attorney Barbara Safreit reported that the National Governors Association (NGA) had recently released a policy document specifically addressing this issue, "The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care." Highlights include: research suggests that Nurse Practitioners (NP) can perform many primary care services as well as physicians do and achieve equal or higher patient satisfaction rates among their patients (including time spent with patients, prescribing accuracy, and the provision of preventive education). State laws and regulations governing NPs revealed wide variation among the states with respect to rules governing scope of practice, including the extent to which states allow NPs to prescribe drugs, to practice independently of physician oversight and to bill insurers and Medicaid under their own provider identifier. "To better meet the nation's current and growing need for primary care providers, states may want to consider easing their current scope of practice restrictions, as well as their reimbursement policies, as a way of encouraging and incentivizing greater NP involvement in the provision of primary care…. None of the studies in NGA's literature review raise concerns about the quality of care offered by NPs."
Cathy Rick, Chief Nursing Services Officer for the Department of Veterans Affairs (VA), described the extraordinary progressive changes in the newest VHA Nursing Handbook, which, in essence, will now provide VA advanced practice nurses with the authority for independent practice, regardless of individual state licensure limitations, unless an individual VA facility limits their scope within that facility. This visionary document has been "cleared" by the relevant legal authorities who will be affirmatively assisting hesitant states in appreciating the federal government's supremacy powers within federal facilities. The handbook notes that research and evidence-based practice have demonstrated the significant and synergistic relationships between delivery of nursing care, patient and resident outcomes, and staff satisfaction as well as process effectiveness and efficiency. It recognizes that nursing care is complex and that paradigms have shifted (and will continue to shift). VHA nursing care delivery will be agile, innovative, and supportive of the Veteran as the driver of their individual healthcare. The basic tenets of VHA nursing are aligned with the ANA Standards of Practice and achieved through evidence-based practice, defined elements of practice, and professional development. Two key underlying components are that the patient owns and drives their care based on the information available and nursing interventions are based on the best available evidence and accepted standards of practice. Specifically the Nursing Handbook states:
"Clinical nursing practice varies widely among the States. To ensure safe and appropriate health care to the nation's Veterans, VA has standardized the elements of practice, within VA, for clinical nursing practice other than the prescribing of controlled substances, without regard to individual State Practice Acts. This ensures a consistent standard of nursing care throughout VA's national health care system…. Under the Federal Controlled Substances Act… a health care practitioner may prescribe controlled substances only if the practitioner's State license authorizes such prescribing. Accordingly, APRNs, including NPs, may prescribe controlled substances within VA only if they are authorized to do so by their State of licensure or registration and comply with the limitations and restrictions on that prescribing authority. Where VA establishes elements of nursing practice that are more expansive or otherwise inconsistent with State practice standards, VA's practice standards control. VA nurses must follow the VA nursing practice standards established in VA rules, regulations, and policies." Without question this is a most impressive development for our nursing colleagues. The readership should recall that the AACN announced that in October, 2004 their member schools voted to endorse moving the current level of preparation necessary for advanced nursing practice from the master's degree to the doctorate-level (i.e., the Doctor of Nursing Practice (DNP)) by the year 2015. Psychology could learn a lot from our nursing colleagues – we are living in "changing times."
Exciting Opportunities To Contribute: One of the most rewarding aspects of being in a university environment is the constant exposure to new ideas and challenges. Steve Brewer recently presented a colloquium on his fascinating research at the Uniformed Services University of the Health Sciences (USUHS). "There is very little research examining the effects of combat deployment on the driving abilities of post-deployment service members. However, there is evidence that service members have an increased risk of being involved in a vehicular accident within the first six months of returning from a combat deployment. Specifically, within the first six months post-deployment there was a 13% increase that all service members (regardless of age/rank) would be in a vehicular accident. Junior enlisted (E1-E4) had a 22% increase and 18-21 year olds had a 25% increase. Also, the number of deployments increased the likelihood of being at-fault in an accident. One deployment meant a 12% increase; two deployments meant a 27% increase; and three or more deployments meant a 36% increase in the likelihood of being at-fault in a vehicular accident. There is also research that describes the effects of PTSD and TBI on cognitive abilities, many of which are required for the safe operation of a motorized vehicle. In order to study the effects of combat deployment on driving abilities, we at the USUHS Ettenhofer Laboratory for Neurocognitive Research ran a pilot study in cooperation with the University of Virginia. We used a virtual reality driving simulator (VRDS) that was designed with multiple testing scenarios. The participants' driving abilities were measured through motor tests and cognitive tests. The findings and feedback from the participants of this pilot study will be used to improve the operational scenarios. These improved scenarios will eventually be used to examine the effects of deployment and other variables to establish the safe and unsafe driving characteristics of participants. Scenarios will also be utilized for rehabilitative purposes to assist with improving unsafe driving abilities into safe ones. Such a process could be included in post-deployment training to decrease the incidence of vehicular accidents."
Interesting Life Journeys: Having retired from the U.S. Senate staff after 38+ years, I have become quite interested in learning what colleagues that I have worked closely with over the decades are now doing post-psychology or in expanded roles. Long time VA psychologist visionary Rod Baker has "retired" authoring, co-authoring, and editing three books on the history of psychology in the VA and has just published his fourth book,More Stories from VA Psychology. This latest publication, like a previous one, features career stories written by retired and current psychology leaders whose careers span 61 of the 66 years of VA psychology history that was established in 1946. The career stories add an entertaining first person perspective that expands the reader's understanding of the formal history of VA psychology. Moreover, I recently learned that Rod has a broader writing activity that includes five published articles on the history of the Old West. And, I just finished reading his very enjoyable historical fiction novel, The Rune Master Saga, set in 9thcentury Norway. Highly recommended – his clinical and developmental perspectives are definitely present. The sequel should be equally intriguing. See his Author page onAmazon.com to learn how Rod became interested in writing fiction.
Kay Daub, Professor of Nursing at the University of Hawaii at Hilo, recently became actively involved in hospice care programs on the Big Island of Hawaii. "Several months ago, I had the opportunity to read a bit about End of Life care and what it means to patients who are dying. I had always been very interested in death and dying, but somehow as way leads on to way, I began my nursing career in telemetry and ICU. Though many cases involved end of life care, my focus had been cure no matter what. So many ethical dilemmas surround the end of life, as I suppose so many ethical dilemmas surround the beginning of life. How does one wrap their head around the concept of comfort care, and let go of the notion of cure no matter how painful, cold, futile, or lonely? I have now taken on this interest and have pursued caring for patients at the end of life; this is in addition to my current busy academic career that removes me from the 'bedside.' What a gift this has been. It is a challenge to go beyond the comfort zone of avoiding communication about a difficult subject. The elephant in the room, what is on my patient's mind; how do I talk about death, active death? I have started meeting the patient and family where they are. I have gotten to hear lovely and sometimes not so lovely stories of memories over a life span. I have even heard a patient talking to someone who died before him. My focus is on comfort rather than cure. My nursing has become more holistic, much more patient and family centered. There is a lesson to be had. Death is our greatest teacher. It does teach us how to live. Death can come at any time in one's life, how wonderful to end with great comfort and reflection."
Reflecting upon the exponential growth and expanding influence of professional psychology over the past four-plus decades, trailblazer Gene Shapiro recently commented: "We need another 'dirty dozen' to fight for the role of tomorrow's providers." As Katherine noted: "No one else is fighting the battles for psychology… and don't expect them to." Aloha,
Pat DeLeon, former APA President – Division 29 – May, 2013
