PLEASANT MEMORIES – MEANINGFUL CONTRIBUTIONS

 The 121^st APA annual convention was a tremendous success with approximately 11,400 registrants.  HPA President Darryl Salvador's Opening Session Aloha and the accompanying Native Hawaiian dancing and music were extremely well received, especially by our colleagues from the Mainland.  Hawaii has much to be proud of.  The Hawaii Prepaid Health Care Act, enacted back in 1974, was one of the models for President Obama's landmark Patient Protection and Affordable Care Act (ACA) and accordingly, is expressly "grandfathered," as long as its benefits meet the evolving national standards.  A decade later in November, 1984, U.S. Senator Daniel K. Inouye urged the HPA to obtain prescriptive authority in order to better serve their clients, resulting in psychology's first RxP legislative efforts in the nation.  The Hawaii Health Connector (Health Insurance Exchange), under the leadership of Coral Andrews, has been focusing upon diversity at all levels of the health care industry, as it prepares to "go live"on October 1^st.  The implementation of the state based marketplace will complement the existing ecosystem but also contribute directly and indirectly to the development of new business models, new professional structures, and new models of care -- again, in the forefront of the nation.  As non-physician providers finally come into their own, a wide range of disciplines will emerge in leadership positions to support the requirements necessary to fully implement ACA.  New markets and new approaches will emerge, notwithstanding the considerable pain inherent in substantive change.

Since retiring from the late Senator's staff, I have been pleased to be affiliated with the William S. Richardson School of Law at the University of Hawaii.  Under the leadership of Dean Avi Soifer, the School has established new programs in Native Hawaiian Law and Health Policy.  Dina Shek administers a most progressive interdisciplinary Medical-Legal Partnership for Children (i.e., legal services clinic) at the federally qualified Kokua Kalihi Valley (KKV) Community Health Center and positive discussions are evolving with the West Oahu Vet Center.  Those who are served by these sites have very unique and pressing psychosocial-legal needs as Don Bersoff's APA Presidential programming identified.  On a personal note, over the years I have been most impressed by the successful and truly holistic community outreach efforts at KKV.  For example, their spacious culturally sensitive food garden targets the life journey of their Polynesian and Pacific Basin clientele, as envisioned by Executive Director David Derauf.  "Healing can and needs to take place at so many levels; sometimes the healers heal and sometimes they are healed.  Sometimes, when we come together as a community, whether we are doctors, lawyers, psychologists, grandparents, or grandchildren, we find that we can figure these things out together, heal each other and our community."  What a wonderful opportunity for meaningful engagement by students in law, psychology, and nursing.

At our APA gathering, Illinois's Beth Rom-Rymer was able to convey the enthusiasm steadily generating within the RxP movement across the nation and internationally.  "In Ontario, requests for extending scopes of practice to include prescriptive authority are directed to the Minister of Health.  The RxP Committee submitted our request in November, 2012.  We have been advised that a ruling on RxP is 'on hold,' pending other requests for legislative change, as the Minister would prefer 'opening up' legislation for more than a single change.  We have a number of meetings scheduled with various officials to discuss how prescribing psychologists would benefit a number of Ministry initiatives in an effort to move the process along.  It should be noted that the provincial government supports non-physician prescribing and has already granted prescriptive authority to other healthcare professionals, such as nurse practitioners, optometrists, naturopaths, pharmacists, and midwives (Jane Storrie and Diana Velikonja, co-chairs)."

            The Congressional Vision:  During its deliberations on the FY 2014 budget for the Department of Health and Human Services (HHS), the Senate Appropriations Committee highlighted several items of particular interest to psychology.  The level of funding for the Native Hawaiian Health Care Program, which in 2011 served more than 8,400 people, is to remain level at $14.4 million, notwithstanding overall budget reductions.  HRSA and SAMHSA are encouraged to continue collaborating in order to develop and replicate community health worker programs that integrate primary care and behavioral health, and provide a report on their efforts for next year's budget.  Under the Graduate Psychology Education initiative, thanks to the efforts of APA's Cynthia Belar, support was expressed for the Secretary's initiative to increase the number of psychologists pursuing clinical work with high-need and high-demand populations.  These are defined as rural, vulnerable, and/or underserved populations, as well as veterans, military personnel, and their families.  "While the Committee commends the emphasis on programs targeting veteran and military personnel population centers, the Committee is concerned that many service members reintegrate into civilian life in communities that are rural and far from military and veteran facilities.  As such, the Committee encourages HRSA to maintain a strong commitment to underserved areas generally."  Those interested in the legal and RxP agendas should note that: "According to a December 2012 GAO report, an alarming 18 percent of foster children are prescribed psychotropic medications, compared with 4.8 percent of privately insured children.  The Committee strongly encourages SAMHSA to establish meaningful partnerships with Medicaid, the foster care program, medical specialty societies, and treatment centers to develop new strategies for treating this vulnerable population.  The Committee would like an update in next year's congressional [budget] justification on the steps SAMHSA has taken to promote the most effective and appropriate treatment approaches, including the use of evidence-based psychosocial therapies instead of, or in combination with, psychotropic medications."

Health psychologists and those who contemplate the long term benefits of integrated care should be pleased with the Committee's recognition of the National Institute on Aging for its investment in large-scale longitudinal surveys, including the National Health and Aging Trends Study and the Health and Retirement Study.  The Senate Committee particularly applauded the National Academies of Science report "Shorter Lives, Poorer Health," which found that Americans live shorter lives and are in poorer health than people in other high-income countries and that behaviors and social circumstances are major contributing factors.  And, as Coral indicated earlier, nurses, in particular, are making significant strides in establishing leadership opportunities as reflected by the Senate's directive that "no less than" $5 million shall be awarded during the coming year to nurse-managed health centers, one of the visionary components of ACA.

            The Past Will Return, Eventually:  During the 110^th Congress Senator Edward Kennedy, Chair of the Health, Education, Labor and Pensions (HELP) Committee favorably reported out of his Committee on October 1, 2007, S.1693, the Wired for Health Care Quality Act, which was a precursor for today's Health Information Technology (HIT) era.  At the time there were 11 cosponsors of the bill, eight of whom were Republicans.  Senator Hillary Rodman Clinton was one of the Democratic cosponsors.  The days of bipartisanship in furtherance of the nation's business will eventually return.  In the meantime, Hilo's Judy Steinman reports: "Our first graduate to take the PEP passed on his first try and he just received his credentials to prescribe.  Another one of our first cohort is enlisted in the USAF and moving to Arizona.  There is a medical psychologist there so she hopefully will be able to complete the program from there.  We are graduating all four of our second cohort students this summer.  Two are planning to take the PEP and two (civilians) are not planning to take it now because they are going to work in states that do not yet have RxP.  One will work in an oncology department so I feel that we are spreading our training into useful areas."  Aloha,

 

Pat DeLeon, former APA President – Hawaii Psychological Association – September, 2013

EXCITING TIMES – CHANGE IS DEFINITELY IN THE AIR

 Throughout the 121^st APA annual convention, held this year in beautiful Honolulu, there was a palpable sense of excitement in creating and responding to unprecedented societal change.  Cynthia Belar described APA's efforts to advance quality in the education and training of health service providers consistent with the realities of the nation's evolving health care environment, especially with the emphasis of President Obama's Patient Protection and Affordable Care Act (ACA) on interdisciplinary, holistic, and integrated systems of comprehensive care.  These efforts include both the articulation of required competencies and the affirmation of accreditation of doctoral and internship programs.  Steve DeMers, Executive Director of the Association of State and Provincial Psychology Licensing Boards, described their efforts, in conjunction with APA and impressively with federal HRSA support, to foster licensure portability for the forthcoming era of telehealth practices.  We wonder if future licensure standards will require enrollment in doctoral programs and in clinical internships that are nationally accredited?  Many are already arguing for a "single standard."  It is becoming clear that this far reaching policy determination may well evolve as the nation steadily advances towards what must be considered national licensure (i.e., uniform standards of practice) for each of the health care professions.

APA President Don Bersoff hosted a most impressive Military-Veterans programmatic theme, addressing a wide range of timely topics including resiliency, family dynamics, evidence-based approaches to the signature wounds of a decade of conflict, and the honor of serving our nation.  Debra Dunivin and Morgan Sammons participated in a moving tribute to Medal of Honor winner, the late U.S. Senator Daniel K. Inouye.  The importance of proactively responding to change was clearly highlighted from a number of perspectives.  For example, serious consideration is finally being given to former APA President Bob Resnick's charge to integrate psychopharmacology training at the pre-doctoral level – perhaps through  joint degree initiatives such as contemplated by the Chicago School of Professional Psychology and others in Illinois; capitalizing upon the unique RxP expertise at Colleges of Pharmacy (University of Hawaii at Hilo); and, creative initiatives such as Forest Institute contemplating the development of a joint PsyD-PA and/or PsyD-APN degree with a focus on primary and integrated care.

Advances in Psychopharmacology (RxP):  Beth Rom-Rymer coordinated a number of perspectives on the maturing RxP agenda, including in her home State of Illinois.  "We have had a remarkable 14 months.  On March 6^th, 2012, the Illinois State Senate Public Health Committee passed our RxP bill out of Committee by a vote of 6-4.  With our lobbyists, we made the critical decision to spend the next 12 months educating our psychologists and legislators around the state on RxP issues; training Illinois psychologists in becoming effective advocates for RxP; and reaching out to mental health associations, social service organizations, law enforcement agencies, hospitals, mental health centers, physician groups, etc. to educate about, and advocate for, RxP.  Because of the strength and longevity of our lobbyists' relationships with our legislators and because of our Illinois psychologists' impressive advocacy and outreach efforts, we have been very fortunate to work with strongly committed and dedicated legislative chief sponsors: Senate President ProTem Don Harmon, Senator Dave Syverson, Representative John Bradley, and Representative Jim Sacia.  On March 12^th, 2013, our RxP legislation passed out of the Senate Public Health Committee by the unanimous vote of 8-0 with one abstention.  On April 25^th, 2013, our RxP legislation overwhelmingly passed out of the Senate by a vote of 37-10 with 4 abstentions.  On May 7^th, 2013, our Senate bill was placed in the House Executive Committee.  Over the next several days, we were continually conferring with our lobbyists over the advisability of calling our bill.  As I said, we made the strategic decision that we wanted to take more time to work with our Representatives so that the vote would reflect an informed understanding of the issues.  We will be working very closely over the next several months with our legislators and all of our third party groups around the state.  We are very fortunate that although this legislative session has concluded on May 31^st, we are in the first year of a two year sequence.  We are, therefore, able to build on all of our terrific accomplishments to date and focus on the House.  We are also in productive discussions with the Governor's Office.  We are looking toward achieving passage during our next legislative session in the spring of 2014.  Together, we are forging a path in Illinois to make a significant change in the way healthcare is being delivered.  There is no turning back."

Bob McGrath and NJPA President Sean Evers reported on their RxP efforts.  The New Jersey bill passed out of the Assembly Regulated Professions Committee on December 6^th, 2012.  It then passed out of the Assembly on April 29^th, 2013 with a vote of 41 to 27, with 8 abstentions and 4 not voting.  The bill remains active.  "We've learned a number of important lessons along the way, including the identification of a core group that maintains control of the bill and its advocacy, the importance of a lead lobbyist with strong expertise in passing legislation, and the key issues to address at different points in the legislative process.  It's been a long, long ride, from the first discussions of prescriptive authority in New Jersey in the early 1990s till now, but we remain optimistic about our chances for the near future."  In California, home of the original Doctor of Mental Health effort in the early 1970s, former CPA President Sallie Hildebrandt reported that they are once again embarking on a long-term, comprehensive grass-roots statewide effort to pass RxP legislation.  They have begun a major fundraising effort led by Sallie, Chair of Division 5 (Clinical Psychopharmacology).  During the convention, involved colleagues including Elaine LeVine, the first civilian female prescribing psychologist, and Steve Tulkin discussed maturing RxP interest internationally, including in New Zealand, Canada, and Africa.

It is important to appreciate that the "power" (i.e., authority) to prescribe is also the power (i.e., legal standing) to unprescribe or appropriately modify what has been prescribed.  The critical underlying objective has always been to provide the highest quality of psychological care to our patients.  In this light, it is of interest that the Senate Appropriations Committee noted in its FY 2014 report: "Psychotropic Medications and Children. – The Committee has become increasingly concerned about the safe, appropriate, and effective use of psychotropic medications and children, particularly children in foster care settings.  According to a December 2012 GAO report, an alarming 18 percent of foster children are prescribed psychotropic medications, compared with 4.8 percent of privately insured children.  The Committee strongly urges SAMHSA to establish meaningful partnerships with Medicaid, the foster care program, medical specialty societies, and treatment centers to develop new strategies for treating this vulnerable population.  The Committee would like an update in next year's congressional [budget] justification on the steps SAMHSA has taken to promote the most effective and appropriate treatment approaches, including the use of evidence-based psychosocial therapies instead of, or in combination with, psychotropic medications."  Under the Office of the Secretary the Committee included additional language: "Prescriber Education. – The administration's 'Prescription Drug Abuse Plan' called on the Department to work with the Department of Justice and the Office of National Drug Control Policy on ways to educate practitioners on safe and proper prescribing of opioid painkillers as a prequalification for those individuals obtaining a Drug Enforcement Administration license to prescribe and dispense controlled substances.  The Committee requests an update on these efforts in next year's congressional [budget] justification."

            The Department of Veterans Affairs:  The VA serves approximately 49.3 million beneficiaries, constituting 15.5 percent of the nation.  It operates the largest Federal health care delivery system in the country, with 152 hospitals, 107 domiciliary residential rehabilitation treatment programs, 133 nursing homes, 300 Vet Centers, and 821 outpatient clinics.  It is estimated that 6.5 million patients will be treated in the coming year.  The VA is the largest employer of psychologists and Advanced Practice Nurses (APNs).  It is in the forefront of providing post-doctoral training opportunities under the leadership of Robert Zeiss (whose wife Antonette Zeiss received the APA Outstanding Lifetime Contributions to Psychology Award at the Opening Session).  Within the VA, our nursing colleagues have done a remarkable job of advancing their scope of practice in order to provide quality care to their patients.  Under the leadership of Cathy Rick, Chief Nursing Services Officer, the new VHA Nursing Handbook, will provide APNs 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 reminding hesitant states about 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 and will continue to shift.  The basic tenets of VHA nursing are to be aligned with the ANA Standards of Practice and achieved through evidence-based practice, defined elements of practice, and professional development.  Two key components are that the patient owns and drives their care based on the information available and that nursing interventions are based on the best available evidence and accepted standards of practice.

Specifically:  "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."  This is a mostimpressive development for our nursing colleagues which we understand will soon be published in the Federal Register for public comment.  The readership should recall that the American Association of Colleges of Nursing (AACN) announced that in October, 2004 their member schools voted to endorse moving the current level of preparation necessary for APNs from the master's degree to the doctorate-level (i.e., the Doctor of Nursing Practice (DNP)) by the year 2015.  Psychology can learn a lot from our nursing colleagues.

            In its deliberations for FY 2014, the House Appropriations Committee urged the VA to strengthen collaborations with research universities and teaching hospitals for the treatment and research of mental health disorders, such as PTSD and traumatic brain injury, to improve the psychological health of veterans and train mental health professionals so they will understand the unique needs of veterans.  The Committee further noted that: "Previous wars have shown that the health care needs of a returning service member population reach their highest point a few decades after the population returns home from war.  The Committee is concerned that the VHA is not adequately preparing for the future mental health needs of the current veteran population.  The Committee requests that VHA prepare a report on what health resources will be needed and the potential cost to serve the needs of Iraq and Afghanistan veterans over the next 30 years."

We believe that competition per se is best for all concerned, especially within the health care arena.  The recently adopted APA policy on accreditation described by Cynthia provides an opportunity for other accrediting groups to evolve, if recognized by the U.S. Secretary of Education.  Accordingly, the House Appropriations Committee's recommendations regarding the psychology accreditation process is most timely.  "The Committee is aware that the Psychological Clinical Science Accreditation System (PCSAS) in September 2012 received recognition and accreditation authority from the Council for Higher Education Accreditation to provide accreditation of PhD programs in psychological clinical science.  The Committee understands that the VHA is in the process of modifying its regulations to permit the training and employment of psychologists at the VHA who are graduates of PCSAS-accredited programs, and urges the VHA to promulgate the regulatory changes as soon as possible in order to increase the number of mental health clinicians available to veterans using the VA healthcare system."  We would expect that similar flexibility will soon evolve during state licensure deliberations.

Change is Definitely Coming:  During this year's deliberations, the Senate also expressed its considerable enthusiasm for the underlying holistic approach of the ACA.  "Integrative Medicine. – The Committee is aware of controlled clinical trials that have shown promising results for mind-body approaches to preventing and treating hypertension, other cardiovascular risk factors, and cardiovascular disease.  Additional research is warranted to determine if integrative medicine interventions offer a unique opportunity to improve the quality of care while reducing healthcare costs from the Nation's leading causes of death.  The Committee encourages CMS to test integrative health interventions to determine health outcomes and the potential for healthcare savings.  In particular, the Committee is supportive of research into mind-body interventions for cardiovascular disease that have been previously shown in peer-reviewed publications of clinical trials to reduce cardiovascular risk factors, mortality, myocardial infarction, and stroke."  In many ways, mental health is nicely maturing itshealth care presence.  A 1944 painting, commissioned as part of the Works Projects Administration (WPA) artists' program of World War II, illustrated the historical function of the Forest Glen annex of the Walter Reed Army Medical Center as a holding and rehabilitation unit for medical patients.  At that time, psychiatric patients were identified, and to an extent stigmatized, by wearing maroon hospital clothing.

An Island Perspective:  "Nice to visit with you.  We finally managed to be on the Island of Hawaii at the same time!  Sorry the weather didn't cooperate for a canoe paddle on the bay.  But the possibility brought out some interesting thoughts about your approach to retirement and mine.  I think the common ground is that we are both loving the opportunity to experience retirement by doing things that we choose to do, rather than things dictated by our jobs and professional roles.  And, even if some (or many) of those things are like those of our former jobs, the ability to choose how we spend our time is what defines 'retirement.'  So, in your case the opportunity to have a bigger role in academic life and experience the joys and challenges of teaching is a satisfying and rewarding experience.  For me, after 35 years in academia I am enjoying other challenges.  In spite of the fact that I was very happy and fully engaged in the academic world throughout my career, toward the end I began to look forward to the time when I would not have to give another lecture or grade another exam.  Instead, I now enjoy waking up and getting to choose whether I will go surfing, paddling, sailing or even snowboarding and skiing on Mauna Kea.  And, weather permitting, it is nice to be able to take my friends along!  My first project upon retirement was to build a 400 square foot workshop in my backyard so I could fix and make 'stuff.'  The pleasure of making something tangible after living in the world of intangibles that is so much of academic life has been very satisfying.  So, Pat, I guess from my perspective the most important aspect of retirement is that it gives us the opportunity to decide how we spend our time.  The important thing is the choice of activities that are satisfying, not the details of what those activities are.  'Smile' back at ya! [Jerry Johnson, retired Professor, University of Hawaii at Hilo]."  Aloha,

Pat DeLeon, former APA President – Division 42 – August, 2013