As the nation's health care leaders anticipate the expanding implementation of President Obama's Patient Protection and Affordable Care Act (ACA), there have been increasing concerns raised at both the state and federal level regarding the availability of qualified health professionals to address the complex behavioral, mental health, and substance-use treatment demands that are expected. Building upon the current Medicaid system, the ACA will provide for the largest expansion of mental health and substance-use coverage in a generation, with 32.1 million Americans gaining access to these services, while another 30.4 million currently with some coverage will gain federal parity protection. Under the law, insurance offered in the new marketplace must cover a core set of "essential health benefits," which includes mental health and substance-use disorder services. As we now move towards integrated systems of care (Accountable Care Organizations (ACOs) and Medical Homes, for example) a critical question surfaces: Does there exist today sufficient numbers of psychologists, doctors of nursing practice (DNPs), and other traditional mental health providers trained to fill this niche, or will other disciplines (such as clinical pharmacists, occupational therapists, or newly evolving behavioral health care providers) expand exponentially into this unchartered arena? And, are our training programs even aware of the changing behavioral health care environment?
Creative Models: Since early 2000, visionary and former APA President Nick Cummings has called for the development of an entirely new training model of Behavioral Care Providers, who would work side-by-side with the patient's designated primary care provider. Today such a program is actively underway at Arizona State University/Mayo Rochester School of Medicine, granting the Doctor of Behavioral Health (DBH) degree and focusing upon the emerging field of integrated behavioral health. The classes are all online, with individual supervision also online. There is two-way internet capacity. The program makes arrangements for field placements in each locale for each student. They have had absolutely no difficulty in placing students, and over half the placements hired the students, upon their receiving their degree, to create or expand an integrated program in their system. The Nicholas A. Cummings Doctor of Behavioral Health program has slightly over 300 students, with 19 full-time faculty and 37 part-time faculty. It is online all over the U.S. with several students being abroad in England, France, Germany, Malaysia, and Dubai. The students come together in Phoenix twice a year; each time for a week. Five of the graduates are now CEOs of large health care systems. Nick's title is appropriately "Founding Sponsor," reporting directly to the University President. It is perhaps unique in combining evidence-based interventions for integrated behavioral health, behavioral entrepreneurship, and management and accountability for clinical and cost outcomes. Nick recently received word from China that they now have an affiliation with Jinan University, the largest university in China, which is affiliated with 10 smaller universities in the region. They will become one of the largest, if not the largest, in the category of U.S. universities applied clinical/management education and training programs in China.
At this year's Illinois Psychological Association (IPA) annual convention, under the Presidency of Beth Rom-Rymer, Keith Baird described his vision for Behavioral Care Providers. "A consortium of behavioral care providers is forming in Illinois, Behavioral Care Management (BCM), aiming to become a large-scale organizer of behavioral care which will negotiate contracts with ACOs and others. Our developing network will have psychiatrists, psychologists, social workers, licensed clinical professional counselors, marriage and family therapists, and addiction specialists working collaboratively to deliver a new healthcare product to the marketplace. We aim to lower health care costs by providing ease of scheduling with our behavioral care providers. We will offer prevention and wellness services to the 'lives' that we cover, as well as promote access to our ever growing internet library resources. This is geared to reduce the occurrence of various healthcare problems. In addition, 40 BCM providers are completing their certification in integrated behavioral care through the University of Massachusetts. We will offer behavioral care solutions to patients with chronic medical conditions that have a behavioral component, such as type II diabetes, high cholesterol, high blood pressure, obesity, and other stress-related health issues. We are also working hard to deliver competitive reimbursement rates to our providers for the traditional services of psychotherapy, psychological testing, consultation, and pharmacotherapy."
Interdisciplinary Training: Although the ACA envisions interdisciplinary, integrative, and collaborative training and service delivery initiatives, at the operational level this is much more difficult to accomplish than one might imagine. Breaking down historical educational silos takes time and high level administrative commitment. Educational institutions may have "different tuition rates" for courses taught, for example, in law vs. psychology; and, different disciplines may be on different quarter or semester schedules even within the same health sciences center. Overcoming such institutional barriers and resistance is definitely a challenge. However, we can assure you that it is well worth the effort. Since retiring from the U.S. Senate staff, I have had the pleasure of serving on the faculty of the Uniformed Services University of the Health Sciences (USUHS) of the Department of Defense (DoD) and fostering interdisciplinary training has become a high personal priority. For ultimately, it will be in the best interest of the next generation of health care providers and their patients (i.e., "educated consumers").
A Personal View: "I recently had the privilege to participate in a military deployment psychology course. During this course, the majority of the students were psychologists. This group dynamic was ideal to be able to communicate and get to know the unique psychologist role along with educating on my role, the psychiatric nurse practitioner. As a student and professional it is vital to learn the different perspectives our colleagues have on the part psychiatric nurse practitioners play in the mental health arena. Partaking in this course gave me insight on the need for educating our colleagues on what our scope of practice encompasses. It also enabled me to put a different lens on and learn about the roles of the whole mental health team including psychiatrists, psychologists, and social workers.
"There were several topics discussed including the deployment experience, cultural considerations in the deployed environment, sexual assault, ethics, traumatic brain injury, provider sustainment, and more. Each topic was of equal significance and essential to the military mental healthcare field. A belief that exists embraces psychologists and social workers doing the therapy while the psychiatrists and nurse practitioners prescribe medication. A part of this course was designed to teach a therapeutic modality, including cognitive behavioral therapy for insomnia and either cognitive processing therapy or prolonged exposure therapy. This section validated that although nurse practitioners are able to prescribe medications, we are also able to do therapy. More importantly, we learned how to do these therapies in the deployed environment.
"Another captivating topic discussed during this course was technology in the mental healthcare field. Technology is constantly evolving and has become integrated in patient care. As providers, we must stay up to date with technology to deliver the most comprehensive care to our patients. We learned about virtual worlds to treat disorders such as posttraumatic stress disorder, and mobile apps to guide patients with relaxation techniques and deep breathing exercises. The lines of which provider was able to deliver the best technological care between different mental health professionals were erased, and together we were taught a treatment option in providing the greatest care for our patients.
"I am looking forward to graduating and working with my mental health colleagues from every path of the academic world. Being able to participate in a course designed for our fellow psychologists is an imperative step in working as a team. This team will help provide the best care for those who defend this nation and their families. We must be able to utilize every specialty and communicate efficiently within our field to deliver healthcare at its finest [Bethany Casper; Capt. USAF]."
The IOM: The Institute of Medicine (IOM) was established in 1970 to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. Acting under the Congressional charter granted to the National Academy of Sciences in 1863, it serves as an advisor to the federal government and upon its own initiative, identifies critical issues of medical care, research, and education. This year psychology was extremely well served by the election of APA CEO Norman Anderson to this distinguished body. This fall, the IOM Board on Children, Youth, and Families convened top experts from multiple disciplines to analyze the best available evidence on critical issues facing children, youth, and families today. Considered perspectives were elicited from the biological, behavioral, health, and social sciences fields focusing upon the entire lifecycle of our nation's families. Psychologists Gary Evans, Ann Masten, Pamela Morris, and former Sesame Street CEO David Britt serve on the board. Kimber Bogard, also a psychologist, serves as staff director.
Having worked on Capitol Hill for nearly four decades, one of the most intriguing presentations personally was that by the Director of the Washington State Institute for Public Policy, the nonpartisan research arm of the Washington State legislature. At the request of the legislature, the institute provides detailed cost-benefit analyses on a wide range of public policy areas. This would include, for example, legislative proposals to reduce crime, improve educational outcomes, reduce child abuse and neglect, improve mental health, and reduce substance abuse. Express dollar consequences (costs and benefits) were assigned to various proposed preventive efforts, such as encouraging nurse practitioner home visits, over the lifetime of the program and its beneficiaries. It reminded me of the Office of Technology Assessment (OTA) which from 1972 to 1995 provided a similar non-partisan perspective for the U.S. Congress. The overarching theme for that segment of the meeting during which the institute director presented focused upon family based preventive interventions which reflected the critical role that the family unit can play as a key mediator for child health outcomes. The overall panel: * Examined science that highlights the effect of the family on child health outcomes; * Assessed how family-based interventions could be brought to scale to sustain positive child health outcomes; * Considered the implications of benefit-cost analysis of these interventions for public policy; and, * Explored how the board could advance family focused science and evidence based policy to promote children's' health, safety, and well-being. One of the underlying questions discussed was: How to "scale-up" those initiatives that were demonstrated to be effective in order to impact the largest possible beneficiary population? An indication of the national impact the board's deliberations can have was the considerable publicity generated by the release of its subsequent recommendations addressing sports-related concussions in youth, from elementary school through young adulthood, including military personnel and their dependents.
An Earlier IOM Report: The critical contribution of interprofessional collaboration to quality care has been known for decades. In 2004, the IOM released its report entitled Improving Medical Educationfor which psychologists Eugene Emory and Neil Schneiderman served as committee members. "There are a number of compelling reasons for all physicians to possess knowledge and skill in the behavioral and social sciences. Perhaps most important is that roughly half of the causes of mortality in the United States are linked to social and behavioral factors [citing HHS reports from 1993 and earlier]. In addition, our nation's population is aging and becoming more culturally diverse. Both of these trends highlight the need for enhanced physician capabilities in the behavioral and social sciences." The committee found that there was very little literature on either barriers to the inclusion of the behavioral and social sciences in medical school curricula or strategies that might be employed to overcome such barriers. However, it was definitely felt that the importance of an institutional commitment to behavioral and social science instruction cannot be overemphasized. That without a firm belief on the part of the medical school faculty and administration, that this knowledge and skill is an important part of a physician's education and training, their recommendations would be ineffective in producing change.
The committee further noted that the then current structure of American medical education was adopted in the early 1900s and had not varied greatly since that time. The basic sciences – anatomy, physiology, biochemistry, and microbiology – were introduced as a scientific foundation on which clinical practice knowledge and skills were built. In addition, the introduction of clinical science in the context of a university constituted a significant shift from a community practice-based, apprenticeship model of preparation for careers in medicine to one in which clinical medicine was taught by full-time faculty in a university-owned or university-affiliated teaching hospital. Over the years, however, shifts have occurred within the basic structure of medical education, including those related to learning techniques. Today, one hears more and more, for example, about the movement from passive learning through lectures to more active learning utilizing problem-based curriculum and most recently, the increasing utilization of technologically oriented simulation models.
Exciting Journeys: "GOLEM HAUNTS HARVARD – There's nothing like a high school or college reunion to focus attention on the reality of aging. I recently attended the 40th reunion of the Harvard and Radcliffe Class of 1973. Name badges were critical to identifying classmates whose 20 year old faces had morphed into those of older adults in the foothills of traditionally defined 'old age.' Unease about the march of time was evident in aging-related joking by classmates about memory and diminished loss of physical vigor. A class discussion about research on aging was well-attended and provoked informal discussions about what each of us might do to make our later years personally, financially, and socially meaningful. As a geropsychologist with 35 years in the field of aging, I shared my own personal and professional perspectives on aging with my classmates that emphasized the resilience of most older adults in contending with late life challenges.
"Skepticism from my classmates about what was seen as an overly rosy view of getting older was not unexpected. Social expectancy research well demonstrates that most individuals acquire negative expectations about the aged and aging throughout their lifetimes. Negative expectations about old age can be self-fulfilling prophecies. As a psychology undergraduate, I remember reading Robert Rosenthal's Pygmalion in the Classroom in which he documented that simply by telling teachers that they should expect good performance from a class of students, those students, in fact, subsequently evidenced good performance. The 'golem effect' is that low expectations lead to low performance. It would be sad if my classmates – who are among the best and brightest of their generation – lived their later years under the shadow of golem and deprived themselves of the satisfactions that the later years can bring" [Greg Hinrichsen, APA Congressional Science Fellow (2007-2008) served with U.S. Senator Ron Wyden]. Rod Hammond, former Director of the Division of Violence Prevention, Centers for Disease Control and Prevention (CDC), was recently elected to the Berkeley Lake, Georgia, City Council – "I am failing the retirement thing! (Smile)." Aloha,
Pat DeLeon, former APA President – Division 42 – November, 2013
