COLLEAGUES MAKING A REAL DIFFERENCE

   The Affordable Care Act (ACA):  With the steady implementation of President Obama's Patient Protection and Affordable Care Act (ACA), psychology's practitioners and nursing's Doctors of Mental Health Nursing Practice (DNP) are increasingly being held to the requirements of the more generic healthcare system.  This evolution is especially relevant to integrated care models; for example, the Accountable Care Organizations and Patient-Centered Medical Homes fostered by the Act.   Central to this evolution is the necessity of appreciating the common procedural terminology (CPT) system which has become the most widely accepted nomenclature used in the reporting and reimbursement of health services under public and private health reimbursement programs.  From a policy perspective, it is evident that the CPT system is just beginning to address the complexity involved in recognizing that mental health and physical health are intimately intertwined, as well as the critical contributions of the psychosocial-economic-cultural gradient to "quality" health care.

            Tony Puente has been working at the interface of practice and policy with the CPT system since the late 1980s.  He served as APA's first representative to AMA and for 15 years has been working with them.  He is presently a voting member of their CPT Editorial Panel.  Tony's report: "The CPT was developed almost 50 years ago by surgeons and physicians and today is copyrighted by the AMA and owned by the Centers for Medicare and Medicaid Services (CMS).  A new code for psychological services would be developed by a Health Care Professional Advisory Committee, all non-physicians, then is edited and researched by a selected work group and referred to the CPT panel on which I serve for review and possible approval.  If successful, this process can take anywhere from two years to twelve years.

            "Out of the approximately 8,000 codes, around 60 are possible codes for psychologists to utilize.  These fall within a few major categories including Psychiatric/Mental Health, Central Nervous System Assessment, and Health and Behavior.  Miscellaneous codes also cover preventive measures, evaluation and management (E&M), and telehealth.  Psychiatric/Mental Health codes were added in the 1970s, testing codes 20 years later, and Health and Behavior codes soon thereafter.  Biofeedback codes have also been included.  Due to changes in practice patterns and increasing recognition of co-morbidities, codes established for psychotherapy underwent major changes last year.  Most current procedure codes reimburse for 'silo' or non-interactive procedures, such as psychotherapy.  There is an expanding vision to create codes that financially incentivize professionals to integrate health services.  APA is well represented by Neil Pliskin and James Georgoulakis in the AMA process and Randy Phelps as Director of APA's new Office of Healthcare Financing."  Tony ran for APA President in 2014 and we fully expect he will be on the ballot for 2015.

            Being at the Table:  At the annual APA State Leadership Conferences (SLC), Katherine Nordal has consistently stressed the importance of psychology becoming actively involved in policy discussions at the local and national level -- "If we're not at the table, it's because we're on the menu."  A Longtime Friend to Hawaii, now in our Nation's Capital:  Diane Elmore: "After spending summers in Hawaii as a child and completing my doctoral internship at the Honolulu VA Medical Center/National Center for PTSD, Pacific Islands Division, I moved to Washington, DC in 2002 to pursue a career in health policy.  I spent nearly a decade at the APA where I served as Associate Executive Director of the Public Interest Government Relations Office, Director of the APA Congressional Fellowship Program, and Coordinator of APA's military and Veterans activities.  During my tenure at APA, I worked on key federal legislation focused on the needs of underserved/priority populations, including indigenous populations, older adults, survivors of trauma across the lifespan, and military service members and Veterans.  As a member of the APA health care reform policy team, I helped to successfully secure key provisions in the ACA related to issues including integrated health care, prevention and wellness, and workforce development.

            "As the former Director of the APA Congressional Fellowship Program, I served as a mentor to dozens of psychologists who came to Washington, DC to experience the policymaking process up close and personal.  My own experience as an APA Congressional Fellow inspired me to help other Fellows navigate and adjust to the fast-paced and exhilarating landscape on Capitol Hill.  I served in the Office of then-U.S. Senator Hillary Rodham Clinton, where I was a member of the health team working on a range of health policy issues.  Among the federal policies the Senator helped to advance were new mental health initiatives for older adults (as part of the reauthorization of the Older Americans Act) and federal legislation to address the needs of family caregivers across the lifespan (Lifespan Respite Care Act), which both became law in 2006.  I helped to share scientific/clinical expertise on timely initiatives related to the mental health of military service members and Veterans and the psychological consequences of terrorism, in the aftermath of 9/11.

            "My passion for engaging scientists and practitioners in policy and advocacy efforts led to a multi-year collaboration with colleagues in the APA Education Government Relations Office to develop the APA PsycAdvocate® Series, which is available on the APA Continuing Education website.  This series of training modules provides psychologists, psychology students/trainees, and others with the skills to become effective public policy advocates at the federal, state, and local levels.

            "Last year, I joined the UCLA/Duke University National Center for Child Traumatic Stress as its Washington, DC-based Policy Program Director.  In this role, I help to lead the National Child Traumatic Stress Network (NCTSN) efforts to educate and inform federal, state, and local policymakers about the critical issue of child trauma.  Today, nearly two-thirds of children in the U.S. are exposed to a traumatic event before age 16.  The cost of child trauma is not only felt in human terms (e.g., physical and mental health effects), but also in billions of dollars in estimated associated costs.

            "The NCTSN was created by Congress in 2000 to raise the standard of care and increase access to services for children and families who experience or witness traumatic events.  Our policy team works closely with current NCTSN grantees and affiliates (formally funded centers) working in hospitals, universities, and community based programs in 43 states across the U.S.  Included among the NCTSN affiliate programs is Catholic Charities Hawaii, Youth Enrichment Services Division.  NCTSN grantees and affiliates provide clinical services, develop and disseminate new interventions and resource materials, offer education and training programs, collaborate with established systems of care, engage in data collection and evaluation, and inform public policy and awareness efforts.  Please visit http://www.nctsn.org/."

With the future stressing integrated and interprofessional care, it is exciting that nursing's leadership is strategically implementing a vision similar to that proposed by Katherine and Diane.  The American Academy of Nursing has announced their participation in the Nurses on Boards Coalition, which is a group of national nursing organizations dedicated to increasing nurses' presence on corporate and non-profit health-related boards of directors throughout the nation.  The coalition is working on implementing a national strategy to bring nurses' valuable perspective to governing boards, as well as to state-level and national commissions with an interest in health.  Their goal is to put 10,000 nurses on boards by the year 2020, pursuant to the recommendations of the Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health (2011).  This effort is being supported by the Robert Wood Johnson Foundation and AARP.  Pursuant to this challenge the Nursing Campaign for Action, which has coalitions in all 50 states and the District of Columbia, is actively seeking to promote healthier lives, supported by a system in which nurses are essential partners in providing care and promoting health.

True Quality Care:  Mike Sullivan, who was instrumental in passing psychology's earlier RxP bills in his APA Practice Directorate State Leadership role: "The September Monitor's article 'On the Reservation' about the Crow/Northern Cheyenne Indian Health System hospital in Montana with RxP is outstanding!  Marie Greenspan's quote 'We maintain a policy of no pills without skills.  If we're giving medication, people also need to come in and talk with us and learn non-pharmacological ways of managing their issues as well.'  That's psychology's contribution to prescribing in a nutshell.  Especially when these services would otherwise be unavailable."  Aloha,

Pat DeLeon, former APA President – Hawaii Psychological Association – December, 2014

 

A LONG DISTANCE RUN

 Hills and Valleys:  During the exciting 2013 APA State Leadership Conference (SLC), Katherine Nordal noted: "The clock is ticking toward full implementation of the law and January 1, 2014 is coming quickly.  But January 1^st is really just a mile marker in this marathon we call health care reform….  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."  With the steady implementation of President Obama's Patient Protection and Affordable Care Act (ACA), our nation's mental and behavioral health providers (regardless of professional discipline) are increasingly being held to the standards and nuances of the overall healthcare system.  For over two and a half decades, Jim Georgoulakis has represented psychology's voice on the American Medical Association's (AMA's) Resource Value Update Committee, which is responsible for advising the Centers for Medicare and Medicaid Services (CMS) on payment policy for services contained in the Current Procedural Terminology (CPT) reimbursement system.  His visionary perspective on the considerable challenges facing our practitioners as they face the inevitable integration of federal, state, and private sector requirements:

"Psychologists and Compliance Plans:  Recently various lit-serves and publications have raised the issue of compliance plans which have unfortunately left a number of psychologists confused as to whether they should develop compliance plans for their practices.  The answer is clearly an unequivocal 'Yes' and there should be no further debate on this matter.  This fall, in an AntiFraud newsletter, the former Department of Health and Human Services (HHS) Inspector General (IG) Richard Kusserow made a number of statements regarding Medicare and Medicaid mental health fraud to the effect that mental health benefits have been 'a special enforcement problem that stretches back decades.'  'Many healthcare fraud investigators believe mental health caregivers such as psychiatrists and psychologists have the worst fraud record of all medical disciplines.'  Support for this assertion comes from Assistant U.S. Attorney Ted Radway, who stated that in Medicaid there has been 'an explosion of fraud in community-based mental health treatments, including billing for services not rendered.'

            "The current IG of HHS Daniel Levinson is also very clear on the need for a compliance plan.  In his keynote address to the Health Care Compliance Association 2014 meeting, he stated that every provider should have a compliance plan.  He noted that a one or two person practice will have a different compliance plan than a large organization.  He also emphasized that each compliance plan should be unique to the practice – he cautioned against an off the shelf program.  The IG also discussed the training materials (written, audio, and video) that his office has produced to assist providers.  These materials can be located on the OIG web site which includes a section titled Compliance 101.  In this package it is important to note specific videos on compliance program basics, documentation, and operating an effective compliance program.  Additionally, there is a caption that states 'ultimate responsibility for complying with federal fraud and abuse laws lies with the provider of the service.'

            "In the main psychologists were very supportive of the passage of the ACA.  However, the ACA included a new section [Section 6401 (a)] which established a new Section 1866 (j) (8) which reads that a provider of medical or other items or services or a supplier shall, as a condition of enrollment in Medicare, Medicaid, or CHIP, establish a compliance program that contains certain 'core elements' of a Federal Compliance Program.  The core elements of such a compliance program have been available on the OIG web site since 1999.  As to be expected when reviewing the compliance plan requirements of the 50 states, there is considerable variability among the states with New York having the most comprehensive and the oldest requirements (i.e., mandatory plans since 2009).

            "The AMA provides CE credit for participating in the OIG training on compliance.  This training is web based and is included in the OIG's web site.  Similar to physicians, I would hope at some time in the near future psychologists would stop debating on whether compliance plans are necessary, develop similar training CE programs, and move forward and improve our standing in the health care compliance community."

            Exciting New Faces and New Agendas:  The Illinois Psychological Association, with the guidance and leadership of Beth Rom-Rymer, in particular, succeeded this year in passing prescriptive authority legislation, which is the first RxP bill to be signed into public law since Louisiana's on May 6, 2004.   "With the passage of our prescriptive authority bill, that gives opportunity for graduate students to take the core component of their training in Clinical Psychopharmacology pre-doctorally, close observers have wondered if only the young students will take the training.  Others have asked, 'Will access to care issues really be addressed?'  Still others have questioned, 'In what ways will the identity of the clinical psychologist change as (s)he also takes on the identity of the prescribing psychologist?  As we are only at the beginning of our prescriptive authority journey, I will, today, address the question of 'Who wants to prescribe' by drawing some portraits of just a few psychologists who have expressed their intention to prescribe in Illinois and/or who are already in the process of gaining their eligibility to prescribe.  These examples are in no way exhaustive but represent the diverse spectrum of psychologists, in Illinois, who will be prescribing.

"* Karla is an early career psychologist, is Director of Behavioral Health and Pastoral Care at a Federally Qualified Healthcare Center (FQHC) that serves a largely Hispanic and African American population on the west side of Chicago.  She has almost completed her training in clinical psychopharmacology from Fairleigh Dickinson University and is looking forward to soon completing the other components of her training.  * Jane has wanted to be a prescribing psychologist since she was a teenager and she is now 62 years old!  A practicing clinical psychologist, she is currently taking the core training in clinical psychopharmacology from Fairleigh Dickinson University.  She is looking forward to taking the undergraduate science courses on-line and/or at a nearby community college.  * Dick is a mid-career clinical psychologist who had been in a joint practice with his pediatrician father for 25 years.  He had been a pre-med major as an undergraduate and has completed all of the undergraduate sciences courses; the core training in clinical psychopharmacology from NOVA Southeastern University; and has taken and passed the PEP.  These dedicated colleagues are leading the way to our future.

            "Since the passage of our legislation, I have been in contact with leaders in more than 10 states in which prescriptive authority initiatives have been reinvigorated.   Indiana is one of those states, where, although never implemented, their original effort became public law back in 1993.  Other states include Hawaii, California, Idaho, Arizona, Texas, Nebraska, Missouri, Michigan, Ohio, Florida, Virginia, and Maryland.  It was a particular pleasure to be able to speak at the convocation of the most recent graduating class of the New Mexico State Psychopharmacology training program where we honored Elaine LeVine for the monumental pioneering work that she has done for all of us in the RxP arena.  The enthusiasm at the grass roots level is contagious!" (Beth Rom-Rymer).  A journey of a thousand miles begins with a single step.  Aloha,

Pat DeLeon, former APA President – Division 42 – November, 2014

 

YESTERDAY, ALL MY TROUBLES SEEMED SO FAR AWAY

 The Newly Elected 114^th Congress:  With the Republican Party having an outstanding election eve, the Grand Old Party controls both the U.S. House of Representatives and the U.S. Senate for the first time since 2006, when President George W. Bush occupied the White House.  Their margin of victory in the House takes them close to surpassing their largest majority of the post-World War II era.  Accordingly, one must expect an extensive public debate regarding the fundamental role of government in our society through a number of different venues, including whether Obamacare (or critical aspects of it) should be repealed.  During my tenure on the U.S. Senate staff, Bob Ax, who worked for the federal Bureau of Prisons for 20 years and before that for the Trenton State Prison in New Jersey, was a frequent visitor, bringing his psychology interns to the Hill to get a firsthand glimpse of the public policy/political process.  From his vantage point of retirement, he has been reflecting upon whether our current federal and state health care systems (including that of DoD and the VA) might undergo a significant privatization evolution in the foreseeable future – as he personally experienced with the prison system.  And, if so, what might be the impact on quality of care and psychology. 

            "The private prison initiative began in America three decades ago and has grown exponentially since then.  Since 2000, an increasing percentage of federal and state inmates have been housed in private facilities, even as the overall prison population plateaued and then dropped slightly.  Privately owned or operated prisons now exist in many first-world countries.  Notwithstanding numerous criticisms about their operations, private prisons are less accountable than those operated through the civil service.  More information can be legally withheld as proprietary, a problem that led to Representative Sheila Jackson Lee introducing the Private Prison Information Act of 2011 as a corrective measure.  The Act died in committee.

            "Many of the immigrant detainee facilities around the country are privately owned and/or operated.  Since 2009, the Department of Homeland Security's funding appropriations bills have included a provision mandating that 34,000 beds in these facilities be available each day, ensuring that tax-payer dollars continue to flow into the coffers of for-profit corporations.  In 2013, Immigration and Customs Enforcement (ICE) detained almost 441,000 aliens.  About half of these were housed in privately-owned or operated facilities.

            "To ensure the continuity of the revenue streams, private prison corporations have contributed directly to political campaigns and otherwise funneled money to politicians to influence the passage of favorable legislation.  They favor states with some of the toughest sentencing laws, particularly those that had enacted legislation to lengthen the sentence given to any offender who was convicted of a felony for the third time.  Between 2000 and 2004, private-prison interests gave almost $2.1 million in 22 states that had a so-called 'three strikes law,' compared with $1.2 million in 22 states that did not pass such legislation.  That is to say, they are actively engaged in the public policy/political process.

The underlying business model relies in part on monetizing inconvenient people: individuals whose behavior and/or status (e.g., as a person with serious and persistent mental illness, indigent, or a member of racial minority group) renders them disproportionately vulnerable to arrest and incarceration.  More behavior criminalized means more prisoners and a greater return on investment.  Tax dollars follow them out of the 'free world' community (where the funds might have been spent on schools, hospitals, or job programs) and into housing these men, women, and children in the criminal justice system.  Private prisons seemed at first to be a necessary stop-gap solution to the burgeoning prison population in the 1980s and 1990s.  Now they've become entrenched within the so-called prison-industrial complex.

            "Under the best of circumstances, correctional health care, whether delivered through the private or public sector, is going to be problematic.  On a day-to-day basis, treatment is inevitably a mission subordinated to safety and security concerns.  Whereas health care providers are trained to consider individual differences, the criminal justice system emphasizes uniformity.  Too often ignored as health care issues are the iatrogenic effects of incarceration, both on those incarcerated and on those impacted by extension: family members and communities.

            "If we want healthier inmates, we should have fewer of them.  Prevention is good health care, but bad business for a company that gets reimbursed for keeping prison cells full.  The public needs to decide where it wants its tax dollars to go: toward healthier, stronger individuals, families and communities, or prisons and jails.  We spent the last four decades tearing down psychiatric hospitals and building prisons.  Now the discourse has begun to shift, with intimations of a move towards reducing incarceration.  However, the incarceration rates – still near, if slightly below, record highs – reflect our abiding ambivalence toward prison reform, which would necessarily impact private prison companies" (Bob Ax).

            The Long Term Policy Contributions of "Think Tanks":  As those currently responsible for determining the role of government (i.e., our elected officials) engage in their ongoing debates, it is incumbent upon healthcare professionals and those of other disciplines to systematically bring to the nation's public consciousness agendas and concerns which should be addressed.  To the extent to which the best of science informs this process, the nation will be well served.  The Board on Children, Youth, and Families, directed by psychologist Kimber Bogard, of the Institute of Medicine (IOM) and the National Research Council recently released its report entitled Investing in the Health and Well-Being of Young Adults.

            Young adulthood – ages approximately 18 to 26 – is a critical time in life.  What happens during these years has profound and long-lasting implications for future employment and career paths and for their economic security, health, and well-being.  Young adults are key contributors to the nation's workforce and military services and, since many are parents, to the healthy development and well-being of the next generation.  In recent decades, the world has changed to place greater demands on young adults and provide less latitude for failure.  The disruption and lengthening of established social and economic pathways into adulthood have presented more choices and opportunities for some young adults and more barriers for others.  Providing educational, economic, social and health supports will help young adults assume adult roles, develop marketable skills, and adopt healthy lifelong habits that will benefit them, their children, and the nation.  Despite popular attention to some of the special circumstances of young adults, however, they are too rarely treated as a distinct population in policy, program design, and research.  Instead they are often grouped with adolescents or, more often, with all adults.

Focusing on the health and well-being of the current cohort of young adults is especially important because of the powerful (and perhaps transformative) economic and social forces now at work – the restructuring of the economy, widening inequality, a rapidly increasing "elder dependency ration" (i.e., the ratio of the population aged 65 and older to the working-age population).  The future well-being of the nation rests on the investments made in all young adults today – particularly those whose background and characteristics put them at risk of experiencing the greatest struggles.  Providing more of the educational, economic, social, and health supports they need will help ensure equal opportunity, erase disparities, and enable more young adults to successfully embrace adult roles as healthy workers, parents, and citizens.

            The IOM report emphasized that: * Young adulthood is a critical developmental period; * The world has changed in ways that place greater demands on young adults; * Young adults today follow less predictable pathways than those in previous generations; * Inequality can be magnified during young adulthood; * Young adults are surprisingly unhealthy; And, * Supporting young adults will benefit society.  Addressing the health status of young adults: Young adulthood is a critical period for protecting health, not just during the transitional years but over the life-course.  Unfortunately, the dominant pattern among young adults today is declining health, seen most clearly in health behaviors and related health statuses.  As adolescents age into their early and mid-20s, they are less likely to eat breakfast, exercise, and get regular physical and dental checkups, and more likely to eat fast food, contact sexually transmitted diseases, smoke cigarettes, use marijuana and hard drugs, and binge drink.  In many areas of risky behavior, young adults show a worse health profile than both adolescents and older adults.  For example, they are more likely to be injured or die in motor vehicle crashes and to have related hospitalizations and emergency room visits.  Many risky behaviors peak, but it is also the time when involvement in risky behaviors begins to decline.  It is a time of heightened psychological vulnerability and onset of serious mental health disorders, a problem compounded by failure to recognize illness or to seek treatment.  Almost one-fifth of young adults had a mental illness in the past year and four percent had a serious mental illness.  Yet, two-thirds of those with a mental illness and almost half of those with a serious mental illness did not receive treatment.  Not surprisingly, the current generation of young adults appears to be in the forefront of the obesity epidemic and is more vulnerable than previous generations to obesity-related health problems consequences in later years.

The higher levels of poor health in young adulthood have important consequences for future health, educational attainment, and economic well-being.  Rapid technological changes, economic challenges, and a prolonged transition to adulthood appear to be contributing to the health problems of young adults by increasing their stress and sedentary habits.  Nevertheless, the report made it clear that it was not intended to imply the creation of an extensive set of new programs targeted only at young adults as this would have the potential to create new silos and concerns about lack of coordination across various ongoing programs.  Rather the intent is to increase focus on how policies and programs are working for young adults.  New policies, programs, and practices should be recommended only when the evidence indicates that young adults' specific needs are not being met.  Three common themes emerged: 1.) Current policies and programs addressing this population too often are fragmented and uncoordinated.  2.) These policies and programs often are inadequately focused on the specific developmental needs of this population.  And, 3.) The evidence base on interventions, policies, programs, and service designs that are effective for young adults is limited in most areas.

            Retirement:  "If you've been a workaholic, it's important to have plans for a 'new mission' in retirement to give your life focus and meaning.  Otherwise, retirement can feel empty initially.  There are unexpected disruptions, financial expenses or losses, deaths of significant friends and family.  But most of those who functioned at a high level in their careers get through it with new activities and new values appropriate to the post-retirement phase of life" (Kris Ludwigsen).  Oh, I Believe In Yesterday.  Aloha,

Pat DeLeon, former APA President – Division 29 – November, 2014

 

TAKE ME HOME, COUNTRY ROADS

 Newly Evolving Horizons:  Over the past several years, Ruth Paige, Rod Baker, and I have been exploring what our senior colleagues are doing with their lives after decades of active involvement within psychology – including hosting an intriguing symposium at APA.  Kris Ludwigsen was recently interviewed by the national media on this topic, reflecting upon her own experiences and those of other colleagues.  Kris has concluded that psychologists have more options for validation in retirement than many other professions as losing one's professional identity does not seem to be a major issue.  "Becoming a psychologist opened the doors to an exciting career that encompassed teaching, research, psychotherapy, consultation, program development, supervision, coaching, advocacy (even prescription privileges), and a military career.  Now boomers and beyond are facing the challenges of retirement.  Some want to work up to the very end; some choose to go part-time, perhaps in a different venue; and others opt for a new life.  So retirement requires a realignment of one's priorities and values after due consideration.  For some, family, creativity, hobbies and travel become paramount.  Others find volunteering a natural extension of the desire to be of service.  There may be a period of floundering before finding new fulfillment and a new mission; but psychologists are fortunate in having a rich diversity of roles that we can return to, tailored to our time and energy now."

Mike Sullivan represents a non-work related success.  "Coming Full Circle:  I've had many experiences in life where my interests and enthusiasms have come full circle.  But I've found the circle to be more of an ascending spiral – the later evolutions build on earlier experiences in new and surprising ways.  For example, I've done volunteer work out of enjoyment that has morphed into professional careers.

"Another example involves my longstanding enjoyment of women's basketball, for its cerebral play and pure teamwork.  While working at APA, I attended college games at George Washington University and professional games of the WNBA Washington Mystics.  (My good friend, APA's Randy Phelps and I were season ticket holders for five years.)  One of the stars I saw in both college and pro venues was Dawn Staley.  She was head coach of women's basketball at Temple University while playing in the WNBA for the Charlotte and Houston teams.  She was unique in doing both at the same time, achieving great success as both player and coach.

"Fast forward several years and my wife and I decided to move to Columbia, South Carolina.  I knew there was a women's basketball program at the University of South Carolina that I could follow.  Lo and behold, the year we arrived was the same year South Carolina made a big-time hire to bring in Dawn Staley to coach their women's basketball team.  This turned out to be a stroke of genius.

"Coach Staley has transformed a last place team that she inherited into a national powerhouse currently ranked #2 in the country.  This has been a fan's dream come true.  I've attended every game and have become a super fan in my support of the program.  Dawn Staley is known for her community work and charitable foundations, as well as being a member of both the women's and men's basketball Halls of Fame.  I've had the good fortune to get to know her, and I follow her inspiring work closely.  It has led me to become a resource for her on Twitter (@mikesullivan08) and to manage my own fan email list.  It's been a huge thrill that keeps me feeling vibrant.  Go Gamecocks!"  Mike is also passionately engaged with his local Meals on Wheels program, recently finishing second in a national volunteer recognition contest.

Anne Petersen personifies the different professional venue to which Kris alluded.  Currently Research Professor at the Center for Human Growth and Development, University of Michigan, Anne formally served as Senior Vice President for Programs at the W.K. Kellogg Foundation and prior to that, as Deputy Director of the National Science Foundation (NSF).  She is a Fellow of the APA, APS, and AAAS.  Anne chaired a committee for the Institute of Medicine (IOM) Board on Children, Youth, and Families, directed by psychologist Kimber Bogard, which conducted a study culminating in an updated version of the 1993 National Research Council (NRC) publication entitled Understanding Child Abuse and Neglect.  This updated consensus report, New Directions in Child Abuse and Neglect Research, provides recommendations for allocating existing research funds and further suggests funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected.

The committee's vision included: * Building on the review of literature and findings from the evaluation of research on child abuse and neglect; * Identifying research that provides knowledge relevant to the programmatic, research, and policy fields; and * Recommending research priorities for the next decade, including new areas of research that should be funded by public and private agencies and providing suggestions regarding fields that are no longer a priority for funding.  Four particularly pertinent areas focused upon the development of a coordinated research enterprise in child abuse and neglect which would be relevant to the programs, policies, and practices that influence children and their caregivers.  These were: * Development of a national strategic research plan that is focused on priority topics identified by the committee and that delineates implementation and accountability steps across federal agencies; * Creation of a national surveillance system; * Development of the structures necessary to train cohorts of high-quality researchers to conduct child abuse and neglect research; and * Creation of mechanisms for conducting policy-relevant research.  In September, 2013 the IOM/NRC hosted a public release event for the report resulting in widespread coverage across the nation.  Copies of the full report and dissemination materials are available on the IOM web.

An Exciting and Expanding Agenda:  "Since we passed our prescriptive authority bill on May 30^th of this year, and Governor Pat Quinn signed the bill into law on June 25^th, we at the Illinois Psychological Association (IPA) have been very busy working on implementation.  I have realized that while bill passage was one big mountain to climb, implementation gives us, yet, a higher peak to reach.  Because our law was passed by a consensus of IPA; the American Nurses Association, Illinois Chapter; the Illinois Society for Advanced Practice Nursing, the Illinois Medical Society, and the Illinois Psychiatric Society, we have the advantage of the full support of our state healthcare medical providers as we explore training venues in hospitals and medical centers.  Our first step has been to draft our rules and regulations for our law.  That process is ongoing.  Simultaneously, we are pursuing the additional steps of meeting with hospital and medical center administrators and signing on those facilities that agree to take prescribing psychologist trainees.  We have encountered many successes and continue to travel around the state to meet with hospital administrators.

Other facets of this journey include: 1) Meeting with graduate psychology directors of training and discussing their initiating the curriculum in Clinical Psychopharmacology for our prescribing psychologist trainees.  2) Meeting with undergraduate advisers in psychology and undergraduate students who are pre-med, pre-vet, nursing, biology, chemistry, and/or psychology majors and talking to them about opportunities for students to become prescribing psychologists with a strong undergraduate foundation in the hard sciences as well as a foundation in psychology courses.  3) Meeting with executives, including chief psychologists, in various Illinois governmental departments and agencies who have a tremendous need for prescribing mental health providers and discussing the options for their staff psychologists to become trained as prescribing psychologists for their special populations.  We are encountering palpable excitement in our meetings from all of our constituent groups: undergraduate students, graduate students, agency administrators, university administrators and faculty, and practicing psychologists.  There is certainly a feeling that there is change in the air and that psychology is leading this charge.  And, beyond what we are doing in Illinois, more than 10 states are re-igniting their RxP initiatives or are quickly gearing up from ground zero.  As I travel around the country, meeting with various state leaders, there is evidence of tangible progress and elevated expectations of success.  Nice to connect with Arlo Guthrie in these moments: 'And, friends, they may think it's a Movement'" (Beth Rom-Rymer).  To The Place I Belong.  Aloha,

Pat DeLeon, former APA President – Division 18 – November, 2014

 

TO REACH A PORT WE MUST SET SAIL

Possessing That Critical Global Vision:  One of the most enjoyable experiences of my approximately quarter of a century of involvement within the APA governance was having the opportunity to work closely with Bruce Overmier on the Board of Directors on behalf of all of psychology.  In May of this year, Bruce retired from the University of Minnesota after 49 years of service – a truly amazing accomplishment.  "I did not stay for the 50^thyear as some friends suggested; after all, 50 is just a number."  It is fascinating to reflect upon the extent to which those elected to the APA Board come to appreciate that they must represent all facets of the field – science, education, and practice – and not merely that "special interest" which might have elected them to the Board.  Although we did not succeed, we worked diligently to bring APS back into APA by ensuring that our national association would be responsive to the unique needs of the scientific community.  Similarly, it is important for those training our next generation of clinicians to appreciate, and be responsive to, the underlying mission of the various federal agencies seeking to improve the quality of life of those subpopulations in which one is particularly interested.  For those concerned about the unique needs of our nation's children and their families, we would suggest that the Fiscal Year 2015 Budget Justification for the Health Resources and Services Administration (HRSA), and particularly for its Maternal and Child Health program, should be of considerable interest.

            The Administration's Priorities:  The stated objective of the Maternal and Child Health block grant program is to improve the health of all mothers, children, and their families.  These legislated responsibilities reduce health disparities, improve access to health care, and improve the quality of health care.  As one of the nation's bona fide healthcare professions, psychology must appreciate that it is our responsibility to ensure that the critical psychosocial-economic-cultural element of quality care is affirmatively included.  As the then-President of the Institute of Medicine (IOM) stated in 2006: "Dealing equally with health care for mental, substance-use, and general health conditions requires a fundamental change in how we as a society and health care system think about and respond to these problems and illnesses.  Mental and substance-use problems and illnesses should not be viewed as separate from and unrelated to overall health and general health care."

Specifically, the Maternal and Child Health program seeks to: (1) assure access to quality care, especially for those with low-incomes or limited availability of care; (2) reduce infant mortality; (3) provide and ensure access to comprehensive prenatal and postnatal care to women (especially low-income and at risk pregnant women); (4) increase the number of children receiving health assessments and follow-up diagnostic and treatment services; (5) provide and ensure access to preventive and primary care services for low income children as well as rehabilitative services for children with special health needs; (6) implement family-centered, community-based, systems of coordinated care for children with special health care needs; and (7) provide toll-free hotlines and assistance in applying for services to pregnant women with infants and children who are eligible for Medicaid.  Of particular interest to psychology should be the Special Projects of Regional and National Significance (SPRANS) initiative for which $77 million has been requested for the coming year.  Over the years, we have come to appreciate the vision and creativity behind this particular approach.  It was instrumental, for example, in fostering a special federal focus upon the unique and pressing needs of Native Hawaiian children and their families during the earliest stages of what has today become the Native Hawaiian Resonance.  HRSA's budget request further notes that in an era of expanding health care coverage under the Patient Protection and Affordable Care Act (ACA), the Maternal and Child Health programs serve to assure continuity of care and to reduce coverage gaps.  It is both a safety net program and a major public health program serving mothers, infants, children (including children with special health care needs), and their families.  Perhaps most significantly for the mental health/behavioral health professions: "In order for there to be measurable gains towards improving the nation's maternal and child health, insurance coverage expansion will need to be accompanied by a significant investment in health promotion and disease prevention strategies that focus on this population."

            The Institute of Medicine (IOM):  Cognitive, affective, and behavioral disorders incur high psychological and economic costs for the young people who experience them, for their families, and for the communities in which they live, study, and will work.  This Spring, the IOM Board on Children, Youth, and Families, directed by psychologist Kimber Bogard, hosted the first workshop of its Forum on Promoting Children's Cognitive, Affective, and Behavioral Health.  The workshop focused on Strategies for Scaling Tested and Effective Family-Focused Preventive Interventions, featuring presentations on and discussion of successes and challenges in scaling family-focused preventive interventions; financing and infrastructure to support implementation, including how provisions of the ACA may affect programs in primary care settings; and innovative models in scaling family-focused interventions.  A perspective paper on unique opportunities and implementation barriers for family-focused interventions for children with neurodevelopmental disorders has been developed for the project's web site.  Their second workshop focused on Harvesting Best Practices from Prevention Science to Promote Child Wellbeing.  This November, another public workshop will be convened addressing Innovations in Design and Utilization of Measurement Systems to Promote Children's Cognitive, Affective, and Behavioral Health.  Presentations will feature the use of data linkage and integration to inform research and practice; the use of quality measures to facilitate system change in health care, classroom, and juvenile justice settings; and tools developed to measure implementation of evidence-based prevention programs at scale to support sustainable program delivery, among other topics. 

            Unprecedented Change Continues:  The National Center for Medical-Legal Partnership, a project of the Milken Institute School of Public Health at George Washington University has recently been awarded a three year grant from HRSA to cultivate and support medical-legal partnerships at community health centers (FQHCs) across the country.  These partnerships will bring together civil legal aid agencies and law schools with healthcare institutions to integrate legal care into the delivery of healthcare and treat individuals' health harming social and legal needs related to housing, insurance, benefits and education.  Legal and healthcare professionals will work together to identify and improve policies and laws that affect community health.  The three year award designates the Center as a technical assistance center for health centers.  It will build relevant toolkits and provide trainings that will assist health centers develop and sustain medical-legal partnerships.  Integrated, interdisciplinary care is a priority of the ACA.  Sail, Not Tie at Anchor.  Sail, Not Drift.  Aloha,

Pat DeLeon – former APA President – Minnesota Psychological Association – November, 2014

 

GO WHERE YOU WANNA GO

With Washington State's Barry Anton soon to be assuming the Presidency of APA, our national Association should be very well served.  Barry has a long history of being a visionary advocate for addressing the pressing holistic needs of our nation's children and their families.  He truly appreciates the "bigger picture" and the critical importance of psychology being actively involved in shaping health policy.  Recently, Barry was instrumental in celebrating the 40^th anniversary of the APA Congressional Fellowship program at our Washington, DC convention.  As the first social science organization to participate in the AAAS Science and Technology Policy Fellowships Program, this is an extremely important program for all of psychology.  The very first fellow, Pamela Ebert Flattau, who frequently still wears her Walter Mondale button, is prominently involved in shaping national science policy as Director of a new start-up known as The PsySiP Project.  In 1994-1995, Libby Street (Central Washington University) served as a Fellow with U.S. Senator Edward Kennedy in his education office.  The following year, another Washington State former Fellow, Margie Heldring, was instrumental during her tenure with U.S. Senator Bill Bradley in having the federal government modify private health insurance benefits for the first time in our nation's history; effectively addressing "drive-through baby deliveries."  Her efforts were signed into Public Law by President Bill Clinton on September 26, 1996 [the Newborns and Mothers' Health Protection Act (P.L. 104-204)] in a Rose Garden ceremony which she got to attend.  Our President-elect has most recently focused upon the importance of psychology learning from international efforts to further integrated care models, pursuant to the proactive vision underlying President Obama's Patient Protection and Affordable Care Act (ACA).

            The Children's Defense Fund (CDF):  The CDF Overview of The State of America's Children 2014 reports that in 2012, for the first time the majority of children in the U.S. under the age of two were children of color, as were the majority of all children in 10 states.  By 2019, the majority of all children nationwide are expected to be children of color.  Child poverty has reached record levels; one in five children (16.1 million) was poor in 2012.  More than 7.1 million children (over 40% of poor children) live in extreme poverty at less than half the poverty level (for a family of four, $11,746 annually).  Children in single-parent families are nearly four times more likely to be poor than children in married-couple families.  Although almost 70% of all children live with two parents, more than half of Black children and nearly one in three Hispanic children live with only one parent, compared to one in five White children.  Nearly 1.2 million public school students are homeless, 73% more than before the recession.  More than one in nine children lack access to adequate food, a rate 23% higher than before the recession.  Guns kill or injure a child or teen every half hour; gun violence disproportionately affects children of color.  Child poverty costs the nation at least $500 billion annually in extra education, health, and criminal justice costs and in lost productivity.  Child abuse and neglect costs $80.3 billion each year in direct costs and lost productivity.

            The Institute of Medicine (IOM):  The IOM Board on Children, Youth, and Families, directed by psychologist Kimber Bogard, in conjunction with the IOM Board on Global Health, has recently launched its Forum on Investing in Young Children Globally.  This initiative seeks to create and sustain, over three years, an evidence-driven community of stakeholders across northern and southern countries who aim to explore existing, new, and innovative science and research from around the world and translate this evidence into sound and strategic investments in policies and practices that will make a difference in the lives of children and their caregivers.  Forum activities will highlight the science and economics of integrated investments in young children living in low resourced regions of the world across the areas of health, nutrition, education, and social protection.  The Forum will promote a holistic view of children and caregivers by integrating analyses and disciplines – e.g., from the microbiome to culture.  It will support an integrative vision linking human capital of individuals with the economic sustainability of nations.

            A concerted effort will be made to build bridges across sectors and partner with other organizations, including other science academies and coalitions working toward improving investments in young children globally.  Activities and products will be used to inform practices from local communities to government systems; policies at the country, state, and local levels; and research agendas.  Inter-generational approaches to investing in young children globally will be an important lens for developing future activities, with a particular emphasis on empowering women and girls.  Another lens to be used to view the science, implementation, and policies under consideration is the cultural contexts, including belief systems and visions of optimal child development from the familial and community perspective.

            Forum goals include identifying an integrated science on children's health, nutrition, education, and social protection and working with policymakers, practitioners, and researchers to raise awareness of integrated approaches to improve the lives of children and their caregivers.  Objectives include:  * To shape a global vision of healthy child development across cultures and contexts, extending from pre-conception through age eight, and across current "silo" areas of health, nutrition, education, and social protection.  * To identify opportunities for inter-sectorial coordination among researchers, policymakers, implementers/practitioners, and advocates to implement quality practices and bring these practices to scale, in the context of the economics of strategic, integrated investing in young children, spanning health, education, nutrition, and social protection.  * To inform ongoing conversations and activities of groups working on issues related to young children globally.  And, * To identify current models of program and policy financing across health, education, nutrition, and social protection, within the framework of reproductive, maternal, newborn and child health that aim to improve children's developmental potential.  This information could be used to illuminate opportunities for new financing structures and forms of investments that may be more effective in improving child outcomes and potentially drive economic development.  Aspirational goals to be sure, and exactly where APA's next President has been engaged for decades.  On a personal note, my fondest memory of WSPA was having the honor of presenting Colleen Hacker with an APA Presidential citation in 2000 for her years of dedication to our nation's female athletes, including those on the U.S. Women's Olympic teams -- my very last APA Presidential event.  Barry's soccer playing daughter attended that event.  These are indeed exciting times.  Do What You Want.  Aloha,

Pat DeLeon, former APA President – WSPA – November, 2014

 

I’M SITTING IN THE RAILWAY STATION

  The Institute of Medicine (IOM):  As one of the "learned professions," it is incumbent upon psychology and nursing to become aware of, and contribute meaningfully to, efforts by colleagues in other disciplines to address society's most pressing needs.  The Board on Children, Youth, and Families of the Institute of Medicine (IOM), directed by Kimber Bogard, released its most timely report Sports-Related Concussions in Youth: Improving the Science, Changing the Culture almost exactly one year ago.  This visionary effort has received considerable attention in the popular media and the White House.  With the intense focus currently on the health status of retired NFL players, and increasingly on those who played sports in college, the groundwork has perhaps been laid for fostering an important and scientifically-based national discussion – one for which psychological expertise should be highly relevant.  A major conclusion of the IOM report is that while some studies provide useful information, much remains unknown about the extent of concussions in youth; how to diagnose, manage, and prevent concussions; and the short- and long-term consequences of concussions, as well as repetitive head impacts that do not result in concussion symptoms.

            Interestingly, among male athletes at the high school and collegiate levels, football, ice hockey, lacrosse, wrestling, and soccer consistently are associated with the highest rates of concussions.  Among female athletes, soccer, lacrosse, basketball, and ice hockey are highest.  There has been little research on the frequency of concussions among those playing intramural and club sports and in those younger than high school age.  Accordingly, the IOM called upon the Centers for Disease Control and Prevention (CDC) to establish and oversee a national surveillance system to accurately determine the incidence of sports-related concussions among those aged 5 to 21.  Although some research indicates that a series of molecular and functional changes take place in the brain following injury, little research has been conducted specifically focusing upon changes in the brain or on the differences between females and males.  Diagnosis is currently based primarily on the symptoms reported by the individual rather than on objective diagnostic markers and there is little empirical evidence as to the optimal degree and duration of physical rest needed to promote recovery.

            The IOM specifically noted that today's culture of sports negatively influences athletes' self-reporting of concussion symptoms and their adherence to return-to-play guidance.  Athletes, their teammates, as well as coaches and parents may not fully appreciate the health threats posed by concussions.  Similarly for the nation's military population, recruits are immersed in a culture that includes devotion to duty and service before self; thus, the critical nature of concussions may often go unheeded.  It is postulated that if the youth sports community can adopt the belief that concussions are serious injuries and emphasize care for players with concussions until they are fully recovered, then the culture in which they compete will become much safer.

            AARP:  At the other end of the demographic continuum, around the same time, the AARP Public Policy Institute released its report exploring the probable availability (or lack thereof) of Family Caregivers in the foreseeable future.  As Lynn Feinberg discussed at our interdisciplinary USUHS health policy class, today the majority of long-term services and supports are provided by family members.  In 2010, the caregiver support ratio was more than 7 potential caregivers for every person in the high-risk years of 80-plus.  By 2030, this ratio is projected to decline significantly to 4 to 1; and is expected to fall further to less than 3 to 1 by 2050, when all "boomers" will be in the high-risk years of late life.

            Family caregivers – including family members, partners, or close friends – are a key factor in the ability to remain in one's home and in the community when disability strikes.  More than two-thirds (68%) of Americans believe that they will be able to rely on their families to meet their eventual long-term services and support needs when they require help.  However, if fewer family members are available to provide everyday assistance to frail older people, more individuals are likely to need institutional care – at significantly greater cost both to themselves and to society.  In recent years, the role of family caregivers has greatly expanded from coordinating and providing personal care and household chores to include medical and nursing tasks (such as wound care and administering injections).  These nursing tasks used to be provided in hospitals and nursing homes and by home care providers, but increasingly are now being provided by family members.  One of the major challenges facing the nation is addressing the sequela from possessing multiple chronic conditions (MCC).  Currently 26% of adults have MCC; 67% of Medicaid beneficiaries with disabilities have three or more conditions.  As conditions increase, so does the frequency of mortality, poor functional status, hospitalizations, readmissions, and adverse drug events.  Today 66% of health care costs are for individuals with MCC, a vulnerable population which we would suggest could benefit significantly from the ready availability of behavioral health expertise.

            AARP's report notes that research has demonstrated the critical importance of family support in maintaining independence and reducing nursing home use among older people with disabilities.  Between 1984 and 2004, institutional use declined by 37% among the older population, as the number of older people living in the community with two or more needs for assistance with activities of daily living (such as bathing, dressing, or using the toilet) rose by two-thirds.  Medicaid costs for institutional care would have been an estimated $24 billion higher in 2004 had utilization rates remained unchanged after 1984.  It is impossible to document the exact portion of these savings that is due to family caregiving; however, the high rates of family support among the growing number of older people with high levels of disabilities who live in the community strongly suggest that such support has been a critical factor in the dramatic decline of institutionalization and Medicaid use during the past couple of decades.

            Notwithstanding, AARP projects that the caregiver support ratio is expected to plummet as boomers transition from caregivers into old age with the decades of the 2010s and 2020s being a period of transition.  The population aged 45-64 is projected to increase by only 1% between 2010 and 2030; during the same period, the 80-plus population is projected to increase by 79%.  The impact of these demographic changes will undoubtedly be further complicated by recent data indicating that the declines in disability rates may have stalled (and perhaps even reversed) among the young old and pre-retirees, largely because of the increases in obesity (which clearly has relevance to behavioral health).  Accordingly, AARP has called for a national comprehensive person- and family-centered Long-Term Services and Supports policy that would better serve the needs of older persons with disabilities, support family and friends in their caregiving roles, and promote greater efficiencies in public spending.

            The Accountable Care Act (ACA):  On March 23, 2010, President Obama signed into public law the Patient Protection and Affordable Care Act (ACA) [P.L. 111-148].  The ACA represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation.   The Commonwealth Fund recently issued a report card on its status.  Four Defining Questions:  * Are the marketplaces fully functional?  Needs Improvement.  * Did people enroll in the law's new coverage options?  Good To Excellent.  * Are fewer people uninsured?  Good To Excellent.  * Is the quality of insurance improving?  Is underinsurance declining and are people satisfied with their plans?  Grade Pending.  For Extra Credit:  * Are people using their new insurance to get health care?  Grade Extra Credit:  * Is growth in health care costs moderating?  Grade Pending.  And finally, * Is the quality of care improving?  Grade Pending.  In summary: "It seems clear that where we have data, the ACA's implementation has been associated with significant progress.  Equally important, some of the potential problems it could have created such as much higher premiums in the individual market or a lack of insurer participation (which has actually increased for 2015) has not materialized.  If the question is: Is the health care system better off in September 2014 than it was in 2010, the answer would seem to be yes."  Impressively, the Commonwealth Fund found that the percentage of adults ages 19-64 who are uninsured has declined from 20% just prior to open enrollment to 15%, which means there are an estimated 9.5 million fewer uninsured adults.

            A critical component of the ACA's commitment to improving access to quality health care throughout the nation is a significant investment in the Federally Qualified Community Health Centers (FQHC) program.  Established during the Great Society Era of President Lyndon Johnson, when psychologist John Gardner was Secretary of the Department of Health, Education, and Welfare (HEW), these centers represent the true safety net for many Americans.  Accordingly, we were very pleased to learn that prescribing psychologist Earl Sutherland was recently appointed medical director for the Big Horn County FQHC where he is actively implementing their integrated care program – another key element of the ACA.  "Some people complain about getting older, but I prefer it to the alternative [Charles Brewer, APF benefactor extraordinaire]."  Homeward Bound.  Aloha,

Pat DeLeon, former APA President – Division 55 – October, 2014

 

OVER THE RAINBOW

    An Exciting Vision:  Upon occasion, I have been "accused" of being overly optimistic about the future of psychology, especially by senior colleagues who might be emotionally invested in the past.  Without question, the health care environment of the 21^st century is rapidly changing.  However, as long as the field continues to attract "the best and brightest," I am confident that psychology and our colleagues in nursing and pharmacy will do very well.  We must appreciate that the vision of our educational leadership is critical to the future.

I am currently serving on the nursing and psychology faculty of the Uniformed Services University of the Health Sciences (USUHS).  Since we are located near our nation's Capital, we are fortunate to be able to interact with psychology leaders from across the country, as well as senior APA staff.  Former APA Presidents Ron Fox and Don Bersoff have addressed our interdisciplinary health policy class, as well as several Directorate Executive Directors.  The students have been invited to a number of APA events, including the annual State Leadership conferences, the recent APA-ABA judicial conference, not to mention being included in ongoing convention activities.  A typical initial response to a very last minute expression of interest in the APA Education Leadership Conference:  "We would be happy to have some of your students participate.  At this point in time we have space limitations or I would try to make this work" (Catherine Grus, Education Directorate).  We fully expect that next time it will be possible.  Throughout these experiences the palpable enthusiasm of the next generation has been very evident, as has been their interest in shaping their own destiny.  USUHS recently announced that our current APA President Nadine Kaslow will be visiting with students and faculty.  APA's genuine responsiveness to the interests of our next generation is most impressive – Mahalo, Norman Anderson.

            Postdoctoral Opportunities:  One of the most exciting developments within the profession has been the establishment of psychology's postdoctoral training initiatives.  As we have evolved from being an exclusively mental health focused discipline into a bona fide health care profession, the breath of clinical opportunities for psychological expertise to improve the quality of patients' lives has been exponential.  During his APA Presidency, World War II Army veteran Jack Wiggins visited with VA Secretary Tony Principi, a Vietnam veteran, and as a result of that discussion, the Secretary called for the VA to begin a psychology postdoctoral training program.  Over the subsequent years, this initiative has steadily expanded, both in numbers and in its clinical focus.  Visionary VA senior psychologist Bob Zeiss:

            "Health professions education, across disciplines, is a core mission of the Department of Veterans Affairs (VA), with a general goal of providing high quality experiential learning opportunities to develop well educated and well trained health professionals for VA and for the nation.  VA's Office of Academic Affiliations (OAA) funds and oversees these training opportunities.  During my tenure at OAA (2005-2013) and continuing today (under the leadership of Kenneth Jones, Director of Associated Health Education), the number of funded postdoctoral training positions increased from 52 to 402.  Phase III of the five year Mental Health Expansion Initiative will increase those numbers even more for the 2015-2016 academic year.

            "Working closely with Mental Health Services and supporting VA's major initiatives to enhance both access to and quality of mental health care in VA, OAA committed to increase the number of trainees in all mental health disciplines.  Because of the strength of psychology staff across the nation, psychology as a discipline was particularly poised to develop new internship and postdoctoral programs and enhance existing ones.  In recent years, we have increased the focus on developing training opportunities in smaller and rural VA health care settings.  These programs provide the same kinds of opportunities as do larger, more traditional programs; they also are intended to generate a cadre of health care professionals eager to remain in and serve in those smaller and more rural settings.

            "The focus on postdoctoral training is based on the premise that VA training provides a particularly highly qualified set of candidates from which to recruit future VA staff.  Though graduating interns are generally experienced and skilled, the internship does not allow sufficient depth of training to become highly skilled in an emphasis or specialty area.  Adding a postdoctoral year to training provides precisely that opportunity.  Thus, not only does VA ensure that these new professionals have the skills relevant and necessary for quality care of Veterans, but we are also in a position to determine exactly which developing practitioners have the skills, attitudes, and dedication to VA care that we treasure in our employees."

            President Obama's Patient Protection and Affordable Care Act (ACA) envisions the health care environment of tomorrow as providing interdisciplinary data-based care, with a priority on wellness, prevention, and services which are high quality and cost-effective (i.e., the "Triple Aim" – simultaneously improving population health, improving the patient experience of care, and reducing per capita cost).  Combined with the Mental Health Parity legislation, the ACA represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation.  And, as Bob indicated, the Administration has demonstrated a concerted effort to engage all health care professions.  Mary Dougherty, Director of Nursing Education OAA, reports that the VA supports academic partnerships with Schools of Nursing via the VA Nursing Academic Partnership (VANAP) which funds both baccalaureate and graduate students.  The graduate programs are focused on Psychiatric Mental Health Nurse Practitioners (PMHNPs).  Both programs require a residency – a post baccalaureate nurse residency or a PMHNP residency.  The OAA provides funds for graduate and undergraduate faculty for both schools of nursing and VA, as well as stipends for graduate trainees, post baccalaureate nurse residents, and PMHNP residents.  The development of a standard PMHNP competency, curriculum, and accreditation standards are expected outcomes of this program.

            Population Focused Health Care:  I have recently been appointed to the national advisory committee on Interdisciplinary Community-Based Linkages of the Health Resources and Services Administration (HRSA).  The committee is charged with providing advice and recommendations on policy and program development to the Secretary of HHS concerning its various Title VII (Health Professions) training programs and is to submit an annual report to the Secretary and to Congress.  Included within its jurisdiction is the Psychology Graduate Education program, as well as the Area Health Education Center, Geriatric Education Center, Quentin N. Burdick Program for Rural Interdisciplinary Training, Allied Health, Mental and Behavioral Health Education and Training initiatives, Education and Training in Pain Care, and the Integration of Quality Improvement and Patient Safety Training into Clinical Education of Health Professionals programs.

            One of the challenges facing the nation is addressing the sequela from possessing multiple chronic conditions (MCC).  Currently 26% of adults have MCC; 67% of Medicaid beneficiaries with disabilities have three or more conditions.  Not surprisingly, as conditions increase, so does the frequency of mortality, poor functional status, hospitalizations, readmissions, and adverse drug events.  Sixty-six percent of US health care costs are for individuals with MCC and 93% of Medicare expenditures are for individuals with MCC.  For those inpatients 18-44 years of age with more than two chronic conditions, depression is the most prevalent.  The HHS Multiple Chronic Conditions Strategic Framework overarching goals include: * Fostering health care and public health system changes; * Maximizing the use of proven self-care management; * Providing better tools and information to workers who deliver care to those with MCC; and, * Facilitating research to fill knowledge gaps.  The poor health outcomes of individuals with serious mental illnesses and other behavioral health problems warrants special attention because of the co-occurrences of these conditions with other chronic conditions.  This is a priority patient population for which psychology's postdoctoral training would seem most appropriate; including those with specialized training in psychopharmacology.

            Ron Rozensky, who served as a former chair of the committee: "It was a great experience representing psychology and having the opportunity to work with the chairs and vice chairs of other advisory committees representing the full range of health care disciplines.  We collaborated on writing a letter to Congress during the drafting of the ACA underscoring the importance of the inclusion of interprofessional education, training, and service.  Our 10^th Report to Congresshighlighted the importance of health behavior as a key component of a truly integrated health care system – what a great honor to chair that report!"

Reflections:  I am intrigued by how our senior colleagues respond to retirement.  Margy Heldring, former APA Congressional Fellow:  "I am nearly full time with the group I founded, Grandmothers Against Gun Violence, after Sandy Hook.  It is amazing to build a new organization of 'Women of a Certain Age' and see everyone feel empowered and turn (return!) to activism.  What an experience!  Psychology seems farther and farther behind me, as I move out and back into policy and politics as a psychologist!"  Why, Oh, Why Can't I?  Aloha,

Pat DeLeon, former APA President – Division 55 – September, 2014

 

A VISION SOFTLY CREEPING

Congressional Engagement:  These are interesting times for our nation's non-physician health care providers, and particularly for those in the mental health/behavioral health field.  In deliberating on the Fiscal Year 2015 Appropriations bill for the Department of Defense (DoD), the U.S. Senate noted: "Mental Health Professionals. – The Committee recognizes that service members and their families face unique stresses beyond those of everyday life.  After over a decade of war, the need for mental health professionals in the Department is at an all-time high, and the Committee believes that every beneficiary of the Military Health System should have timely access to mental health services.  However, the Committee is concerned with the Department's inability to recruit and retain enough psychiatrists, psychologists, social workers, nurse practitioners, and registered nurses to provide adequate mental healthcare.  The Committee has asked the Government Accountability Office to review this issue including the Department's current inventory of mental health providers, current and future needs for providers, challenges the Department faces in recruitment and retention, actions taken to mitigate these challenges, and recommendations going forward to ensure an adequate inventory of mental health professionals within the Military Health System.  The Committee looks forward to receiving the results of this review and working with the Department to provide the tools necessary to implement any recommendations."  We would suggest that this is an excellent time for psychology to showcase its innovative treatment initiatives, communicate the ways in which the integration of behavioral and mental health services into primary care improves health outcomes, as well as its success in appropriately expanding its clinical scope of practice in obtaining prescriptive authority (RxP).

            The Patient Protection and Affordable Care Act (ACA):  President Obama's landmark Patient Protection and Affordable Care Act (P.L. 111-148) provides an exciting opportunity to make a real difference for those colleagues with vision and the willingness to demonstrate leadership.  Combined with the enacted Mental Health Parity legislation, this represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation.  Mental health and substance-use treatments are deemed "essential health benefits" under the ACA.  Priority will be given to prevention, wellness care, and services which are high quality and cost-effective, as our nation moves our health care system towards population health-based care, rather than stressing individual acute care episodes.  The ACA calls for the development of integrated, interdisciplinary systems of patient-centered care which will be transformational.  Chief among these is the integration of behavioral health and medical health care, where the public sector has consistently demonstrated proactive leadership.

The foundation is steadily being put in place for bringing the advances occurring within the communications and health information technology (HIT) fields into the health care environment.  As a nation, we are moving from reimbursement for specific clinical procedures towards encouraging value-based care – including the critical psychosocial-economic-cultural gradient of quality care.  This fundamental shift in emphasis is expected to result in the U.S. no longer being ranked by the Commonwealth Fund as last among developed nations on overall measures of health system quality, efficiency, access to care, equity, and healthy lives, as compared with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom.  This is in spite of the fact that we presently spend more on health care than anywhere in the world.

            The Need for Greater Public Awareness:  At the Uniformed Services University of the Health Sciences, we are fortunate to have a number of APA elected officials and senior staff address our interdisciplinary health policy seminar.  Rhea Farberman recently described APA's efforts to ensure that the value of psychological expertise is appreciated by health policy experts, other disciplines, and the public.  There is a surprisingly significant knowledge gap with only 4% of Americans being aware of the Mental Health Parity and Addiction Equity Act and what it means for their access to mental health and addictions care.  Consumers report that psychology can help people lead healthier lifestyles (51% somewhat agree and 42% strongly agree).  And, that health care can be improved through better understanding of human behavior (49% somewhat agree and 26% strongly agree).  Consumers believe that psychological research has a role to play in finding ways to address health issues such as obesity and smoking (49% somewhat significant and 23% very significant).  Yet, the public often doesn't pursue psychological services for themselves or loved ones when it could make all the difference in their treatment outcome.  This action gap could be the result of stigma; it could be due to access issues.  Regardless, it presents both an opportunity and responsibility for psychology.  As highly educated professionals, we may understand how psychology can contribute to improving the overall quality of health care in our nation if appropriately recognized.  However, we have a significant way to go before the rest of society does.  And, this is particularly true with our physician colleagues!  When physicians were asked:  Does psychological research have a role in finding ways to address health issues such as obesity and smoking – 45% responded somewhat significant and 40% very significant.  Even more telling: How helpful do you think a psychologist would be when it comes to assisting your patients in making lifestyle and behavior change?  Fifty-eight percent indicated somewhat helpful and 24% very helpful.

            Prescriptive Authority (RxP):  In her recent mailing to the membership, APA's Katherine Nordal praised the Illinois Psychological Association for their success in obtaining RxP.  "It's good news for our profession and very good news for the residents of Illinois….  Right now in our country, nearly 80% of psychotropic medications are being prescribed by primary care physicians who have very little training in mental health.  I'm sure you agree that mental health patients are well served by having qualified mental health professionals available to prescribe.  That's why the victory in Illinois is so important."  The World Health Organization (WHO) defines an adverse drug reaction as "harmful, unintended reactions to medicines that occur at doses normally used for treatment" and points out that these are among the leading causes of death in many countries.

Reflecting upon their success in Illinois, Beth Rom-Rymer reminds us that: "The Illinois Medical Society and the Illinois Psychiatric Society vigorously and vociferously lobbied against our RxP bill until they realized that we wouldn't stop fighting and until they had already spent $1 million to keep us out of the prescribing community!"  Persistence and community involvement are the key to long term change, which Beth and her colleagues vividly demonstrated.  Why is it that more colleagues within the VA have not sought prescriptive authority?  The experiences of their DoD colleagues clearly demonstrate that they can obtain these clinical skills and that the quality of care they would provide would be excellent.  The need is there.  There are a significant number of psychologists who are veterans and who belong to veterans' organizations -- the true beneficiaries.  Under President G.W. Bush, VA Secretary Tony Principi was quite open to initiating a pilot project, similar to the way that the DoD program initially began.  At that time psychology's leadership was not willing to demonstrate proactive leadership; notwithstanding that a number of individual VA psychologists had informed me that they were, in fact, prescribing.  Have we matured sufficiently as a bona fide healthcare profession to affirmatively accept this clinical responsibility?  The Sounds of Silence.  Aloha,

Pat DeLeon, former APA President – Division 18 – September, 2014