The Importance of "The Bigger Picture": Over lunch in the Uniformed Services University of the Health Sciences (USUHS) cafeteria, Kevin McGuinness recently discussed with several nursing doctoral students the importance of appreciating the "bigger picture" for those wishing to become actively involved in health policy. A former military Service Member and now an officer in the USPHS (and a national leader in the federal RxP movement), Kevin's personal goal is to see mental health addressed with the same urgency as physical health within the federal system and for psychology to be understood as a primary weapon in the armamentarium of public health, capitalizing upon its cost-effectiveness when integrated within primary health. Kevin consistently emphasized the necessity of taking a broad holistic view of "health care," including the context in which one works. Looking around the room, it became evident that the historical emotionally charged battles over the possible "purple suit" identity of uniformed Defense health care providers really represented concerns of the past. Here were nurses and other health care disciplines, selected from each of the Services, learning and socializing together. That afternoon he would address our health policy class, attended by nursing and psychology students – reminding us that integrated, interprofessional training is one of the hallmarks of President Obama's Patient Protection and Affordable Care Act (ACA).
Moving Away From Isolated Silos: During its deliberations on the Fiscal Year 2014 Appropriations bill for the Department of Defense (DoD), the Senate Appropriations Committee addressed the importance of DoD working collaboratively with the Department of Veterans Affairs (VA) on behalf of their beneficiaries. "While the DoD and VA may have different missions, they are bound together in a mutual mission to support those who have served in the defense of the country. Over the past several years, collaboration between the Departments has significantly increased and the number of joint projects and services has expanded. The Committee applauds these efforts and believes that future information sharing between DoD and VA must strengthen in order to ensure a seamless transition from active duty and timely access to VA benefits. Nowhere is this more evident than in the transmission of service treatment records from DoD to VA. These records are essential in the VA's process of making accurate and timely determinations of benefits to which a veteran may be entitled…. In October 2010, DoD and VA established a first-of-its-kind partnership with the opening of the Captain James A. Lovell Federal Health Care Center [FHCC]. This is a fully integrated Federal healthcare facility that serves Active Duty military, their family members, military retirees, and veterans. The Committee continues to support the pilot program at FHCC and believes it will produce valuable lessons that can be used to expand future collaboration between DoD and VA hospitals as well as produce substantial savings to the taxpayer by combining the two healthcare systems where practical."
Earlier this year, VA announced its partnership with Kaiser Permanente to pool resources and ideas to solve some of the largest and most complex challenges in VA health care. The Secretary: "VA is always on the lookout for opportunities for partnerships with the private sector and other federal agencies to enhance care for Veterans. We are proud to partner with Kaiser Permanente for the health and wellbeing of our Nation's Veterans." It is expected that this joint effort will enable more effective research and sharing of best practices, focusing initially on four areas: Telehealth and virtual care; Genomics; Care of Veterans who are members of Kaiser Permanente; and Advanced analytics to use large data sets and population management with appropriate patient privacy protections. The two systems expect to develop recommendations for how to design care using advanced analytics and technologies, as well as research. This is building upon a 2010 agreement in which the two organizations launched a pilot program to exchange medical data using the Nationwide Health Information Network. That project allowed clinicians from both organizations to obtain a more comprehensive view of a patient's health record using electronic health record information, including information about health issues, medications and allergies; while ensuring privacy and confidentiality. An expressed goal is to increase ease of access and quality of services. With over 8 million enrollees, VA operates the largest integrated health care delivery system in the nation. We would be interested in learning whether VA is negotiating similar agreements with Federally Qualified Community Health Centers, which are the true "safety net" for many Americans, particularly in rural America where a number of veterans reside.
The Importance of Investing in Prevention: Several of the lessons which Kevin shared are: * Change takes time, often far longer than one would initially expect. And, * Those establishing policy often focus upon the immediate crisis, rather than investing in prevention in order to avoid future crises. A graphic example: Today, the nationwide epidemic of obesity is a high priority for the Obama White House. However, in 2007 the RAND Corporation proclaimed: "America appears to be in the midst of an obesity epidemic. Should we care?" Obesity in the U.S. had been increasing steadily over the past two decades – with severe obesity increasing the fastest. Obesity translates into higher health care costs (more than smoking or drinking) and contributes to disability at all ages. It was apparent that traditional clinical approaches, in particular bariatric surgery, could not slow the trend. Medicare and Medicaid savings stemming from increasingly good health among the elderly could be swamped by the cost consequences of disability among the young. More than one in five U.S. adults were then classified as obese based on self-reported weight, and almost one in three based on objectively measured weight. Compared with their normal-weight counterparts, the obese spend 36% more on health care services and 77% more on medications; the comparable numbers for current smokers are 21% and 28% respectively, and less for problem drinkers. Severely obese people are more than twice as likely to be in fair or poor health and have about twice as many chronic medical conditions. For men, severe obesity is associated with a 300% increased probability of having limitations on basic activities of daily living; for women, the effects are even larger.
Another RAND study that year found: "When it comes to getting the right care at the right time, children in this country fare even worse than adults." They are not receiving recommended preventive care and screening services, such as regular weight and measurement checks to ensure they are growing properly and not at risk for obesity. Foreshadowing another one of Kevin's policy messages: * Neighborhoods exert a powerful effect on residents' physical activity and thus neighborhood design should be considered a public health issue. Girls pose a particular concern because their physical activity is known to decrease as they progress through adolescence. "Obesity is the most serious public health problem confronting America today." Testifying before the Senate Appropriations Committee in 2012, U.S. Army Major General Jimmie Keenan noted: "In America, we in DoD spend an average of 100 minutes each year with our health care team. The other 525.500 minutes of the year our patients are not with us – the same amount of time our environment influences the behaviors that determine our health occur." The psychosocial-cultural-economic gradient of health care is absolutely critical. Public service psychology and advanced practice nursing must embrace their professional responsibility of addressing broad public policy/public health issues in order to be effective in the long run, including focusing upon and advancing wellness, patient responsibility, and environmental risk factors.
The National Institute on Minority Health and Health Disparities (NIMHD) (NIH): The Fiscal Year 2014 budget request for NIMHD was $283.3 million. Its fundamental mission is to lead scientific research to improve minority health and eliminate health disparities. Cognizant of the potential of science and the multiple factors and related issues that underlie health disparities, NIMHD's approach to achieving this mission is embodied in building a broad-based coalition of partners across multiple disciplines and sectors. Although the U.S. has seen recent improvements in the overall quality of care, stark disparities in health quality and access to care persist in many communities, as well as pervasive differences in health between groups around the country. Increasing evidence-based research findings continue to underscore the complex interplay of factors such as race, ethnicity, social, economic, geographic, environmental, genetic, and behavioral influences across the life-course that contribute to the early onset of disease, the aggressive progression of a disease, and to premature death. In particular, Translational Science and Recruiting and Retaining Diverse Scientific Talent and Creativity are foundational aspects of the Institute's efforts to eliminate health disparities.
The approach of the NIMHD health disparities programs is to examine the causes of health disparities; integrate science, practice, and policy approaches to address health disparities; provide a platform for academic institutions to conduct research and support the training of a diverse workforce; offer a vehicle to build community research capacity, study national and global patterns of health disparities; and advance the translation and dissemination of research results. The elimination of health disparities requires a transdisciplinary evidence-based approach, which incorporates efforts to promote translational science to ensure that the benefits of scientific discoveries reach those most affected by health disparities.
A series of community health reports resulting from NIMHD-funded research reveal that social, economic and environmental conditions of low-income and non-white neighborhoods in some U.S. counties can project who is sick, healthy, and will live longer. The results of these reports have policy and practice implications as it relates to the systems and structures that contribute to health disparities. In another study utilizing quantitative and qualitative methods to study racial/ethnic disparities in early life risk factors for childhood obesity, researchers will study several factors. Including, for example, the extent to which maternal experiences of two chronic stressors, racism and interpersonal violence - before and during pregnancy – are of significance. It is felt that there is a unique and compelling need to promote diversity in the biomedical, behavioral, clinical and social sciences research workforce. Thus, enhancing workforce diversity is a priority. We would suggest that many of those who receive care from the Division's membership could benefit from NIMHD's vision.
He Never Drank Water. He Always Drank Wine: It has been fascinating to hear from colleagues of different disciplines describing their post-retirement experiences. Some wistful; some exhilarating. "I still feel that I have something to share and pass on. The desire to teach and educate this upcoming generation of health care professionals is strong. I am applying for another opening at…." "I decided to end my job search. I am getting older, and there is age discrimination. I accept it. So I am cobbling together consultancies and subsidizing the payers. I am frugal; so far I am making it. Not to worry, I am doing fine! It is what it is." Two other colleagues with extraordinary professional backgrounds described trying unsuccessfully to join the Peace Corps, even though both were in excellent physical and mental health.
And at the same time, "I am retired from all things psychological thus not doing reviews anymore. Priscilla and I are enjoying retired life in central Virginia, especially the increased family time. Lunch in C'ville yesterday with an old friend. Lang Lang concert last night in C'ville (incredible performance!!). Breakfast at our house this morning with our daughter and son-in-law who live here. They brought the homemade muffins, we fixed the rest. UVa women's basketball game this afternoon with friends (we have season tickets). Strategic planning committee meeting for me tomorrow for our neighborhood association (750 homes), and couples bridge on Tuesday night at our country club. Staying busy. It's a good life [Ludy Benjamin]." Times are changing as today's generation of senior colleagues steadily departs from their prior, in retrospect predictable professional lives. Former Division 18 President Jacqueline Wall recently sensed what is perhaps a fundamental shift in perspective: "Just so you know, I have received 20 nominations for President-elect. Most people say that they are too busy to assume the responsibility. It makes me wonder if the nature of our work has changed so much that people are beginning to protect their time to the point of decreasing involvement in anything that isn't obligated by an employer or for which compensation is given. I mentioned the other day that when I started, the standard organizational practice was 50% patient contact time. I'm hearing now that my colleagues are in direct patient care 80-90% of the day; leaving little time for things like writing reports, making phone calls, answering e-mails, etc. Gives one pause and makes me think we'd best rethink how we do things." If I'd bet on ol' Stewball, I'd be a free man today. Aloha,
Pat DeLeon, former APA President – Division 18 – March, 2014
