Having served for nearly four decades on Capitol Hill, I remain impressed by the astute observation of former APA Congressional Science Fellow Neil Kirschner, more than a decade ago, at our annual convention in Toronto: "More often than not, research findings in the legislative arena are only valued if consistent with conclusions based upon the more salient political decision factors. Thus, within the legislative setting, research data are not used to drive decision-making decisions, but more frequently are used to support decisions made based upon other factors. As psychologists, we need to be aware of this basic difference between the role of research in science settings and the legislative world. It makes the role of the researcher who wants to put 'into play' available research results into a public policy deliberation more complex. Data needs to be introduced, explained, or framed in a manner cognizant of the political exigencies. Furthermore, it emphasizes the importance of efforts to educate our legislators on the importance and long-term effectiveness of basing decisions on quality research data…. If I've learned anything on the Hill, it is the importance of political advocacy if you desire a change in public policy."
Katherine Nordal, Executive Director of the APA Practice Directorate, issued a similar challenge at last year's State Leadership Conference, reflecting upon President Obama's landmark legislative accomplishment: "The Affordable Care Act [ACA] has survived, and implementation of the largest expansion of the health care safety net will proceed. But January 1st is really just a mile marker in this marathon we call health care reform. We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us. One of the first steps in positioning for reform is for practitioners to recognize that they bring numerous professional skills and strengths to integrated care setting. Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care. No one else is fighting the battles for psychology… and don't expect them to. Health care is a marathon – we're in it for the long haul. We can't hope to finish the marathon called health care reform if we're not at the starting line."
Those of you who are working in Long-Term Care are to be truly commended. Many years ago, the late Powell Lawton of the Philadelphia Geriatric Center, who was a visionary in the field of healthy aging, shared his excitement about the potential contributions of the behavioral sciences to the future of our elderly. Even then, it was clear that our nation was rapidly aging and further, with the advances beginning to occur within the communications and technology fields, that it would be increasingly possible to bring unprecedented social-environmental changes (e.g., stimulation modules) to the lives of our most senior citizens, regardless of where they were residing. Today, there is considerable discussion at the national level regarding the ever-escalating costs of health care. The United States spends more on health care than any other industrialized nation, if not twice as much; and yet, our health outcomes are not comparably favorable. Further, the Institute of Medicine (IOM) reports: "Regions that deliver more services do not appear to achieve better health outcomes than those that deliver less." "In fact, underuse, misuse, and overuse of various services often put patients in danger." It is estimated that 50+% of all resource expenditures in hospitals is quality-associated waste (i.e., recovering from preventable foul-ups, building unusable products, providing unnecessary treatments, and simple inefficiency). Health care systems need to be focused and accountable.
A number of the underlying provisions of the ACA are envisioned as building coordinated, patient-centered systems of care where psychology can contribute significantly to integrated care teams – regardless of the age or disability of the patient. Historical procedure-oriented reimbursement mechanisms are to be steadily replaced with outcome-oriented metrics. Cross-provider and cross-diagnostic comparisons are increasingly being called for. We are optimistic that the critical psychosocial-economic-cultural gradient of "quality" health care will finally be appreciated by other disciplines and most importantly, by those who ultimately make financial decisions. As Katherine continues to emphasize, the ACA is merely a stage in the evolution of our nation's health care environment.
Unfortunately for psychology, however, our profession is not expressly included in the underlying statute or implementing regulations of either the critical Accountable Care Organization or Patient-Center Medical Home provisions of the law. Further, although historically Medicaid has been the major source of financial support for long term care services, the profession of psychology has been significantly remiss in not being actively involved. Accordingly psychology is not recognized in many state Medicaid programs. If one appreciates that law and business have long been the major professional backgrounds of those elected to Congress and reflect upon Neil's observations, substituting "health care" for "research," one can appreciate that we have a long way to go. And yet, there can be no question that our clinical expertise can make a real difference in the quality of life of our nation's senior citizens.
Visiting Professor Ann Burgess at the Daniel K. Inouye Graduate School of Nursing, USUHS: "Sexual assault has no barriers to the victim's age or gender. For example, in the Albert Lea case in Minnesota five teenage nursing assistants were found guilty of sexual harassment and sexual assault of over a dozen male and female Alzheimer residents over a six month period. Court papers revealed that the nursing assistants were laughing as they talked of poking the breasts and genitalia of elders and taking pictures for online posting. Family members, after learning of the assaults, said they had noticed changes in behaviors but attributed it to advancing dementia or medication. This case emphasizes that therapy has no barriers as to age, gender, or mental capacity. There is the need for caregivers as well as family members to take seriously any patient complaint or behavior that has an oblique or direct sexual content. In addition, studies show that elder demented patients respond positively to expressive therapies, especially music therapy." Will those who are working with Long-Term Care families take the next step to ensure that psychology's expertise is appropriately recognized? Aloha,
Pat DeLeon, former APA President – Psychologists in Long-Term Care – March, 2014
