IT ALWAYS SEEMS IMPOSSIBLE UNTIL ITS DONE

State Leadership Conference (SLC):  At this year's exciting Practice Directorate State Leadership Conference (SLC) titled "Creating Roadmaps for Practice," visionary Executive Director Katherine Nordal emphasized: "The way the Affordable Care Act [ACA] is unfolding reminds us that no single advocacy strategy for psychology can address the diverse legislative, regulatory and marketplace environments we see from one state to another.  Meanwhile, our country still doesn't pay nearly enough attention to mental health and substance use treatment.  We've carved out this treatment from medical care and made people jump through hoops to get the psychological services they need.  And mental health is chronically underfunded.  About 20% of our population experiences a mental health disorder in any given year, compared to a lifetime incidence of 6% for adults with cancer.  Yet, in 2012, the federal government invested more than 5 billion dollars in the National Cancer Institute but less than 1.5 billion dollars in NIMH.  Health care reform implementation is a work in progress.  There are hopeful signs, especially related to the goal of increasing the ranks of Americans with health insurance coverage.  A combination of professional, marketplace, legislative and regulatory developments encourages more collaborative, multi-disciplinary practice models.  As the landscape shifts towards more integrated care, new reimbursement mechanisms will emerge.  The demand for evidence-based practices and use of quality measures related to process and outcome, including behavioral health measures, will grow.  And the increasing use of technology for electronic health record keeping and telepsychology service delivery will continue to evolve.  Many of our members seem attuned to this evolution."  As Katherine also indicated at last year's SLC conference: "Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  If we are not valued as a health profession, it will detract from our value in other practice arenas as well.  Health care reform is a marathon – we're in it for the long haul.  New models of care and changes in health care financing won't take shape overnight."

            Integrated Care:  Katherine's description of the "changing winds" of health care reform is extraordinarily accurate.  The Alliance for Health Reform recently sponsored a Hill briefing – "Is the Mind Part of the Body?  The Challenge of Integrating Behavioral Health and Primary Care in a Reform Era."  "As more people gain coverage that includes behavioral health benefits, and given a limited supply of mental health professionals, analysts and advocates are raising concerns over how and whether new laws and regulations will be able to change that situation.  One option being explored in many settings is the integration of behavioral health services with primary care.  There is early evidence that coordinating care in this manner may deliver high-quality care more efficiently.  For almost 20 years, bipartisan majorities in Congress have been legislating ways of bringing behavioral health services to the 62 million Americans in need of them.  Beginning with the 1996 Mental Health Parity Act, Congress has steadily broadened access to these services.

            "All state Medicaid programs and plans sold on the health insurance marketplaces cover behavioral health services.  Yet 60% of adults and 70% of children with a mental health disorder do not receive treatment.  In children, the average time between onset and treatment of mental illness is nine years.  And one in six adults has co-morbid mental health and medical conditions.  More commonly their medical condition is being treated while their mental health condition goes undiagnosed and untreated.  Do current models of integrating behavioral and physical health hold promise?  Are there enough providers to meet the demand of the newly insured?  What is needed to help primary care fill the gap?  How are the states meeting the budgetary challenge in Medicaid programs?  Is parity a reality?"

            Our colleagues in the American Psychiatric Association (ApA) would appear to agree with Katherine, recently calling for much tighter integration of primary care and mental health care, thereby providing better services with a reduction in costs.  "Studies have shown that concurrently treating behavioral and physical conditions leads to better control of the illness itself, but also better patient satisfaction, quality of life, and reduced costs [ApA President]."  The ApA commissioned report shows that effective integration could save $26 billion to $48 billion a year in general medical care.  Almost half of people with a mental disorder first consult with a primary care physician and approximately 50% of the 38,000 individuals who commit suicide each year have seen a primary care physician within a month of the completed attempt.  Their report, which drew on claims data for 20 million enrollees, found that only 14% of those who had a mental disorder were receiving treatment but that they accounted for 30% of the spending reviewed.  "Even though they are insured and are being treated for their mental illnesses, the lack of coordinated care represents lost opportunities….  The higher costs were mostly attributable to patients falling through the cracks or not getting proper care – which showed up in more emergency room visits, more hospitalizations, and hospital readmissions [ApA President-Elect]."

            In our judgment, critical to the success of Katherine's vision of psychology being recognized as a bona fide "health care profession" is affirmatively embracing our societal responsibility to provide proactive leadership in addressing society's most pressing needs.  Psychology is one of the "learned professions" and with that come a fundamental obligation to effectively utilize our clinical skills, beyond the confines of traditional practice.  Last year we were very pleased to learn of Gaby Toloza's efforts on behalf of the Hawaii Psychological Association (HPA) to address the needs of families with an autistic child.  Her "call to action" this year: "We are in need of about 6-7 psychologists to volunteer ONE hour of their time on Saturday at the Windward YMCA to give an interactive psycho-educational talk about an aspect of Self Care to a group of 15-20 parents of autistic children.  Some previous topics related to mind body connection, achieving balance, how to change behavior, role of nutrition, stress management, financial stress management and relationship health.  This is a wonderful way to give back to the community and promote psychology as a profession, but more importantly the necessity of self-care and a wellness model.  This supports HPA and APA initiatives for public education and it's just a fun, simple and meaningful experience for both the families and providers.  It is a collaborative project with HPA, YMCA, Hawaii Autism Foundation and Creative Connections Foundation, so it also represents yet another way that the work of psychologists can be integrated and effectively used to support a given population.  Thank you for your time and hope I hear back from many of you wonderful helping professionals (Yes, shameless positive feedback in hopes of soliciting your time)."

            Interdisciplinary Training For The Next Generation:  The Robert Wood Johnson Foundation (RWJ) Nursing and Health Policy Collaborative at the University of New Mexico reports that over 100 doctoral level nursing programs have stand-alone, required courses in health policy, with numerous other programs incorporating health policy content into related courses.  In sharp contrast, we have been able to find very few related courses within psychology' training programs.  An appreciation of the legislative and administrative process is essential for all health professions.  For example, the Institute of Medicine (IOM) found that although the primary purpose of a state licensing board is specifically to protect the interests of the public, 52% of dentists thought that the primary purpose of their state dental board was to protect the interests of dentists and 32% thought they protected the interests of both dentists and the general public.  The IOM report also concluded that publicly funded health programs should not separate oral health from overall health.  The IOM President: "Can you imagine a time when we fully incorporate mental and dental health into our thinking about health?  What is it about problems above the neck that seems to exclude them so often from policy about health care?"

            At the Uniformed Services University of the Health Sciences (USUHS), the next generation of psychologists and doctors of nursing practice (DNP) train together in a number of venues, including health policy.  "My colleague, CPT Kathleen Young and I had the pleasure of attending the American Association of Colleges of Nursing (AACN) Student Policy Summit held in Washington, DC.  The Summit provided a panoply of distinguished nursing professionals and activists committed to the advancement of nursing and nursing practice that bestowed upon us the importance of uniting as a profession to influence changes that affect our profession and the care that we provide to our patients.  Astonishingly we have approximately 3.1 million nurses of which only approximately 100,000 belong to the American Nurses Association (ANA).  While this statistic does not include the many other nursing organizations that nurses may be members of, it is nonetheless an astonishing fact that nurses make up the majority of the healthcare industry, yet we have the least amount of members participating in organizations that influence the very policies that impact our profession.

            "The AACN Summit provided an opportunity to show the ease with which nurses can become politically involved to improve health status and the delivery of healthcare.  Mindful of relevant DoD Directives, my colleague and I were graciously allowed to accompany Dr. Jane Kirschling, President of the AACN and Dean of the University of Maryland School of Nursing, as well as several bright undergraduate and graduate nursing students from the State of Maryland as they were welcomed by the offices and staff of the Maryland Senators and Congresspersons.  The well-spoken students impressed upon their Representatives the importance for continued support for Title VIII funding for nursing education, increased funding for nursing research, and support for nursing practice bills designed to promote the role of Advanced Practice Nurses in the healthcare delivery system.

            "The AACN Student Summit Policy Summit was an extraordinary opportunity to network with nursing leaders, advocates for the advancement of nursing practice, and colleagues with the common goal of imparting change.  In an era of unprecedented health care reform nurses, one of the most trusted health professions in the nation, have a unique opportunity and dare I say obligation, to provide our expertise in matters that affect the profession of nursing and the delivery of care that we provide [Capt. Kellie Webb-Casero, USAF]."  Aloha,

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

 

LEAVING ON A JET PLANE

 This Spring's Practice Directorate State Leadership Conference (SLC) was appropriately titled "Creating Roadmaps for Practice."  Last year Executive Director Katherine Nordal reminded those attending that: "The clock is ticking towards full implementation of the law [President Obama's Patient Protection and Affordable Care Act (ACA)] and January 1, 2014 is coming quickly.  But January 1^st is really just a mile maker 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.  What many of our practitioners increasingly will need to promote: the value and quality they can contribute to emerging models of care.  I believe that if we are not valued as a health profession, it will detract from our value in other practice arenas as well.  So regardless of how we feel about the current state of our health care system, psychology must take its seat at the table and contribute to the solutions needed to fix our ailing system."  SLC continues to be, in my judgment, one of the highlights of APA's year.  The leaders of our profession from around the country get a first-hand glimpse of the policy/political forces that are impacting their daily professional lives.  Perhaps most importantly, our next generation of colleagues is actively encouraged to become involved in shaping the future of theirprofession.

The 500+ colleagues in attendance this year – including President Nadine Kaslow and President-elect Barry Anton -- heard an inspiring vision from Katherine: "The way the [ACA] is unfolding reminds us that no single advocacy strategy for psychology can address the diverse legislative, regulatory and marketplace environments we see from one state to another.  The landscape continues to take shape.  Speaking of landscapes, you know as well as I that the professional terrain for psychologists – and other health care providers – has been somewhat rocky in recent years.  Disruption and demands on practitioners have raised anxiety levels.  Meanwhile, our country still doesn't pay nearly enough attention to mental health and substance use treatment.  We've carved out this treatment from medical care and made people jump through hoops to get the psychological services they need.  Mental health care is chronically underfunded.  About 20 percent of our population experiences a mental health disorder in any given year, compared to a lifetime incidence of six percent for adults with cancer.  Health care reform implementation is a work in progress.  And there are hopeful signs, especially related to the goal of increasing the ranks of Americans with health insurance coverage.  Keep in mind that all enrollees in the new health insurance exchange plans benefit from federal requirements for mental health parity.  As we confront serious problems and the uncertainty of a health care system in flux, psychology continues to demonstrate that we're poised to face those challenges.

"Many psychologists know that we scored a major win regarding Medicare payment in 2014.  In essence, we reversed the downward payment trajectory for psychological services.  The 2014 Medicare fee schedule marked the first time since 2007 that the payment pool allocated for Medicare psychological services increased.  The eight percent jump meant that psychologists gained the second highest increase in payment allocation among all Medicare provider groups for 2014.  A combination of professional, marketplace, legislative and regulatory developments encourages more collaborative, multi-disciplinary practice models.  The demand for evidence-based practices and the use of quality measures related to process and outcome, including behavioral health measures, will grow.  And the increasing use of technology for electronic health record keeping and telepsychology service delivery will continue to evolve.

"Many of our members seem attuned to this evolution.  In a survey last fall, we asked what specific changes members were likely to make in their practice over the next three to five years.  Nearly half of respondents indicated they will increase their use of technology for professional purposes.  And one-third of all respondents said they 'will further diversify practice activities and skills.'  That was particularly true for our early-career respondents.  Again, there is no single optimal path forward for practitioners.  We need lean, mean advocacy machines to protect our seat at the table and move psychology forward as the health care marketplace evolves.  Psychology is a learned profession filled with smart, creative people.  We achieve good results when psychologists get energized and commit themselves to making positive things happen.  These experiences fill me with optimism as I look down the road toward our practice future.  Let's all continue putting to good use our collective energy and enthusiasm for the profession we love.  Our patients, our profession and our future are depending on leaders like you!"

A Special Vision For The U.S. Army:  This April, the Senate Appropriations Committee invited the three military Surgeons General to testify on their budget priorities for the coming fiscal year.  Interestingly, the DoD announcement regarding the hearing highlighted the critical nature of their mental health and psychological providers for the achievement of the services' underlying mission.  The U.S. Navy Surgeon General noted: "Psychological Health is an important component of overall force health protection.  We recognize that prolonged operational stress can have potentially debilitating consequences."  This institutional appreciation of the value of mental health care represents a fundamental change in the historical DoD posture and, as the nation steadily implements the ACA with its emphasis upon encouraging comprehensive and holistic systems of care, speaks well for the potential future of all behavioral and mental health disciplines.

The U.S. Army Surgeon General Patricia Horoho consistently reminds her colleagues that the Army health care system only sees its beneficiaries 100 hours a year.  And, that what the Soldiers and their Family Members do during the rest of the time has a significant impact upon their overall health status.  "Since 1775, America's medical personnel have stood shoulder to shoulder with our fighting troops, received them at home when they returned, and been ready when called upon to put their lives on the line.  While the wounds of war have been ours to mend and heal during a period of persistent conflict, our extraordinarily talented medical force also cared for the non-combat injuries and illnesses of our Soldiers and their Families.  It is an honor to serve as the commander of this outstanding healthcare organization, caring honorably and compassionately for our 3.9 million beneficiaries….

"Our medical teams have achieved the highest combat survival rates in history.  Multiple improvements in battlefield medical care… have contributed to the all-time high survivability rate of 91% during Operations Enduring Freedom and Operations Iraqi Freedom despite more severe and complex wounds.  Moreover, our unwavering support of wounded, ill, or injured Soldiers has allowed necessary healing and recovery, and enabled a 47% return to duty rate for the Force.  This translates to a cost-avoidance to recruiting and training of $2.2 billion.  We also have considered the long-term impacts of war, recognizing that not all combat injuries are visible.  The rapid coordination of traumatic brain injury screening and clinical practice guidelines allowed for our in-theater concussive care centers to provide a 98% Return-to-Duty rate.  In addition, by embedding capabilities such as behavioral health and physical therapy with deployed units, we provide early intervention and treatment, keeping the Soldier with the unit and decreasing the requirements to evacuate Soldiers from theater.  Through a combination of efforts, suicides in Active Duty Soldier ranks fell from 165 to 126 in 2013….  To maintain a ready and deployable Force, our Nation's Total Army requires a comprehensive System for Health designed to maximize the fighting strength, prevent disease and injury, build resiliency and promote healthy behaviors….  Our readiness platforms include… programs and initiatives designed to improve healthy behaviors, such as the Performance Triad of healthy sleep, activity, and nutrition, increase the health and resilience of our Soldiers to better prepare them for challenges unseen."

Lt. General Horoho pointed out that since September 11, 2001, more than 1.5 million Soldiers have deployed and many have deployed multiple times.  Our nation has never endured two simultaneous conflicts for this length of time.  The Army is charged with being prepared to face tomorrow's challenges.  As Katherine emphasized, there will be an increased reliance upon evidence-based guidelines and the Army is a good example.  "Wartime medical lessons learned have led to over 36 evidence-based, battlefield-relevant Clinical Practice Guidelines that have decreased combat morbidity and mortality….  While research in civilian medicine can take 16 years to integrate findings into clinical practice, through collaboration with organizations such as the Defense Centers of Excellence and the Defense and Veterans Brain Injury Center, we are able to more rapidly translate research findings into the latest guidelines, products, and technologies.  Improved data sharing between agency, academic and industry researchers accelerate progress and reduce redundant efforts without compromising privacy.  This rapid coordination is what led to a 98% RTD [return-to-duty] rate in theater for those Service Members treated at our Coordinated Care Centers in Afghanistan.  In August, 2013, the White House released the National Research Action Plan (NRAP) mandating interagency collaboration to better coordinate and accelerate TBI and psychological health (including suicide) research.  MRMC [Army Medical Research and Materiel Command] is working closely with other federal agencies such as National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS), National Institute on Disabilities and Rehabilitation Research (NIDRR) and the Department of Veterans Affairs (VA) to execute the President's National Research Action Plan.

"A key element of our Warrior Ethos is that we never leave a Soldier behind on the battlefield.  This commitment extends beyond the battlefield to the unwavering commitment of Army Medicine….  As an Army, as a military, and as a Nation, we have a global influence on medicine and health….  Women have been a part of America's military efforts since the Revolutionary War.  As their roles continue to evolve, Army Medicine recognizes the unique health concerns of women in the military.  Females make up 15.8% of the Force today – including Active Duty and RC [reserve components] – and the percentage of women continues to grow, up from about 4% from 20 years ago….  The Army is the first military service to focus specifically on women's health issues, particularly related to deployed environments.

"We are aggressively moving from a healthcare system – a system that primarily focused on injuries and illness – to a System for Health that now incorporates and balances health, prevention and wellness as a part of the primary focus for readiness.  Through early identification of injury and illness, surveillance, education, and standardization of best practices, we are building and sustaining health and resiliency.  This also moves our health activities outside of the brick and mortar facility, brings it outside of the doctor's office visit, and into the Lifespace where more than 99% of time is spent and decisions are made each day that truly impact health.  We are investing on research focused on prevention….  We recruit Soldiers, but re-enlist families….  We have an enduring obligation to the men and women in uniform, to their families who serve with them, and to the retired personnel and families who have served in the past….  The Army Medicine Team is proudly Serving to Heal, and Honored to Serve."

Telehealth/Telepsychology:  One of the most intriguing workshops at SLC was chaired by Deborah Baker -- "Developing a Roadmap for Telepsychological Practice."  Already 21 states have affirmatively addressed the issue of insurance reimbursement for telehealth services, with an additional 19 state legislatures currently considering legislation.  The underlying issue of licensure mobility/portability is complex.  For example, does the locus of the patient or provider or both provide the legal authority for licensure board jurisdiction?  Thoughtful views from the APA Insurance Trust (Jana Martin) and the Association of State and Provincial Psychology Licensing Boards (ASPPB) (Fred Millan) were shared – all clearly seeking ways to ensure that psychology will be responsive to the dramatically evolving health care environment.  Will, for example, a special licensure category be established for providing Telepsychology care?  It was refreshing to hear how proactive the joint APA-ASPPB-Insurance Trust taskforce, co-chaired by Fred and Linda Campbell, has been during its deliberations.  Steve DeMers pointed out that ABPPB has received a special grant from the Health Resources and Services Administration (HRSA) to address the underlying issues.  In her testimony, SG Patricia Horoho noted that the Army currently offers care via telehealth in multiple medical disciplines across 18 time zones and in over 30 countries and territories.  In fiscal year 2013 the Army provided over 34,000 real-time patient encounters and consultations between providers in garrison and over 2,300 additional encounters in operational environments.  While the Army provides care via telehealth in 28 specialties, Tele-Behavioral Health accounts for 85% of the total volume in garrison and 57% in operational environments, with over 2,000 portable clinical video-teleconferencing systems having been deployed to support Behavioral Health providers across the globe.  The April APA Monitor reported that 44 percent of veterans returning from Iraq and Afghanistan come home to rural ZIP codes.  The shortage of health care providers of all specialties in rural America has been well documented.  Telehealth/Telepsychology is increasingly becoming a viable response to this critical national need.

The Substance Abuse and Mental Health Services Administration (SAMHSA):  In submitting her Fiscal Year 2015 budget justification, the Administrator of SAMHSA echoed many of the themes raised by Katherine at SLC.  "Our nation stands at a critical crossroad.  Recent tragic events and the Administration's call to action on the mental health and well-being of our citizens, have spurred critical public health investments.  At the same time, our health care system is preparing for the influx of individuals now eligible and enrolling for coverage.  The Mental Health Parity and Addiction Equity Act along with the Affordable Care Act also requires coverage for mental or substance use disorders to provide the same level of benefits as is provided for general medical/surgical treatment.  Yet, millions of Americans do not receive the help they need.  It is time for our country to address these issues, and SAMHSA must lead the way….  Behavioral health problems contribute to early death, disability, lost productivity, and high health care costs.  But if we intervene early, we can save lives and lower these costs.  Despite the existence of effective treatments, it typically takes more than six years for people to receive treatment after the onset of a mental illness or substance use disorder.  The FY 2015 Budget Request includes funding to help teachers and other individuals who interact with youth recognize early signs of mental illness, and to improve referrals and access to mental health services for young people ages 16-25."  The budget emphasizes SAMHSA's responsibility to help the nation act on the knowledge that: Behavioral health is essential for health; Prevention works; Treatment is effective; and, People recover from mental and substance use disorders.

Two of SAMHSA's proposed Strategic Initiatives are * Health Care and Health Systems Integration and * Health Information Technology.  The first Strategic Initiative focuses on health care and integration across systems including systems of particular importance for persons with behavioral health needs such as community health promotion, health care delivery, specialty behavioral health care, and community living needs.  Integration efforts will seek to increase access to appropriate high quality prevention, treatment, recovery and wellness services and supports; reduce disparities between the availability of services for mental illness (including serious mental illness) and substance use disorders compared with the availability of services for other medical conditions; and support coordinated care and services across systems.  The Health Information Technology Strategic Initiative will ensure that the behavioral health system – including states, community providers, patients, peers, and prevention specialists – fully participate with the general healthcare delivery system in the adoption of Health IT, including interoperable electronic health records (EHRs), and the use of other electronic training, assessment, treatment, monitoring, and recovery support tools, to ensure high-quality integrated health care, appropriate specialty care, improved patient/consumer engagement, and effective prevention and wellness strategies.

A Critical Agenda --The Elderly: As Katherine pointed out at SLC, psychology is one of the "learned professions."  As such, we have a societal responsibility to provide proactive leadership.  Former Hawaii Psychological Association (HPA) President Terri Needels:  "Thanks for the letter about long-term care.  I am increasingly concerned about the way that Medicare does not address the needs of patients with Alzheimer's or dementia if they are not incontinent.  I am seeing more and more caretakers who are utterly exhausted and besides themselves trying to care for a family member with Alzheimer's at home.  Their family members are wandering around during the day, getting lost, falling, and are at risk for exploitation and harm while the caretakers are at work.  The caretakers are reporting that they can't get their loved ones into nursing homes unless they are incontinent.  Does this sound correct?  I am not an expert on the admission rules but am really concerned and appalled that the system (if this is really true) would only allow admission into a high level of care if someone has a physical, rather than psychological, difficulty.  Medicare must cover memory care or we are going to be facing a huge social crisis in the near future.  Who is taking responsibility for changing this?  I would certainly be willing to work on supporting proposals for the necessary changes in coverage.  I have clients who would be willing to testify and I imagine there are many other providers treating clients with similar situations.  Seems to me that I worked on this a long time ago."  If psychology will not act on behalf of our patients and their families – who should we reasonably expect will?

            Wisdom From The Past:  This Spring I had the opportunity of returning to Purdue University where I obtained my psychology degree.  A fellow graduate, Angela McBride, was present and we were able to reflect upon our personal journeys.  She is a "living legend" within the nursing profession, having retired as Dean of the Indiana University-Purdue University (IUPUI) School of Nursing, which is the largest in the nation (if not in the world).  Visiting with my major professor, Clifford Swensen, was a definite highlight: "Having been involved in politics, and for a long time in university politics, there are some things I have observed.  1.) Any change hurts somebody.  Who is being hurt and how can you ameliorate that?  2.) The status quo has a lot of vested interests.  Where are they and how can you alleviate their concerns?  3.) Any change brings about unanticipated, undesirable side effects.  How can you anticipate them as much as possible, but more important have in place means of coping with and ameliorating them.  4.) Opponents are not evil enemies.  They are people who have a vested interest somewhere and have a different point of view.  And, 5.) In any fight, the objective and overall purpose often gets lost, and the goal is simply to win the fight.  The longer I observe, the more I am convinced that a lot of conflict is based on the last item [Cliff Swensen]."  Is it any wonder that at the federal level, and we expect with the implementation of the ACA, change often takes significantly longer than initially expected?  All my bags are packed, I'm ready to go.  Aloha,

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