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