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
