Division 42 August, 2015 column

THERE ARE NO PROBLEMS WE CANNOT SOLVE TOGETHER

            This summer I was invited to the Florida Psychological Association (FPA) annual convention.  It was extremely exciting to see President Lori Butts focus her Town Hall luncheon on the unprecedented changes occurring within the Florida health care environment.  As speaker after speaker described what they have been doing over the past several years – for example, utilizing telehealth/telepsychology within the Veterans Administration (VA) or working within the judicial system – it became evident that FPA is well positioned to capitalize upon the monumental changes envisioned by President Obama’s Patient Protection and Affordable Care Act (ACA).  Steve Ragusea and his son Tony, both of whom were formally recognized at the subsequent awards ceremony, discussed the maturing Florida prescriptive authority (RxP) task force – which is being actively supported by Illinois/Florida resident Beth Rom-Rymer.  “Illinois has been a great success story for RxP.  Over 640 psychologists throughout the state came together to lobby for our bill.  We now have over 50 psychologists in training and two licensed prescribing psychologists on our licensing board.”  Forensic, neuropsychology, and active involvement in public education were several of the topics addressed throughout the convention.

The enthusiasm and energy demonstrated by the FPA membership were very refreshing and reminded me of Katherine Nordal’s charge at this year’s annual State Leadership Conference:  “To be innovators we need to shake off some old ways of thinking about traditional practice models.  We need to shake off the negative attitudes some of our colleagues have about what’s happening in health care.  That world is changing.  Health care is moving ahead – with or without psychology.  We need to think differently about our professional roles and the way we provide services.  Too many psychologists are stuck in the traditional 50-minute therapy box.  And that box is way too confining.”  My message was that psychology has become one of our nation’s bone fide healthcare professions.  We must adapt to the healthcare environment of tomorrow.

An underlying foundation of the ACA is fostering the importance of providing patient-centered, best-practice oriented, holistic care within an interdisciplinary collaborative model.  To be successful, psychology must learn what other disciplines are doing.  FPA’s leadership and membership have clearly expressed their faith in the profession’s ability to adjust to the new healthcare environment and FPA is nicely positioning itself to move into that quickly emerging future in order to seize the opportunities that will evolve.

            The Legal Profession:  Dina Shek is the Legal Director of Hawaii’s Medical-Legal Partnership (MLP) at the Kokua Kalihi Valley Federally Qualified Community Health Center (FQCHC) on Oahu, Hawaii -- which seeks to address the holistic needs of a number of traditionally underserved residents from throughout the Pacific Basin region, the Philippines, and Native Hawaiians.  “‘I can’t imagine practicing medicine without a lawyer on my team!’ stated Dr. Alicia Turlington, MLP Medical Director, in the national Community Health Forum.  She continued: ‘I think I’d be practicing substandard care.  Not asking questions about housing, benefits and food would feel wrong, but so would asking if I couldn’t do anything about it.  Our lawyers help me treat those things.’

            “In 2004, Dr. Barry Zuckerman and other MLP advocates published ‘Why Pediatricians Need Lawyers to Keep Children Healthy.’  As a law student at the time, this helped inspire me to start Hawaii’s first MLP for Children.  Now in our seventh year, our MLP addresses systemic advocacy issues while building on our work that provides free legal services on-site at community health clinic settings.  Co-location is not enough, however – the key is integration.  Integration means listening to patients’ stories, promoting their self-advocacy skills, and supporting community-led policy efforts.  True collaboration means building relationships with providers, discussing trends and policy changes, and sharing stories of success and possible solutions.  At times, building trust with patients means doing things that don’t necessarily appear ‘lawyerly’ – such as completing Head Start applications, making food bank referrals, and reviewing clients’ mail.  People then will trust you with a food stamp termination letter or the employment discrimination story burdening a single mother’s soul.

            “By collaborating at the place where low-income people get their healthcare, MLP attorneys provide ‘legal care’ to enhance health and family well-being.  HRSA now recognizes the value of legal care, and recently included ‘legal services’ as an ‘enabling service’ eligible for community health funding.  Pediatricians frequently uncover health-harming legal needs, but doctors are limited in their capacity to address non-medical problems.  The MLP model ensures that health centers can address all the most pressing needs of their patients.  Dr. Turlington’s words merit repeating: ‘I can’t imagine practicing medicine without a lawyer on my team.’”

            The MLP for Children is a project of the William S. Richardson School of Law and is the leading clinical project for the Health Law Policy Center.  Appropriately, the late-Chief Justice Richardson was Native Hawaiian and has authored some of the most far-reaching legal decisions affecting Native Hawaiians and their cultural relationship with the land.  Currently MLPs exist in 235 health institutions in 38 states, with a national network.  The American Bar Association and American Medical Association have passed national resolutions in support of this model.  Dina has expanded her efforts to another Hawaii FQCHC, one serving an extraordinary number of Native Hawaiians in rural Oahu, as well as developed ongoing discussions with the Hawai’i Primary Care Association.  Twice-weekly free legal advocacy clinics are hosted, as well as numerous professional training and educational workshops for healthcare providers, including students in nursing, social work, psychology, and medicine.

            Clinical Pharmacy:  Following up on a National Governors Association (NGA) 2015 policy paper, “The Expanding Role of Pharmacists in a Transformed Health Care System,” the National Alliance of State Pharmacy Associations (NASPA) convened a workshop to develop recommendations for what elements of collaborative practice authority should appropriately be defined under state law and/or regulations, and what should best be left to be determined between pharmacists and other practitioners when developing their specific collaborative practice arrangements (CPA).  Noting that state laws and regulations authorizing CPAs are highly variable, the underlying key issues were: What is in the best interest of the patient and, Is the recommendation aligned with pharmacists’ considerable education and training?  The participants felt “Any practitioner with prescriptive authority may collaborate with pharmacists using a CPA.”  Further, “All prescription drugs, including controlled substances, may be included within pharmacists’ collaborative practice authority.”  The workgroup took the approach that rapid innovation in education, training, technology, and evidence-based guidelines necessitate a collaborative practice framework that is flexible and facilitates innovation in care delivery.

Art Kellerman, Dean of America’s Medical School at USUHS, recently Tweeted: “U.S. healthcare system wastes more $$ each year on inefficient/inappropriate care than we annually spend on defense.”  There are no problems we cannot solve together and very few that we can solve by ourselves.  Aloha,

Pat DeLeon, former APA President – Division 42 – August, 2015

 

THERE ARE NO PROBLEMS WE CANNOT SOLVE TOGETHER

 This summer I was invited to the Florida Psychological Association (FPA) annual convention.  It was extremely exciting to see President Lori Butts focus her Town Hall luncheon on the unprecedented changes occurring within the Florida health care environment.  As speaker after speaker described what they have been doing over the past several years – for example, utilizing telehealth/telepsychology within the Veterans Administration (VA) or working within the judicial system – it became evident that FPA is well positioned to capitalize upon the monumental changes envisioned by President Obama's Patient Protection and Affordable Care Act (ACA).  Steve Ragusea and his son Tony, both of whom were formally recognized at the subsequent awards ceremony, discussed the maturing Florida prescriptive authority (RxP) task force – which is being actively supported by Illinois/Florida resident Beth Rom-Rymer.  "Illinois has been a great success story for RxP.  Over 640 psychologists throughout the state came together to lobby for our bill.  We now have over 50 psychologists in training and two licensed prescribing psychologists on our licensing board."  Forensic, neuropsychology, and active involvement in public education were several of the topics addressed throughout the convention.

The enthusiasm and energy demonstrated by the FPA membership were very refreshing and reminded me of Katherine Nordal's charge at this year's annual State Leadership Conference:  "To be innovators we need to shake off some old ways of thinking about traditional practice models.  We need to shake off the negative attitudes some of our colleagues have about what's happening in health care.  That world is changing.  Health care is moving ahead – with or without psychology.  We need to think differently about our professional roles and the way we provide services.  Too many psychologists are stuck in the traditional 50-minute therapy box.  And that box is way too confining."  My message was that psychology has become one of our nation's bone fide healthcare professions.  We must adapt to the healthcare environment of tomorrow.

An underlying foundation of the ACA is fostering the importance of providing patient-centered, best-practice oriented, holistic care within an interdisciplinary collaborative model.  To be successful, psychology must learn what other disciplines are doing.  FPA's leadership and membership have clearly expressed their faith in the profession's ability to adjust to the new healthcare environment and FPA is nicely positioning itself to move into that quickly emerging future in order to seize the opportunities that will evolve.

            The Legal Profession:  Dina Shek is the Legal Director of Hawaii's Medical-Legal Partnership (MLP) at the Kokua Kalihi Valley Federally Qualified Community Health Center (FQCHC) on Oahu, Hawaii -- which seeks to address the holistic needs of a number of traditionally underserved residents from throughout the Pacific Basin region, the Philippines, and Native Hawaiians.  "'I can't imagine practicing medicine without a lawyer on my team!' stated Dr. Alicia Turlington, MLP Medical Director, in the national Community Health Forum.  She continued: 'I think I'd be practicing substandard care.  Not asking questions about housing, benefits and food would feel wrong, but so would asking if I couldn't do anything about it.  Our lawyers help me treat those things.'

            "In 2004, Dr. Barry Zuckerman and other MLP advocates published 'Why Pediatricians Need Lawyers to Keep Children Healthy.'  As a law student at the time, this helped inspire me to start Hawaii's first MLP for Children.  Now in our seventh year, our MLP addresses systemic advocacy issues while building on our work that provides free legal services on-site at community health clinic settings.  Co-location is not enough, however – the key is integration.  Integration means listening to patients' stories, promoting their self-advocacy skills, and supporting community-led policy efforts.  True collaboration means building relationships with providers, discussing trends and policy changes, and sharing stories of success and possible solutions.  At times, building trust with patients means doing things that don't necessarily appear 'lawyerly' – such as completing Head Start applications, making food bank referrals, and reviewing clients' mail.  People then will trust you with a food stamp termination letter or the employment discrimination story burdening a single mother's soul.

            "By collaborating at the place where low-income people get their healthcare, MLP attorneys provide 'legal care' to enhance health and family well-being.  HRSA now recognizes the value of legal care, and recently included 'legal services' as an 'enabling service' eligible for community health funding.  Pediatricians frequently uncover health-harming legal needs, but doctors are limited in their capacity to address non-medical problems.  The MLP model ensures that health centers can address all the most pressing needs of their patients.  Dr. Turlington's words merit repeating: 'I can't imagine practicing medicine without a lawyer on my team.'"

            The MLP for Children is a project of the William S. Richardson School of Law and is the leading clinical project for the Health Law Policy Center.  Appropriately, the late-Chief Justice Richardson was Native Hawaiian and has authored some of the most far-reaching legal decisions affecting Native Hawaiians and their cultural relationship with the land.  Currently MLPs exist in 235 health institutions in 38 states, with a national network.  The American Bar Association and American Medical Association have passed national resolutions in support of this model.  Dina has expanded her efforts to another Hawaii FQCHC, one serving an extraordinary number of Native Hawaiians in rural Oahu, as well as developed ongoing discussions with the Hawai'i Primary Care Association.  Twice-weekly free legal advocacy clinics are hosted, as well as numerous professional training and educational workshops for healthcare providers, including students in nursing, social work, psychology, and medicine.

            Clinical Pharmacy:  Following up on a National Governors Association (NGA) 2015 policy paper, "The Expanding Role of Pharmacists in a Transformed Health Care System," the National Alliance of State Pharmacy Associations (NASPA) convened a workshop to develop recommendations for what elements of collaborative practice authority should appropriately be defined under state law and/or regulations, and what should best be left to be determined between pharmacists and other practitioners when developing their specific collaborative practice arrangements (CPA).  Noting that state laws and regulations authorizing CPAs are highly variable, the underlying key issues were: What is in the best interest of the patient and, Is the recommendation aligned with pharmacists' considerable education and training?  The participants felt "Any practitioner with prescriptive authority may collaborate with pharmacists using a CPA."  Further, "All prescription drugs, including controlled substances, may be included within pharmacists' collaborative practice authority."  The workgroup took the approach that rapid innovation in education, training, technology, and evidence-based guidelines necessitate a collaborative practice framework that is flexible and facilitates innovation in care delivery.

Art Kellerman, Dean of America's Medical School at USUHS, recently Tweeted: "U.S. healthcare system wastes more $$ each year on inefficient/inappropriate care than we annually spend on defense."  There are no problems we cannot solve together and very few that we can solve by ourselves.  Aloha,

Pat DeLeon, former APA President – Division 42 – August, 2015

 

“EDUCATION IS THE MOST POWERFUL WEAPON…”

  Interprofessional Collaborative Practice:  One of the fundamental tenants of President Obama's Patient Protection and Affordable Care Act (ACA) is that quality care requires respectful collaboration among the various health care disciplines.  Our colleagues in pharmacy have been on the cutting-edge of this evolution with the Departments of Defense (DoD) and Veterans Affairs (VA), under the leadership of Toni Zeiss, affirmatively demonstrating its contributions.  The National Alliance of State Pharmacy Associations (NASPA) convened a workgroup to build upon relevant recommendations from the National Governors Association (NGA), emphasizing the importance of alignment with pharmacists' considerable education and training.  They took the approach that rapid innovation in education, training, technology, and evidence-based guidelines necessitate a collaborative practice framework that is flexible and facilitates innovation in health care delivery, especially at the practice level.

            Give An Hour – An Inspirational Vision:  Earlier this year I had the opportunity to attend the launch of Give An Hour's new initiative, The Campaign to Change Direction, which focuses upon how our nation views and talks about mental health/behavioral health issues.  First Lady Michelle Obama was the keynote speaker with active participation from the highest level of leadership within DoD and VA, as well as numerous Wounded Warriors.  A national public awareness campaign has been launched featuring Mrs. Obama.  On July 21, 2015, while addressing the Veterans of Foreign Wars (VFW), the President himself urged all American to learn the five signs that may mean someone you know is in emotional pain and might need help: Personality Change, Agitation, Withdrawal, Poor Self-Care, and Hopelessness.  Currently 18% of Americans have a mental health condition and 90% of those who die by suicide have a mental disorder.  If one remains until the very end of the film Love & Mercy, one will see that as a nation we are finally moving towards viewing emotional issues in the same manner as physical ailments as the First Lady urged.  Barbara Van Dahlen, Ph.D., President and CEO of Give an Hour, credits her inspirational vision to her young daughter's concern 10 years ago about how the nation has historically treated (or forgotten its responsibility for) homeless veterans.  Immediate family members do have a major impact upon our life journeys.

            An Interesting Aspect of the Hoffman Report:  Having been interviewed by David Hoffman and one of his colleagues, I made a special point of carefully reading, and admittedly re-reading, the entire 542 page document.  Since my 2000 APA Presidential term, I have been away from the governance feeling that it is time for our next generation.  I can understand how the process might have unfolded.  I learned many of the specifics enumerated in the report for the first time.  My sincerest congratulations to Past-President Nadine Kaslow for being willing to pursue this independent review which, in my judgment, was an act of true courage.  Personally, I could never condone torture in any fashion, a conviction I am confident that the vast majority of our colleagues strongly support.  One vividly remembers the messages passed on by one's grandparents – "Those were your relatives whom you see hanging for public display."  My wife and I were on the National Mall participating in the unfortunately small anti-war demonstration the night before the President acted.  These are very important issues for all Americans.  Although lengthy, I would strongly urge everyone to read the entire Hoffman report – there is much to be learned which must never be forgotten.

            The report describes psychology's long history of involvement with the Department of Defense (DoD).  During World War I, on the day that Congress declared war on the German Empire, APA President Robert Yerkes convened a meeting of a group of psychologists to discuss how psychology could assist in the war effort.  A special meeting of APA's Council established 12 committees to assist the government in addressing psychological problems, including committees on the psychological examination of recruits; psychological problems of incapacity, including those of shell shock; and, recreation in the army and navy.  One of the largest endeavors undertaken with the assistance of psychologists in support of the war effort involved the administration of tests to assess potential recruits.  The Army administered a battery of tests similar to the Binet-Simon intelligence scale to more than 1.7 million recruits to attempt to differentiate between potential recruits who were unsuitable for service, those who would be suitable privates, and those who could serve as officers.  During World War II, the effort to assess potential recruits expanded and by 1945 more than 13 million people had been screened.  A number of prominent psychologists also developed an intensive program designed to assess the suitability of a candidate seeking to serve in the Office of Strategic Services (OSS), which had been created by President Roosevelt as the agency responsible for intelligence collection, espionage, subversion, and psychological warfare.  Psychologists' participation in the war effort led directly to the creation of the modern APA.  Throughout the Cold War, psychology had a close relationship with the military.

The G.I. Bill strengthened the profession of psychology both by expanding enrollments in institutions of higher education and by allowing some returning soldiers to train to become psychologists and join APA.  The military also drove a major expansion in infrastructure supporting clinical psychology.  Over time, the military and the VA created a demand for psychologists to care for soldiers and veterans with mental and emotional problems.  Psychology had an important influence on the development of military doctrine regarding interrogations.  Beginning in at least 1956, the military forbade the use of tactics it deemed coercive in interrogations.

            Quoting Directly From The Report:  "The very substantial benefits APA obtained from DoD help explain APA's motive to please DoD, and show that APA likely had an organizational conflict of interest, which it needed to take steps to guard against.  DoD is one of the largest employers of psychologists and provides many millions of dollars in grants or contracts for psychologists around the country.  The history of DoD providing critical assistance to the advancement and growth of psychology as a profession is well documented, and includes DoD's creation of a prescription-privileges 'demonstration project' in which psychologists were certified to prescribe psychiatric drugs within DoD after going through a two-year training course…."

            "The APA Board also asked three sub-questions….  The third sub-question was 'whether any APA action related to torture was improperly influenced by government-related financial considerations,' including grants, contracts, or prescription-privileges policy for military psychologists.  As described above, the substantial financial benefits in the form of employment, grants, and contracts that DoD provided to psychologists around the country had a strong influence on APA's actions relating to the PENS Task Force (and therefore 'relating to torture'), since preserving and improving APA's relationship with DoD (including the benefits to psychology that flowed from it) formed an important part of the motive behind APA's actions.  We did not find that APA was motivated by a specific contract or grant, or that APA itself actually received any substantial grants, contracts, or other payments from DoD during this period.  The financial motivations for APA related to the substantial benefits that flowed from DoD to the profession of psychology."

            "As for the prescription-privilege program, we found that APA believed that this program has provided a very substantial benefit to psychology and APA, because obtaining prescription privileges in order to better compete with psychiatry was one of APA's leading priorities for many years.  DoD's 'demonstration project,' created in 1991 and in place through 1997, which was initiated principally by Pat DeLeon (APA President in 2000) and his boss, Senator Daniel Inouye (D-HI) and his Chief of Staff, psychologist Pat DeLeon (APA President in 2000), allowed psychologists to have prescribing privileges in DoD and other federal locations, and created a two-year certification program that could be recognized by a state that authorized properly-certified psychologists to have prescription privileges like psychiatrists.  Approximately ten psychologists were trained and certified through the DoD demonstration project, including Debra Dunivin.  The demonstration project thus served a crucial unlocking function for psychology and APA, since it established the legitimacy of a prescription-training program outside of traditional medical school, thus providing a strong answer to the traditional critique from psychiatrists that the only way to be trained in prescribing psychiatric medications was to graduate from a traditional four-year medical school."

            "We do not believe that by 2005, APA officials were realistically seeking or expecting anything further from DoD on the topic of prescription privileges.  Nor do we believe that APA officials actually worried that a failure to curry favor with DoD would cause DoD to reverse course on prescription privileges by, for instance, disallowing previously-certified psychologists from continuing to prescribe medication when they treated DoD personnel.  Thus, we do not believe that the prescription-privileges issue was a significant 'financial consideration' for APA in taking the actions it took in 2005."

            "Nevertheless, it is clear to us that the way in which DoD had supported psychology in crucial ways in the prior years, including through the prescription-privileges program, played a fundamental role in APA feeling motivated to curry favor with DoD.  This was less of a function of APA seeking something concrete with regard to a specific contract or program (like prescription privileges), but more of a function of APA knowing very concretely how willing and able DoD was to provide large-scale support to psychology as a profession – now and perhaps in the future in unknown ways.  This was support that APA did not want to risk jeopardizing by taking a position that was at odds with what APA perceived as DoD's clearly stated preferences within the PENS process."

            On pages 83-85 of the report, the authors provide a comprehensive overview of the DoD "demonstration project" (PDP).  "In 1999, the U.S. General Accounting Office ('GAO') found that PDP graduates were well-integrated into the Military Health Service, that they held positions of responsibility and treated a broad spectrum of patients, carrying patient caseloads that were comparable to those of psychiatrists.  It found that most of the graduates had been granted independent status, which allowed them to operate with only the same level of review as psychiatrists at their locations.  The GAO further found that the graduates were evaluated as good to excellent, both by their clinical supervisors, and an outside panel of psychiatrists and psychologists, and found no evidence of quality problems in their credential files.  However, the GAO also found that the PDP program was more costly than the Department of Defense's traditional mix of psychiatrists and non-prescribing psychologists, and stated that the impact of the program on combat readiness was minimal at best."  We would strongly urge all psychologists to carefully review the entire Hoffman report.  You may agree or disagree with its conclusions; clearly, reasonable colleagues do.  Nevertheless, it is a fascinating document.  "Which You Can Use To Change The World."  Aloha,

Pat DeLeon, former APA President – Division 29 – August, 2015

 

Division 29 August, 2015 column

“EDUCATION IS THE MOST POWERFUL WEAPON…”

            Interprofessional Collaborative Practice:  One of the fundamental tenants of President Obama’s Patient Protection and Affordable Care Act (ACA) is that quality care requires respectful collaboration among the various health care disciplines.  Our colleagues in pharmacy have been on the cutting-edge of this evolution with the Departments of Defense (DoD) and Veterans Affairs (VA), under the leadership of Toni Zeiss, affirmatively demonstrating its contributions.  The National Alliance of State Pharmacy Associations (NASPA) convened a workgroup to build upon relevant recommendations from the National Governors Association (NGA), emphasizing the importance of alignment with pharmacists’ considerable education and training.  They took the approach that rapid innovation in education, training, technology, and evidence-based guidelines necessitate a collaborative practice framework that is flexible and facilitates innovation in health care delivery, especially at the practice level.

            Give An Hour – An Inspirational Vision:  Earlier this year I had the opportunity to attend the launch of Give An Hour’s new initiative, The Campaign to Change Direction, which focuses upon how our nation views and talks about mental health/behavioral health issues.  First Lady Michelle Obama was the keynote speaker with active participation from the highest level of leadership within DoD and VA, as well as numerous Wounded Warriors.  A national public awareness campaign has been launched featuring Mrs. Obama.  On July 21, 2015, while addressing the Veterans of Foreign Wars (VFW), the President himself urged all American to learn the five signs that may mean someone you know is in emotional pain and might need help: Personality Change, Agitation, Withdrawal, Poor Self-Care, and Hopelessness.  Currently 18% of Americans have a mental health condition and 90% of those who die by suicide have a mental disorder.  If one remains until the very end of the film Love & Mercy, one will see that as a nation we are finally moving towards viewing emotional issues in the same manner as physical ailments as the First Lady urged.  Barbara Van Dahlen, Ph.D., President and CEO of Give an Hour, credits her inspirational vision to her young daughter’s concern 10 years ago about how the nation has historically treated (or forgotten its responsibility for) homeless veterans.  Immediate family members do have a major impact upon our life journeys.

            An Interesting Aspect of the Hoffman Report:  Having been interviewed by David Hoffman and one of his colleagues, I made a special point of carefully reading, and admittedly re-reading, the entire 542 page document.  Since my 2000 APA Presidential term, I have been away from the governance feeling that it is time for our next generation.  I can understand how the process might have unfolded.  I learned many of the specifics enumerated in the report for the first time.  My sincerest congratulations to Past-President Nadine Kaslow for being willing to pursue this independent review which, in my judgment, was an act of true courage.  Personally, I could never condone torture in any fashion, a conviction I am confident that the vast majority of our colleagues strongly support.  One vividly remembers the messages passed on by one’s grandparents – “Those were your relatives whom you see hanging for public display.”  My wife and I were on the National Mall participating in the unfortunately small anti-war demonstration the night before the President acted.  These are very important issues for all Americans.  Although lengthy, I would strongly urge everyone to read the entire Hoffman report – there is much to be learned which must never be forgotten.

            The report describes psychology’s long history of involvement with the Department of Defense (DoD).  During World War I, on the day that Congress declared war on the German Empire, APA President Robert Yerkes convened a meeting of a group of psychologists to discuss how psychology could assist in the war effort.  A special meeting of APA’s Council established 12 committees to assist the government in addressing psychological problems, including committees on the psychological examination of recruits; psychological problems of incapacity, including those of shell shock; and, recreation in the army and navy.  One of the largest endeavors undertaken with the assistance of psychologists in support of the war effort involved the administration of tests to assess potential recruits.  The Army administered a battery of tests similar to the Binet-Simon intelligence scale to more than 1.7 million recruits to attempt to differentiate between potential recruits who were unsuitable for service, those who would be suitable privates, and those who could serve as officers.  During World War II, the effort to assess potential recruits expanded and by 1945 more than 13 million people had been screened.  A number of prominent psychologists also developed an intensive program designed to assess the suitability of a candidate seeking to serve in the Office of Strategic Services (OSS), which had been created by President Roosevelt as the agency responsible for intelligence collection, espionage, subversion, and psychological warfare.  Psychologists’ participation in the war effort led directly to the creation of the modern APA.  Throughout the Cold War, psychology had a close relationship with the military.

The G.I. Bill strengthened the profession of psychology both by expanding enrollments in institutions of higher education and by allowing some returning soldiers to train to become psychologists and join APA.  The military also drove a major expansion in infrastructure supporting clinical psychology.  Over time, the military and the VA created a demand for psychologists to care for soldiers and veterans with mental and emotional problems.  Psychology had an important influence on the development of military doctrine regarding interrogations.  Beginning in at least 1956, the military forbade the use of tactics it deemed coercive in interrogations.

            Quoting Directly From The Report:  “The very substantial benefits APA obtained from DoD help explain APA’s motive to please DoD, and show that APA likely had an organizational conflict of interest, which it needed to take steps to guard against.  DoD is one of the largest employers of psychologists and provides many millions of dollars in grants or contracts for psychologists around the country.  The history of DoD providing critical assistance to the advancement and growth of psychology as a profession is well documented, and includes DoD’s creation of a prescription-privileges ‘demonstration project’ in which psychologists were certified to prescribe psychiatric drugs within DoD after going through a two-year training course….”

            “The APA Board also asked three sub-questions….  The third sub-question was ‘whether any APA action related to torture was improperly influenced by government-related financial considerations,’ including grants, contracts, or prescription-privileges policy for military psychologists.  As described above, the substantial financial benefits in the form of employment, grants, and contracts that DoD provided to psychologists around the country had a strong influence on APA’s actions relating to the PENS Task Force (and therefore ‘relating to torture’), since preserving and improving APA’s relationship with DoD (including the benefits to psychology that flowed from it) formed an important part of the motive behind APA’s actions.  We did not find that APA was motivated by a specific contract or grant, or that APA itself actually received any substantial grants, contracts, or other payments from DoD during this period.  The financial motivations for APA related to the substantial benefits that flowed from DoD to the profession of psychology.”

            “As for the prescription-privilege program, we found that APA believed that this program has provided a very substantial benefit to psychology and APA, because obtaining prescription privileges in order to better compete with psychiatry was one of APA’s leading priorities for many years.  DoD’s ‘demonstration project,’ created in 1991 and in place through 1997, which was initiated principally by Pat DeLeon (APA President in 2000) and his boss, Senator Daniel Inouye (D-HI) and his Chief of Staff, psychologist Pat DeLeon (APA President in 2000), allowed psychologists to have prescribing privileges in DoD and other federal locations, and created a two-year certification program that could be recognized by a state that authorized properly-certified psychologists to have prescription privileges like psychiatrists.  Approximately ten psychologists were trained and certified through the DoD demonstration project, including Debra Dunivin.  The demonstration project thus served a crucial unlocking function for psychology and APA, since it established the legitimacy of a prescription-training program outside of traditional medical school, thus providing a strong answer to the traditional critique from psychiatrists that the only way to be trained in prescribing psychiatric medications was to graduate from a traditional four-year medical school.”

            “We do not believe that by 2005, APA officials were realistically seeking or expecting anything further from DoD on the topic of prescription privileges.  Nor do we believe that APA officials actually worried that a failure to curry favor with DoD would cause DoD to reverse course on prescription privileges by, for instance, disallowing previously-certified psychologists from continuing to prescribe medication when they treated DoD personnel.  Thus, we do not believe that the prescription-privileges issue was a significant ‘financial consideration’ for APA in taking the actions it took in 2005.”

            “Nevertheless, it is clear to us that the way in which DoD had supported psychology in crucial ways in the prior years, including through the prescription-privileges program, played a fundamental role in APA feeling motivated to curry favor with DoD.  This was less of a function of APA seeking something concrete with regard to a specific contract or program (like prescription privileges), but more of a function of APA knowing very concretely how willing and able DoD was to provide large-scale support to psychology as a profession – now and perhaps in the future in unknown ways.  This was support that APA did not want to risk jeopardizing by taking a position that was at odds with what APA perceived as DoD’s clearly stated preferences within the PENS process.”

            On pages 83-85 of the report, the authors provide a comprehensive overview of the DoD “demonstration project” (PDP).  “In 1999, the U.S. General Accounting Office (‘GAO’) found that PDP graduates were well-integrated into the Military Health Service, that they held positions of responsibility and treated a broad spectrum of patients, carrying patient caseloads that were comparable to those of psychiatrists.  It found that most of the graduates had been granted independent status, which allowed them to operate with only the same level of review as psychiatrists at their locations.  The GAO further found that the graduates were evaluated as good to excellent, both by their clinical supervisors, and an outside panel of psychiatrists and psychologists, and found no evidence of quality problems in their credential files.  However, the GAO also found that the PDP program was more costly than the Department of Defense’s traditional mix of psychiatrists and non-prescribing psychologists, and stated that the impact of the program on combat readiness was minimal at best.”  We would strongly urge all psychologists to carefully review the entire Hoffman report.  You may agree or disagree with its conclusions; clearly, reasonable colleagues do.  Nevertheless, it is a fascinating document.  “Which You Can Use To Change The World.”  Aloha,

Pat DeLeon, former APA President – Division 29 – August, 2015

 

ALOHA -- Division 55 column

THE NEXT CHALLENGE ALONG THE WAY

            Spending this segment of my career at the Uniformed Services University of the Health Sciences (USUHS) (DoD) as a distinguished professor of psychology and nursing, gives one an interesting perspective on Wounded Warriors and their families.  Not surprisingly, this has led to reflecting upon those living APA Presidents who are themselves veterans.  Joe Matarazzo was one of the original members of the USUHS Board of Regents and was absolutely critical to the establishment of the department of psychology.  Bill McKeachie was a Navy destroyer radar officer.  Ron Fox, former Division President and grandfather of the RxP movement, served in the National Guard.  Current APA President Barry Anton and Don Bersoff have addressed our USUHS health policy seminar.  Jack Wiggins, Nick Cummings, and Stan Graham, who were among the initial proponents of prescriptive authority (RxP) decades ago, and have also honorably served.  In our judgment, the next major focus for those seriously interested in pursuing the RxP agenda should be the Department of Veterans Affairs (VA).

            Quality Care:  The DoD has admirably demonstrated the cost-effectiveness and clinical appropriateness of psychology obtaining prescriptive authority.  Elaine Foster, one of the original DoD prescribing psychologists: “After graduating from the DoD Psychopharmacology Demonstration Project (PDP) I served as a prescribing psychologist in the Air Force for over 20 years.  I continued to serve our active duty military after retiring, again as a prescribing psychologist under contract with the Air Force.  During that time, I prescribed for our veterans when we had space available at our military clinic….  If I walked across the hospital parking lot to our annexed VA clinic, I could no longer prescribe to that same patient I’d been prescribing to while he or she was active duty.  The current VA restrictions are illogical….  Because New Mexico recognizes prescribing psychologists, I can now prescribe to our veterans, but only in New Mexico, and only through a third party contractor….  This just does not make sense.”  We would rhetorically ask: Where are the collective voices of those psychologists who are themselves veterans?  They are the constituency who would most directly benefit from RxP.  And, they are the interest group that APA’s Heather O’Beirne Kelly is seeking to galvanize.

            Congressional Interest:  The Senate Appropriations Committee report accompanying the Fiscal Year 2016 Appropriations bill for the Department of Veterans Affairs (Sen. Rpt. #114-57) notes that the VA’s mission is to serve America’s veterans and their families as their principal advocate in ensuring that they receive the care, support, and recognition they have earned in service to the Nation.  As of September 30, 2014, there were an estimated 22 million living veterans and an estimated 25.7 million dependents of living veterans; as well as 566,000 survivors of deceased veterans who are receiving VA survivor benefits.  Thus, there are approximately 48.3 million people, or 15% of the total estimated resident population, who are recipients or potential recipients of VA benefits.  The Veterans Health Administration (VHA) is the nation’s largest integrated healthcare system, consisting of 167 medical centers, 1,018 community-based outpatient clinics, 300 Vet centers, and 135 community-based living centers.

            Under the Obama Administration a concerted effort has been made to expand the clinical responsibility of VA nursing personnel to the fullest extent of their training and education -- pursuant to Institute of Medicine (IOM) recommendations -- notwithstanding local state statute limitations.  Although this would provide uniformity across the VA system, organized medicine has been less than supportive.  The Senate Committee report: “Nursing Handbook. – The Committee understands the VHA Nursing Handbook is currently under review.  The Committee encourages VHA to seek input from internal VA program offices and external professional stakeholders prior to possible regulatory action and submission to the Under Secretary for Health for final approval.  The Committee believes all possible outreach efforts should be used to communicate the proposed changes, to gather public comment, and to collaborate with Congress, stakeholders, VA nursing staff, and external organizations.  The Committee requests VHA ensure changes to its handbooks do not conflict with other handbooks already in place within VHA.”  Admittedly, the Committee language is not as expressly supportive of nursing as we would prefer; however, it does reflect progress.  Again, we would ask: Could not concerned psychologists, especially those who are themselves veterans, develop similar congressional interest for psychology’s potential expansion of practice by obtaining prescriptive authority – especially, given the impressive success within the sister federal agencies of DoD and the Indian Health Service?

            The Senate report also included thoughtful language highlighting the unique needs of female veterans.  “Women Veterans. – The Committee believes VA must make better progress in addressing the needs of women veterans.  Towards this end, the advance appropriation for fiscal year 2016 provided last year and the fiscal year 2017 advance appropriation included in the act fully fund gender-specific healthcare.  Access to and utilization of VA benefits and services by women veterans remain low, with women often encountering cultural roadblocks in a system that was largely designed to meet the needs of male veterans.  The Committee anticipates the results of an ongoing system-wide review intended to determine what type and number of healthcare workers the system should have to address current and future demand of gender-specific care.  This review will help VA properly staff hospitals and clinics with healthcare professionals providing gender-specific care and lead to improved access for women veterans.  Last year… VA was also encouraged, in consultation with the Department of Defense, to establish a women’s working group within the VA/DoD Joint Executive Committee aimed at creating or strengthening transition programs which address female concerns and cultural roadblocks so more women veterans access VA benefits and services….  Furthermore, recent studies have shown servicewomen who experience sexual assault while serving in the military are far more likely to develop PSTD as compared to other female veterans.  VA must be prepared to provide these veterans with mental health services designed to treat the effects of military sexual trauma.”  As Elaine and her DoD colleagues have demonstrated over a prolonged period of time, this is a population for which psychology has much to offer in assuring quality of care.

            State Leadership Conference (SLC):  At this year’s inspirational APAPO state leadership conference, Katherine Nordal urged those attending to: “Shake off the negative attitudes some of our colleagues have about what’s happening in health care.  This world is changing.  And health care is moving ahead – with or without psychology.”  The Senate report makes clear that the VA will change: “Congress authorized the employment of licensed professional mental health counselors [LPMHC] and marriage and family therapists [MFT] by VA.  However, the two professions comprise less than 1 percent of the VA behavioral health workforce despite representing 40 percent of the overall independent practice behavioral health workforce in the United States….  The Department is directed to report to the Committees on Appropriations of both Houses of Congress no later than 180 days after enactment of this act on the status of hiring additional LPMHC and MFT professionals and detailing how many are currently enrolled and planned to be enrolled in VA’s mental health professional trainee program.”  Further, “The Committee encourages the Department to consider the expanded use of physician assistants [PAs] specializing in psychiatric care to address the mental health provider gap.  PAs provide high quality, cost-effective medical care and are held to the same standard of healthcare delivery as their physician colleagues.  Furthermore, the Department is directed to review and report to Congress a plan to improve recruitment and retention initiatives for PAs.”  Times are definitely changing.

            Clinical Pharmacy:  The American Pharmacists Association (APhA) recently highlighted for its membership the extent to which our nation’s healthcare environment is undergoing unprecedented change.  “Pharmacists are frequently referred to as the most underutilized health care professional.  In part, this can be attributed to the sometimes antiquated pharmacy practice acts currently in use.  As pharmacist education and training has evolved, the pharmacist scope of practice has not kept up with the pace of advancement.  In order to align pharmacist education and training with scope of practice, states are incrementally making improvements to their pharmacy practice acts.  Through efforts led by state pharmacy associations, there have been 32 bills introduced this year in 11 states addressing issues ranging from immunization authority to collaborative practice agreements and more.

            “As Pharmacy Today goes to print, there are six states with active legislation addressing pharmacist collaborative practice authority.  Several are seeking authority for nurse practitioners and in some cases physician assistants to be authorized to enter into a collaborative agreement with pharmacists.  As primary care is evolving to a more team based approach and nurse practitioner and physician assistants playing a larger role in chronic disease management, it is important that they be able to access pharmacists’ medication expertise.  Under current law, there are 20 states where nurse practitioners and pharmacists can work together under a formal collaborative agreement.”  The future will require similar psychology-pharmacy collaborative practice agreements to be enacted by individual state legislatures, as well as developing a personal comfort level with interdisciplinary practice.  Have any of our State Psychological Associations initiated joint meetings with pharmacy?  Aloha,

Pat DeLeon, former APA President – Division 55 – June, 2015

 

never can predict who says

Thanks but….

 

Aloha

 

They are fun to do

 

Division 31 June column

SITTIN’ IN THE MORNING SUN

            From a policy perspective, it is informative to reflect upon how long change may take even if it makes intuitive sense and is in the best interest of those who might initially oppose.  At this year’s exciting State Leadership Conference Katherine Nordal urged those present to: “Shake off the negative attitudes some of our colleagues have about what’s happening in health care.  The world is changing and health care is moving ahead – with or without psychology.  We need to think creatively… how we practice… where we practice… and what we practice.”

Back in the early 1990’s, Bruce Bennett shared the Physician Specialty Report of a major pharmaceutical company indicating that of the 135+ million psychotherapeutic prescriptions written during 1991, only 17.3% were by psychiatrists; less than internists and family practitioners.  Several years later, Morgan Sammons and I were collaborating on an article and we independently proffered the same percentages.  In August, 1995 the APA Council of Representatives endorsed prescription privileges for appropriately trained psychologists and called for the development of model legislation and a model training curriculum.  To date, New Mexico, Louisiana, and this year Illinois have passed enacting statutes; Guam and Indiana having yet to implement their earlier RxP laws.

Dan Ullman: “In January, 2015 the Nebraska Psychological Association (NPA) entered an administrative review process to create a new credential, the prescribing psychologist permit.  This administrative review is required in Nebraska before a legislative bill may be introduced, and provides an opportunity to develop a credentialing proposal that stands a better chance of passing through the political, legislative process.  Based on feedback received during this process, NPA’s proposal is being slightly modified for a subsequent review.  The prescribing permit would be a voluntary, supplemental credential with its own set of standards and requirements and would not affect the general scope of practice of psychology.  Much of the impetus for the proposal stems from serious problems with access to care in Nebraska in both rural and urban areas of the state.  One large area of the state has never had a child and adolescent psychiatrist.  Primary care providers (PCPs) will often not prescribe to clients if they have chronic or severe mental illness.  Also, data indicated consumers may wait 2-3 months for an appointment with a psychiatrist.  A consumer noted that she could not obtain reliable care from a psychiatrist, and was frustrated trying to find a PCP who had the skills to provide mental health medications for her chronic and complex conditions.  The NPA is committed to the creation of the prescribing psychologist permit to address the unmet needs of behavioral health clients.  A newspaper article in the panhandle (rural) area of the state was appropriately titled, ‘Psychologists look for additional ways to help clients’.”

Alaska’s James Fitterling noted that in March, 2015 Nebraska’s Governor turned aside the objections of organized medicine and signed legislation making his state the 20^th in the nation to allow nurse practitioners (NPs) to work independently; i.e., without physician supervision.  “Looks like nothing’s gonna change.”  Aloha,

Pat DeLeon, former APA President – Division 31 – June, 2015