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
