A “TIPPING POINT” FOR MILITARY PSYCHOLOGY -- PERHAPS?

  This spring the House Committee on Armed Services recommended the enactment of H.R. 4909, their Fiscal Year 2017 Department of Defense Authorization Act (NDAA), by a bipartisan vote of 60 to 2.  Included was a proposed major reorganization of the Department's health care system.  The Military Officers Association of America (MOAA) proffered: "The most dramatic change would involve placing all military treatment facilities (MTFs) under the direction of the Defense Health Agency, effective Oct. 1, 2018, for purposes of unified policy, administration, and budgeting.  MOAA has long supported this proposal based on the cost and inefficiency of building military health care programs around three separate systems for each of the services."  From a public policy perspective, this sounds very similar to the arguments over the past decade for developing a "purple suit" health care system, and/or integrating the public and private sectors to better serve the Department of Veterans Affairs (VA) beneficiaries.

            "Reform of Administration of the Defense Health Agency and Military Medical Treatment Facilities.  This section would require the Defense Health Agency to become responsible for management of military treatment facilities throughout the Department of Defense, while preserving the responsibilities of the commanders of such facilities for ensuring the readiness of the members of the armed forces and civilian employees at such facilities and for furnishing the health care and medical treatment provided at such facilities.  The Defense Health Agency would establish an executive-level management office consisting of professional health care administrators to manage health care operations, finance and budget, information technology, and medical affairs across all military treatment facilities.  In addition, this section would direct the Secretary of Defense to submit an interim report to the congressional defense committees not later than March 1, 2017, on the preliminary plan to implement these changes, and a final report not later than March 1, 2018.  This section would also require the Comptroller General of the United States to review each of the plans submitted by the Secretary and to submit the Comptroller's assessment to the congressional defense committees by September 1, 2017, and September 1, 2018 respectively."

            The House proposal further authorized (i.e., urged) the: "Secretary of Defense to develop and implement value-based incentive programs as part of the TRICARE contracts to encourage health care providers under the TRICARE program to improve the quality of care and the experience of the covered beneficiaries.  [This represents the "Triple Aim" of former CMS (Centers for Medicare and Medicaid Services) Administrator Don Berwick.]  Not later than 1 year after implementation of a value-based incentive program and annually thereafter through 2022, the Secretary of Defense would be required to brief the Committees on Armed Services of the Senate and the House of Representatives, and any other appropriate congressional committee, on the quality performance metrics and expenditures related to the incentive program."

Those familiar with the evolving reimbursement changes currently being implemented by CMS, pursuant to President Obama's Patient Protection and Affordable Care Act (ACA), should appreciate the importance of Practice Directorate Executive Director Katherine Nordal's State Leadership conference charge for psychology to be "at the table" when and where important policy decisions are made.  During our health policy seminar this year at the Uniformed Services University of the Health Sciences (USUHS), "Dr. Janet Heinrich, Senior Advisor at CMS's Center for Medicaid and Medicare Innovation (CMMI), described the mission of CMS to promote healthcare that is better and smarter, as well as health care that ultimately leads to healthier persons.  CMMI is pursuing this goal by developing, testing, and implementing new payment and delivery models that not only acknowledge disease symptoms, but also the 'social determinants of health' that place individuals at risk for specific diseases and serve to maintain symptomology" (Omni Cassidy, USUHS).

As of January, 2015 HHS announced its goals for value-based payments within Medicare fee-for-service as having payments tied to quality or value through alternative payment models at 30 percent by the end of 2016 and 50 percent by the end of 2018.  And, fee-for-service payments tied to quality or value at 85 percent by the end of 2016 and 90 percent by the end of 2018.  Medicare growth has fallen below GDP (Gross Domestic Product) growth and national health expenditures since 2010, due, in part, to these efforts.  Currently 477 Accountable Care Organizations (ACOs) – another initiative established under the ACA to foster systems of organized care – have been established across the nation, with 121 new ACOs in 2016, which cover 8.9 million assigned beneficiaries.  Pioneer ACOs were designated for organizations with experience in coordinated care and ACO-like contracts.  These models demonstrated savings for three years in a row of $92, $96, and $120 million.

Change is definitely coming.  The critical question for psychology and for nursing is: Whether their next generation of clinical providers and professional leaders are proactively visionary and willing to become personally engaged in the public policy process, focusing upon the real needs of their patients?  Ray Folen, HPA Executive Director as of this year, notes that over the last 10 years, while at Tripler Army Medical Center: "I have written 3,178 prescriptions and my colleague Mike Kellar has written 5,780.  No adverse events."  Decades ago U.S. Army Col. (Ret) Greg Laskow and Col. Tom Williams fortunately appreciated the importance of prescriptive authority for their Army colleagues.   Aloha.

Pat DeLeon, former APA President – Division 19 – May, 2016

 

Sent from my iPhone

ALOHA - Division 19 May column

A “TIPPING POINT” FOR MILITARY PSYCHOLOGY -- PERHAPS?

            This spring the House Committee on Armed Services recommended the enactment of H.R. 4909, their Fiscal Year 2017 Department of Defense Authorization Act (NDAA), by a bipartisan vote of 60 to 2.  Included was a proposed major reorganization of the Department’s health care system.  The Military Officers Association of America (MOAA) proffered: “The most dramatic change would involve placing all military treatment facilities (MTFs) under the direction of the Defense Health Agency, effective Oct. 1, 2018, for purposes of unified policy, administration, and budgeting.  MOAA has long supported this proposal based on the cost and inefficiency of building military health care programs around three separate systems for each of the services.”  From a public policy perspective, this sounds very similar to the arguments over the past decade for developing a “purple suit” health care system, and/or integrating the public and private sectors to better serve the Department of Veterans Affairs (VA) beneficiaries.

            “Reform of Administration of the Defense Health Agency and Military Medical Treatment Facilities.  This section would require the Defense Health Agency to become responsible for management of military treatment facilities throughout the Department of Defense, while preserving the responsibilities of the commanders of such facilities for ensuring the readiness of the members of the armed forces and civilian employees at such facilities and for furnishing the health care and medical treatment provided at such facilities.  The Defense Health Agency would establish an executive-level management office consisting of professional health care administrators to manage health care operations, finance and budget, information technology, and medical affairs across all military treatment facilities.  In addition, this section would direct the Secretary of Defense to submit an interim report to the congressional defense committees not later than March 1, 2017, on the preliminary plan to implement these changes, and a final report not later than March 1, 2018.  This section would also require the Comptroller General of the United States to review each of the plans submitted by the Secretary and to submit the Comptroller’s assessment to the congressional defense committees by September 1, 2017, and September 1, 2018 respectively.”

            The House proposal further authorized (i.e., urged) the: “Secretary of Defense to develop and implement value-based incentive programs as part of the TRICARE contracts to encourage health care providers under the TRICARE program to improve the quality of care and the experience of the covered beneficiaries.  [This represents the “Triple Aim” of former CMS (Centers for Medicare and Medicaid Services) Administrator Don Berwick.]  Not later than 1 year after implementation of a value-based incentive program and annually thereafter through 2022, the Secretary of Defense would be required to brief the Committees on Armed Services of the Senate and the House of Representatives, and any other appropriate congressional committee, on the quality performance metrics and expenditures related to the incentive program.”

Those familiar with the evolving reimbursement changes currently being implemented by CMS, pursuant to President Obama’s Patient Protection and Affordable Care Act (ACA), should appreciate the importance of Practice Directorate Executive Director Katherine Nordal’s State Leadership conference charge for psychology to be “at the table” when and where important policy decisions are made.  During our health policy seminar this year at the Uniformed Services University of the Health Sciences (USUHS), “Dr. Janet Heinrich, Senior Advisor at CMS’s Center for Medicaid and Medicare Innovation (CMMI), described the mission of CMS to promote healthcare that is better and smarter, as well as health care that ultimately leads to healthier persons.  CMMI is pursuing this goal by developing, testing, and implementing new payment and delivery models that not only acknowledge disease symptoms, but also the ‘social determinants of health’ that place individuals at risk for specific diseases and serve to maintain symptomology” (Omni Cassidy, USUHS).

As of January, 2015 HHS announced its goals for value-based payments within Medicare fee-for-service as having payments tied to quality or value through alternative payment models at 30 percent by the end of 2016 and 50 percent by the end of 2018.  And, fee-for-service payments tied to quality or value at 85 percent by the end of 2016 and 90 percent by the end of 2018.  Medicare growth has fallen below GDP (Gross Domestic Product) growth and national health expenditures since 2010, due, in part, to these efforts.  Currently 477 Accountable Care Organizations (ACOs) – another initiative established under the ACA to foster systems of organized care – have been established across the nation, with 121 new ACOs in 2016, which cover 8.9 million assigned beneficiaries.  Pioneer ACOs were designated for organizations with experience in coordinated care and ACO-like contracts.  These models demonstrated savings for three years in a row of $92, $96, and $120 million.

Change is definitely coming.  The critical question for psychology and for nursing is: Whether their next generation of clinical providers and professional leaders are proactively visionary and willing to become personally engaged in the public policy process, focusing upon the real needs of their patients?  Ray Folen, HPA Executive Director as of this year, notes that over the last 10 years, while at Tripler Army Medical Center: “I have written 3,178 prescriptions and my colleague Mike Kellar has written 5,780.  No adverse events.”  Decades ago U.S. Army Col. (Ret) Greg Laskow and Col. Tom Williams fortunately appreciated the importance of prescriptive authority for their Army colleagues.   Aloha.

Pat DeLeon, former APA President – Division 19 – May, 2016

 

ALOHA

LOOKING OUTWARDS FOR A CHANGE – INTERPROFESSIONAL COLLABORATION

            Early last year, APA systematically inquired with the leadership of its divisions and state associations as to what in their view were the major issues which the discipline of psychology would be facing in the next 5-10 years.  Seven themes evolved, the first of which was Positioning for the Future.  Under this topic were: Engaging and positioning psychology in integrated healthcare settings; Globalization and Internationalizing psychology; the Role of technology; and Telehealth/Telemedicine.  APA President Susan McDaniel has been personally involved with these issues for the past several decades and thus her election to our highest leadership office could not have come at a better time for the association.  She recently represented APA at the British Psychological Society and earlier, when we were both fortunate to have been invited to attend the Beach Boys’ tribute to Barbara Van Dahlen’s Give An Hour initiative – which has already provided over 185,000 hours of free care to our military and veterans communities -- she passionately described her contributions to the World Federation for Mental Health Congress in Cairo.  I still vividly recall that when I was serving on the APA Board of Directors Ray Fowler constantly reminded us that American psychology represented only a small subset of psychology and that those of us who were active in the APA governance had much to learn from our international colleagues.

            This spring, with great enthusiasm, Susan hosted her Integrated Primary Care Alliance Presidential initiative which, by all accounts, was a major success.  Co-hosted by Institute of Medicine (IOM) (recently renamed the National Academy of Medicine (NAM)) member, family physician Frank deGruy, MD, the meeting occurred on the weekend of April 8-9^th in the Tower Conference Room at APA.  APA hosted a CEO and a leader in the Presidential cycle of 23 different health and mental health professional organizations that compose the integrated primary care team.  This list resulted in over 80 participants (pediatricians, internists, family physicians, nurse practitioners, physician assistants, psychiatrists, social workers, clinical pharmacists, etc.).  The objective for the weekend was to develop inter-organizational goals to move the needle forward on integrated primary care.  Panels of 4-6 experts provided five minute “lightening talks” to stimulate discussion in four areas: clinical innovation, interprofessional education, new methods of research and evaluation, and needed policy and payment methods.  After each panel, participants divided into five action discussion groups to discuss what policies these organizations might collectively agree to lobby for and what projects they might want to support.  The participants left very energized by the opportunity to work together.  To start, they already have three letters to Congress that all agreed to sign (e.g., one on giving psychologists access to electronic health records (EHR)).  A number of other work groups have been established that need future attention.

Conference attendee Lucinda Maine, Executive Vice President of the American Association of Colleges of Pharmacy, reports: “I immediately responded ‘yes’ to Susan’s invitation to attend the summit because I knew that ‘integrated primary care’ was central to our work on interprofessional education and practice.  Yet it was not until I reviewed the preconference materials that I fully comprehended that it was behavioral health integration that we would be discussing.  I suppose that should have been self-evident!  That said, both the style and the content of the summit were powerful and the caliber of attendees was simply amazing.  It will be a meeting that influences my thinking about patient care forever.”  As Susan reflectively summarized: “It is our hope that this effort has legs….”

            An Expanding Definition of Health:  Also this spring, the IOM released its report: A Framework for Educating Health Professionals to Address the Social Determinants of Health which highlighted that the World Health Organization (WHO) defines the social determinants of health as: “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”  These forces and systems include economic policies, development agendas, cultural and social norms, social policies, and political systems.  Educating health professionals in and with communities negatively affected by the social determinants of health can generate awareness among those professionals about the potential root causes of ill health; thereby contributing to more effective strategies for improving health and health care for underserved individuals, communities, and populations.

The IOM’s review of the salient literature supports the need for a holistic, consistent, and coherent framework that can align the education, health, and other sectors, in partnership with communities, to educate health professionals in the social determinants of health.  The outcome of its deliberations provides a framework for lifelong learning for health professionals in understanding and addressing the social determinants of health.  To impact health equity requires the movement of knowledge into action, and this requires more than just accruing knowledge.  Health professionals must develop appropriate skills and attitudes to be advocates for change.  Governments, ministries, communities, foundations, and health professional and educational associations all have a role to play in how health professionals learn to address the social determinants of health.  Transformative learning, together with partnerships and lifelong learning are fundamental principles from which the IOM built their framework.  We would remind the readership that one of the fundamental elements of President Obama’s Patient Protection and Affordable Care Act (ACA) is the furtherance of data-based, population focused health care.  Our nation’s health care and educational systems are undergoing unprecedented change.

            An Inspirational Vision by Our Colleagues in Nursing:  Over the past several years, we have become increasingly impressed by the public policy sophistication demonstrated by our colleagues in nursing.  Fellow Purdue University graduate Angela McBride invited me to participate in the American Academy of Nursing’s (AAN’s) Institute for Nursing Leadership, which is in alignment with the Nurses on Boards Coalition (NOBC), a funded effort of the Robert Wood Johnson Foundation (RWJF).  The NOBC, of which AAN is a founding member, has the express goal of placing 10,000 nurses on various policy boards, commissions, and councils by the year 2020 with the goal to position nurses to lead change to improve health and drive policy.  NOBC’s efforts emanated from the comprehensive recommendations of the 2010 IOM report The Future of Nursing: Leading Change, Advancing Health, chaired by former Department of Health and Human Services (HHS) Secretary Donna Shalala.

Similar to WHO, the Institute proffers a board definition of “health,” including areas that impact health outcomes and population health.  Three related efforts have been articulated: increase the appointments of their members, prepare their membership for serving, and continually evaluate the impact of these efforts.  The AAN has three strategic goals:  * Influence the implementation of healthcare reform with the goal of achieving the Triple Aim of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.  * Lead efforts, in partnership with others, to address the broad range of factors that affect the health of populations.  And, * Position nurses to lead change to improve health and health care and drive policy.  Twenty-two organizations are now members of the NOBC, all working on similar efforts.  One can find the latest “count” of nurses on boards by viewing the live thermometer on www.nursesonboardscoalition.org.

I was very pleased to have the opportunity to serve as a reviewer last year for the follow-up IOM report Assessing Progress on the IOM Report The Future of Nursing.  Both of these visionary reports were sponsored by the RWJF and have resulted in several impressive national stakeholder conferences held in Washington, DC.  Several of the highlights of the follow-up report:  The passage of the ACA will require the U.S. health-care system to expand to accommodate a significant increase in demand for services, “particularly those needed to manage patients with chronic conditions or mental health illnesses or for basic primary care.”  Nurses are in a unique position to take on a leadership role in helping the nation attain this goal.  “Nurses have a key role to play as team members and leaders for a reformed and better integrated patient-centered health care system.”  With approximately three million members, nurses make up the largest segment of the nation’s health care profession.

The changing climate of health care policy and practice has sharpened the national focus on the challenges of providing high-quality and affordable care to an aging and increasingly diverse population.  The priorities of this changed climate will increasingly require the collaboration of health professionals to provide patient-centered, coordinated, and community-based primary and specialty care services.  We would emphasize that it is important for psychology to appreciate that one element of organized nursing’s response – pursuant to numerous IOM reports – has been the launching of their Campaign for Action, in conjunction with AARP, to shepherd the various recommendations towards implementation at the national, state, and institutional level.  Several of the key areas to be addressed are: removing scope-of-practice barriers, implementing nursing residency programs (a provision of the ACA), doubling the number of nurses with a doctorate by 2020, and building an infrastructure for the collection and analysis of interprofessional health care workforce data.  Susan Hassmiller, Senior Advisor for Nursing at RWJF, spent two years on loan to the IOM as staff director for the initial report and currently serves as National Campaign Director.

“The Campaign has made significant progress in many aspects of this effort.  In a short period of time, it has galvanized the nursing community through its work at the national level and through the 51 state Action Coalitions it has organized.  The (IOM) found that the Campaign has met or exceeded expectations in many areas.  However, given the changing health care culture and, in particular the increasing importance placed on interprofessional collaboration, the Campaign needs to engage a broader network of stakeholders.  The present report also recommends addressing challenges in the areas of scope of practice, education, collaboration, leadership, diversity, and data.  The (IOM) believes these contributions can change the impact of nurses on the health care system and on patient care and outcomes.”

The original IOM report emphatically proposed that advanced practice registered nurses (APRNs) could help build the workforce necessary to meet the country’s health care needs if permitted to practice to the full extent of their education and training.  The follow-up report: “While there has been on-the-ground collaboration between medicine and nursing, opposition by some physicians and physician organizations has been noted as a barrier to expansion of ARPNs’ scope of practice.  The health care environment continues to evolve and demand greater team-based and value-based care.  There is growing evidence that new models of practice in which all health professionals practice to the full extent of their education and training offer greater efficiency and quality of services.  Several studies have shown, moreover, that these care models enhance satisfaction among health care providers.  This is an important contextual change since the release of the (initial) report, one that offers potential common ground for that report’s goals regarding scope-of-practice expansion.”

A senior colleague and I were recently admiring nursing’s success in obtaining support from a number of foundations.  For example, the Jonas Center for Nursing and Veterans Healthcare has the impressive accomplishment of supporting 1,000 Jonas Scholars, committing nearly $25 million in grants to nurses pursuing PhDs and DNPs.  This is also evident in the nearly $20 million that the Future of Nursing Action Coalitions have leveraged from additional sources, including other foundations, to match the RWJF dollars that are supporting their efforts.  Our nation’s health care environment is, indeed, undergoing dramatic change.  Aloha,

Pat DeLeon, former APA President – Division 29 – May, 2016

 

Division 29 May column

LOOKING OUTWARDS FOR A CHANGE – INTERPROFESSIONAL COLLABORATION

            Early last year, APA systematically inquired with the leadership of its divisions and state associations as to what in their view were the major issues which the discipline of psychology would be facing in the next 5-10 years.  Seven themes evolved, the first of which was Positioning for the Future.  Under this topic were: Engaging and positioning psychology in integrated healthcare settings; Globalization and Internationalizing psychology; the Role of technology; and Telehealth/Telemedicine.  APA President Susan McDaniel has been personally involved with these issues for the past several decades and thus her election to our highest leadership office could not have come at a better time for the association.  She recently represented APA at the British Psychological Society and earlier, when we were both fortunate to have been invited to attend the Beach Boys’ tribute to Barbara Van Dahlen’s Give An Hour initiative – which has already provided over 185,000 hours of free care to our military and veterans communities -- she passionately described her contributions to the World Federation for Mental Health Congress in Cairo.  I still vividly recall that when I was serving on the APA Board of Directors Ray Fowler constantly reminded us that American psychology represented only a small subset of psychology and that those of us who were active in the APA governance had much to learn from our international colleagues.

            This spring, with great enthusiasm, Susan hosted her Integrated Primary Care Alliance Presidential initiative which, by all accounts, was a major success.  Co-hosted by Institute of Medicine (IOM) (recently renamed the National Academy of Medicine (NAM)) member, family physician Frank deGruy, MD, the meeting occurred on the weekend of April 8-9^th in the Tower Conference Room at APA.  APA hosted a CEO and a leader in the Presidential cycle of 23 different health and mental health professional organizations that compose the integrated primary care team.  This list resulted in over 80 participants (pediatricians, internists, family physicians, nurse practitioners, physician assistants, psychiatrists, social workers, clinical pharmacists, etc.).  The objective for the weekend was to develop inter-organizational goals to move the needle forward on integrated primary care.  Panels of 4-6 experts provided five minute “lightening talks” to stimulate discussion in four areas: clinical innovation, interprofessional education, new methods of research and evaluation, and needed policy and payment methods.  After each panel, participants divided into five action discussion groups to discuss what policies these organizations might collectively agree to lobby for and what projects they might want to support.  The participants left very energized by the opportunity to work together.  To start, they already have three letters to Congress that all agreed to sign (e.g., one on giving psychologists access to electronic health records (EHR)).  A number of other work groups have been established that need future attention.

Conference attendee Lucinda Maine, Executive Vice President of the American Association of Colleges of Pharmacy, reports: “I immediately responded ‘yes’ to Susan’s invitation to attend the summit because I knew that ‘integrated primary care’ was central to our work on interprofessional education and practice.  Yet it was not until I reviewed the preconference materials that I fully comprehended that it was behavioral health integration that we would be discussing.  I suppose that should have been self-evident!  That said, both the style and the content of the summit were powerful and the caliber of attendees was simply amazing.  It will be a meeting that influences my thinking about patient care forever.”  As Susan reflectively summarized: “It is our hope that this effort has legs….”

            An Expanding Definition of Health:  Also this spring, the IOM released its report: A Framework for Educating Health Professionals to Address the Social Determinants of Health which highlighted that the World Health Organization (WHO) defines the social determinants of health as: “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”  These forces and systems include economic policies, development agendas, cultural and social norms, social policies, and political systems.  Educating health professionals in and with communities negatively affected by the social determinants of health can generate awareness among those professionals about the potential root causes of ill health; thereby contributing to more effective strategies for improving health and health care for underserved individuals, communities, and populations.

The IOM’s review of the salient literature supports the need for a holistic, consistent, and coherent framework that can align the education, health, and other sectors, in partnership with communities, to educate health professionals in the social determinants of health.  The outcome of its deliberations provides a framework for lifelong learning for health professionals in understanding and addressing the social determinants of health.  To impact health equity requires the movement of knowledge into action, and this requires more than just accruing knowledge.  Health professionals must develop appropriate skills and attitudes to be advocates for change.  Governments, ministries, communities, foundations, and health professional and educational associations all have a role to play in how health professionals learn to address the social determinants of health.  Transformative learning, together with partnerships and lifelong learning are fundamental principles from which the IOM built their framework.  We would remind the readership that one of the fundamental elements of President Obama’s Patient Protection and Affordable Care Act (ACA) is the furtherance of data-based, population focused health care.  Our nation’s health care and educational systems are undergoing unprecedented change.

            An Inspirational Vision by Our Colleagues in Nursing:  Over the past several years, we have become increasingly impressed by the public policy sophistication demonstrated by our colleagues in nursing.  Fellow Purdue University graduate Angela McBride invited me to participate in the American Academy of Nursing’s (AAN’s) Institute for Nursing Leadership, which is in alignment with the Nurses on Boards Coalition (NOBC), a funded effort of the Robert Wood Johnson Foundation (RWJF).  The NOBC, of which AAN is a founding member, has the express goal of placing 10,000 nurses on various policy boards, commissions, and councils by the year 2020 with the goal to position nurses to lead change to improve health and drive policy.  NOBC’s efforts emanated from the comprehensive recommendations of the 2010 IOM report The Future of Nursing: Leading Change, Advancing Health, chaired by former Department of Health and Human Services (HHS) Secretary Donna Shalala.

Similar to WHO, the Institute proffers a board definition of “health,” including areas that impact health outcomes and population health.  Three related efforts have been articulated: increase the appointments of their members, prepare their membership for serving, and continually evaluate the impact of these efforts.  The AAN has three strategic goals:  * Influence the implementation of healthcare reform with the goal of achieving the Triple Aim of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.  * Lead efforts, in partnership with others, to address the broad range of factors that affect the health of populations.  And, * Position nurses to lead change to improve health and health care and drive policy.  Twenty-two organizations are now members of the NOBC, all working on similar efforts.  One can find the latest “count” of nurses on boards by viewing the live thermometer on www.nursesonboardscoalition.org.

I was very pleased to have the opportunity to serve as a reviewer last year for the follow-up IOM report Assessing Progress on the IOM Report The Future of Nursing.  Both of these visionary reports were sponsored by the RWJF and have resulted in several impressive national stakeholder conferences held in Washington, DC.  Several of the highlights of the follow-up report:  The passage of the ACA will require the U.S. health-care system to expand to accommodate a significant increase in demand for services, “particularly those needed to manage patients with chronic conditions or mental health illnesses or for basic primary care.”  Nurses are in a unique position to take on a leadership role in helping the nation attain this goal.  “Nurses have a key role to play as team members and leaders for a reformed and better integrated patient-centered health care system.”  With approximately three million members, nurses make up the largest segment of the nation’s health care profession.

The changing climate of health care policy and practice has sharpened the national focus on the challenges of providing high-quality and affordable care to an aging and increasingly diverse population.  The priorities of this changed climate will increasingly require the collaboration of health professionals to provide patient-centered, coordinated, and community-based primary and specialty care services.  We would emphasize that it is important for psychology to appreciate that one element of organized nursing’s response – pursuant to numerous IOM reports – has been the launching of their Campaign for Action, in conjunction with AARP, to shepherd the various recommendations towards implementation at the national, state, and institutional level.  Several of the key areas to be addressed are: removing scope-of-practice barriers, implementing nursing residency programs (a provision of the ACA), doubling the number of nurses with a doctorate by 2020, and building an infrastructure for the collection and analysis of interprofessional health care workforce data.  Susan Hassmiller, Senior Advisor for Nursing at RWJF, spent two years on loan to the IOM as staff director for the initial report and currently serves as National Campaign Director.

“The Campaign has made significant progress in many aspects of this effort.  In a short period of time, it has galvanized the nursing community through its work at the national level and through the 51 state Action Coalitions it has organized.  The (IOM) found that the Campaign has met or exceeded expectations in many areas.  However, given the changing health care culture and, in particular the increasing importance placed on interprofessional collaboration, the Campaign needs to engage a broader network of stakeholders.  The present report also recommends addressing challenges in the areas of scope of practice, education, collaboration, leadership, diversity, and data.  The (IOM) believes these contributions can change the impact of nurses on the health care system and on patient care and outcomes.”

The original IOM report emphatically proposed that advanced practice registered nurses (APRNs) could help build the workforce necessary to meet the country’s health care needs if permitted to practice to the full extent of their education and training.  The follow-up report: “While there has been on-the-ground collaboration between medicine and nursing, opposition by some physicians and physician organizations has been noted as a barrier to expansion of ARPNs’ scope of practice.  The health care environment continues to evolve and demand greater team-based and value-based care.  There is growing evidence that new models of practice in which all health professionals practice to the full extent of their education and training offer greater efficiency and quality of services.  Several studies have shown, moreover, that these care models enhance satisfaction among health care providers.  This is an important contextual change since the release of the (initial) report, one that offers potential common ground for that report’s goals regarding scope-of-practice expansion.”

A senior colleague and I were recently admiring nursing’s success in obtaining support from a number of foundations.  For example, the Jonas Center for Nursing and Veterans Healthcare has the impressive accomplishment of supporting 1,000 Jonas Scholars, committing nearly $25 million in grants to nurses pursuing PhDs and DNPs.  This is also evident in the nearly $20 million that the Future of Nursing Action Coalitions have leveraged from additional sources, including other foundations, to match the RWJF dollars that are supporting their efforts.  Our nation’s health care environment is, indeed, undergoing dramatic change.  Aloha,

Pat DeLeon, former APA President – Division 29 – May, 2016

 

LOOKING OUTWARDS FOR A CHANGE – INTERPROFESSIONAL COLLABORATION

Early last year, APA systematically inquired with the leadership of its divisions and state associations as to what in their view were the major issues which the discipline of psychology would be facing in the next 5-10 years.  Seven themes evolved, the first of which was Positioning for the Future.  Under this topic were: Engaging and positioning psychology in integrated healthcare settings; Globalization and Internationalizing psychology; the Role of technology; and Telehealth/Telemedicine.  APA President Susan McDaniel has been personally involved with these issues for the past several decades and thus her election to our highest leadership office could not have come at a better time for the association.  She recently represented APA at the British Psychological Society and earlier, when we were both fortunate to have been invited to attend the Beach Boys' tribute to Barbara Van Dahlen's Give An Hour initiative – which has already provided over 185,000 hours of free care to our military and veterans communities -- she passionately described her contributions to the World Federation for Mental Health Congress in Cairo.  I still vividly recall that when I was serving on the APA Board of Directors Ray Fowler constantly reminded us that American psychology represented only a small subset of psychology and that those of us who were active in the APA governance had much to learn from our international colleagues.

            This spring, with great enthusiasm, Susan hosted her Integrated Primary Care Alliance Presidential initiative which, by all accounts, was a major success.  Co-hosted by Institute of Medicine (IOM) (recently renamed the National Academy of Medicine (NAM)) member, family physician Frank deGruy, MD, the meeting occurred on the weekend of April 8-9^th in the Tower Conference Room at APA.  APA hosted a CEO and a leader in the Presidential cycle of 23 different health and mental health professional organizations that compose the integrated primary care team.  This list resulted in over 80 participants (pediatricians, internists, family physicians, nurse practitioners, physician assistants, psychiatrists, social workers, clinical pharmacists, etc.).  The objective for the weekend was to develop inter-organizational goals to move the needle forward on integrated primary care.  Panels of 4-6 experts provided five minute "lightening talks" to stimulate discussion in four areas: clinical innovation, interprofessional education, new methods of research and evaluation, and needed policy and payment methods.  After each panel, participants divided into five action discussion groups to discuss what policies these organizations might collectively agree to lobby for and what projects they might want to support.  The participants left very energized by the opportunity to work together.  To start, they already have three letters to Congress that all agreed to sign (e.g., one on giving psychologists access to electronic health records (EHR)).  A number of other work groups have been established that need future attention.

Conference attendee Lucinda Maine, Executive Vice President of the American Association of Colleges of Pharmacy, reports: "I immediately responded 'yes' to Susan's invitation to attend the summit because I knew that 'integrated primary care' was central to our work on interprofessional education and practice.  Yet it was not until I reviewed the preconference materials that I fully comprehended that it was behavioral health integration that we would be discussing.  I suppose that should have been self-evident!  That said, both the style and the content of the summit were powerful and the caliber of attendees was simply amazing.  It will be a meeting that influences my thinking about patient care forever."  As Susan reflectively summarized: "It is our hope that this effort has legs…."

            An Expanding Definition of Health:  Also this spring, the IOM released its report: A Framework for Educating Health Professionals to Address the Social Determinants of Health which highlighted that the World Health Organization (WHO) defines the social determinants of health as: "the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life."  These forces and systems include economic policies, development agendas, cultural and social norms, social policies, and political systems.  Educating health professionals in and with communities negatively affected by the social determinants of health can generate awareness among those professionals about the potential root causes of ill health; thereby contributing to more effective strategies for improving health and health care for underserved individuals, communities, and populations.

The IOM's review of the salient literature supports the need for a holistic, consistent, and coherent framework that can align the education, health, and other sectors, in partnership with communities, to educate health professionals in the social determinants of health.  The outcome of its deliberations provides a framework for lifelong learning for health professionals in understanding and addressing the social determinants of health.  To impact health equity requires the movement of knowledge into action, and this requires more than just accruing knowledge.  Health professionals must develop appropriate skills and attitudes to be advocates for change.  Governments, ministries, communities, foundations, and health professional and educational associations all have a role to play in how health professionals learn to address the social determinants of health.  Transformative learning, together with partnerships and lifelong learning are fundamental principles from which the IOM built their framework.  We would remind the readership that one of the fundamental elements of President Obama's Patient Protection and Affordable Care Act (ACA) is the furtherance of data-based, population focused health care.  Our nation's health care and educational systems are undergoing unprecedented change.

            An Inspirational Vision by Our Colleagues in Nursing:  Over the past several years, we have become increasingly impressed by the public policy sophistication demonstrated by our colleagues in nursing.  Fellow Purdue University graduate Angela McBride invited me to participate in the American Academy of Nursing's (AAN's) Institute for Nursing Leadership, which is in alignment with the Nurses on Boards Coalition (NOBC), a funded effort of the Robert Wood Johnson Foundation (RWJF).  The NOBC, of which AAN is a founding member, has the express goal of placing 10,000 nurses on various policy boards, commissions, and councils by the year 2020 with the goal to position nurses to lead change to improve health and drive policy.  NOBC's efforts emanated from the comprehensive recommendations of the 2010 IOM report The Future of Nursing: Leading Change, Advancing Health, chaired by former Department of Health and Human Services (HHS) Secretary Donna Shalala.

Similar to WHO, the Institute proffers a board definition of "health," including areas that impact health outcomes and population health.  Three related efforts have been articulated: increase the appointments of their members, prepare their membership for serving, and continually evaluate the impact of these efforts.  The AAN has three strategic goals:  * Influence the implementation of healthcare reform with the goal of achieving the Triple Aim of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.  * Lead efforts, in partnership with others, to address the broad range of factors that affect the health of populations.  And, * Position nurses to lead change to improve health and health care and drive policy.  Twenty-two organizations are now members of the NOBC, all working on similar efforts.  One can find the latest "count" of nurses on boards by viewing the live thermometer on www.nursesonboardscoalition.org.

I was very pleased to have the opportunity to serve as a reviewer last year for the follow-up IOM report Assessing Progress on the IOM Report The Future of Nursing.  Both of these visionary reports were sponsored by the RWJF and have resulted in several impressive national stakeholder conferences held in Washington, DC.  Several of the highlights of the follow-up report:  The passage of the ACA will require the U.S. health-care system to expand to accommodate a significant increase in demand for services, "particularly those needed to manage patients with chronic conditions or mental health illnesses or for basic primary care."  Nurses are in a unique position to take on a leadership role in helping the nation attain this goal.  "Nurses have a key role to play as team members and leaders for a reformed and better integrated patient-centered health care system."  With approximately three million members, nurses make up the largest segment of the nation's health care profession.

The changing climate of health care policy and practice has sharpened the national focus on the challenges of providing high-quality and affordable care to an aging and increasingly diverse population.  The priorities of this changed climate will increasingly require the collaboration of health professionals to provide patient-centered, coordinated, and community-based primary and specialty care services.  We would emphasize that it is important for psychology to appreciate that one element of organized nursing's response – pursuant to numerous IOM reports – has been the launching of their Campaign for Action, in conjunction with AARP, to shepherd the various recommendations towards implementation at the national, state, and institutional level.  Several of the key areas to be addressed are: removing scope-of-practice barriers, implementing nursing residency programs (a provision of the ACA), doubling the number of nurses with a doctorate by 2020, and building an infrastructure for the collection and analysis of interprofessional health care workforce data.  Susan Hassmiller, Senior Advisor for Nursing at RWJF, spent two years on loan to the IOM as staff director for the initial report and currently serves as National Campaign Director. 

"The Campaign has made significant progress in many aspects of this effort.  In a short period of time, it has galvanized the nursing community through its work at the national level and through the 51 state Action Coalitions it has organized.  The (IOM) found that the Campaign has met or exceeded expectations in many areas.  However, given the changing health care culture and, in particular the increasing importance placed on interprofessional collaboration, the Campaign needs to engage a broader network of stakeholders.  The present report also recommends addressing challenges in the areas of scope of practice, education, collaboration, leadership, diversity, and data.  The (IOM) believes these contributions can change the impact of nurses on the health care system and on patient care and outcomes."

The original IOM report emphatically proposed that advanced practice registered nurses (APRNs) could help build the workforce necessary to meet the country's health care needs if permitted to practice to the full extent of their education and training.  The follow-up report: "While there has been on-the-ground collaboration between medicine and nursing, opposition by some physicians and physician organizations has been noted as a barrier to expansion of ARPNs' scope of practice.  The health care environment continues to evolve and demand greater team-based and value-based care.  There is growing evidence that new models of practice in which all health professionals practice to the full extent of their education and training offer greater efficiency and quality of services.  Several studies have shown, moreover, that these care models enhance satisfaction among health care providers.  This is an important contextual change since the release of the (initial) report, one that offers potential common ground for that report's goals regarding scope-of-practice expansion."

A senior colleague and I were recently admiring nursing's success in obtaining support from a number of foundations.  For example, the Jonas Center for Nursing and Veterans Healthcare has the impressive accomplishment of supporting 1,000 Jonas Scholars, committing nearly $25 million in grants to nurses pursuing PhDs and DNPs.  This is also evident in the nearly $20 million that the Future of Nursing Action Coalitions have leveraged from additional sources, including other foundations, to match the RWJF dollars that are supporting their efforts.  Our nation's health care environment is, indeed, undergoing dramatic change.  Aloha,

Pat DeLeon, former APA President – Division 29 – May, 2016

 

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