IN RECOGNIZING THE HUMANITY OF OUR FELLOW BEINGS

 Serving The Nation:  This fall I had the opportunity to attend the American Academy of Nursing 2017 Leadership Luncheon during which Sheila Burke moderated the inspirational panel discussion "Aspire to Achieve."  During her career, Sheila has held a number of key leadership positions including chief of staff for U.S. Senator Robert Dole and is currently on the Board of Regents of the Uniformed Services University (USU).  The two panelists were Mary Wakefield and Sylvia Trent-Adams.  Mary served as Acting Deputy Secretary of HHS under President Obama and Sylvia was Acting USPHS Surgeon General.  A key message delivered by both of the speakers was the importance of constantly focusing upon one's underlying mission.  Ask -- What is best for the patient or targeted program/population?  Not -- How can I advance my own profession?  Nursing and psychology have much to bring to the public policy table.  Yet, both professions still have to educate others by being actively involved in solving real societal problems.

            In what was perhaps one of the most visionary developments for APA during the past year, Interim CEO Cynthia Belar established the Office of Director of Military and Veterans Health Policy and appointed Heather O'Beirne Kelly, who has worked for APA for nearly two decades, as its first director.  This decision was widely supported by our public sector colleagues and especially those working for the Department of Veterans Affairs (VA) which is the largest employer (and trainer) of psychologists.  Having served for nearly four decades on Capitol Hill, we have been extremely impressed by the extent to which Heather has been able to capitalize upon this opportunity to expand psychology's collective contributions to the wellbeing of our nation's Veterans and, perhaps equally importantly, the Congress's appreciation of the profession.  It is without question, a national public health tragedy that the VA still reports that every day 20 Veterans commit suicide; a clinical situation for which psychology and nursing have considerable expertise to offer.

            "It was an honor to attend The Science of Veteran Suicide: VA Research in Prevention and Intervention at the U.S. Capitol, hosted by the Friends of VA Medical Care and Health Research (FOVA) and the APA.  It was a special privilege to meet the new VA Deputy Secretary, Thomas Bowman, and receive the most up-to-date vision of the VA in caring for Veterans at risk for suicide.  The state of the science on Veteran suicide prevention provided by key VA scientists was especially relevant to me as a Ph.D. student in the Daniel K. Inouye Graduate School of Nursing at USU, as an active duty USAF Officer, and as a Veteran of OEF/OIF.  The presentation highlighted current work related to the critical factors of traumatic brain injury, sleep disorders, primary care encounters, and smartphone apps in the prevention of Veteran suicides.  Key findings presented on the association between sleep disturbance and suicide offer a potential biological intervention target for presenting suicide among affected Veterans.  The association of TBI, hopelessness, and suicide found among combat Veterans also offer an avenue for interrupting the negative psychological processes which contribute to suicidal ideation.

"From the prevention perspective, decreasing isolation and engaging Veterans is being undertaken by the VA through innovative smartphone apps which provide instant access to emotional regulation tools outside the clinic.  Overall an emphasis is being placed by the VA on developing trusting collaborative relationships between Veterans and providers to focus on ways to cope with the underlying feelings of hopelessness and loss of purpose during life transitions.  The big takeaway from this presentation is that Veteran suicide prevention is a multi-faceted issue which requires a biopsychosocial scientific approach and the collaborative efforts of the VA, DOD, and our whole society.  Veterans will always carry the physical and psychological wounds of war, but we all carry the responsibility of ensuring they do not endure this burden alone and without hope" (Maj. Sarah Huffman, USAF).

            A subsequent Capitol Hill event Heather also facilitated: "I was sincerely moved by the documentary film, Served Like a Girl.  Although I had heard of the Ms. Veteran America pageant, I had no idea that it arose from homelessness among female Vets, 55,000 even today.  Viewing the film with the pageant's founder, the film director, and three of the featured Veterans was especially meaningful.  During the post-film Q&A session, MAJ. Jaspen Boothe, the founder of the pageant and Final Salute Inc. (http://www.finalsaluteinc.org/ and http://www.msveteranamerica.org/) explained why she chose a pageant as her organization's primary event.  After serving honorably and battling cancer, MAJ. Boothe was released from active duty and quickly realized the staggering shortage of social services available to female veterans.  Vowing to 'never leave a fallen comrade behind,' she started the Ms. Veteran American pageant because she recognized that many Veterans miss the 'tribe' mentality when their military service is over.  She needed to create a 'tribe' that would welcome any female Veteran to be supported, encouraged, and reminded that she still had so much to offer, and to remind society that women are Veterans too.  The personal stories of tragedy and triumph featured in the film are incredibly thoughtful, heartbreaking, and heartwarming at the same time.  I encourage everyone to view a screening of the film or watch it on PBS next year.  And remember that women have truly been serving in combat for decades" (Capt. Michelle Binder, USAF).  Several psychologists were present, including former APA President Ron Fox, former APA Congressional Science Fellow Andrea Solarz, and Veterans advocate Nate Ainspan.

            Easter Seals has a long and admirable history of advocating for and providing exceptional services to ensure that all people with disabilities or special needs have equal opportunities to live, learn, work, and play in their communities.  CDR Eric Pauli of the GSN faculty and I had the opportunity to attend the Opening Celebration of the Steven A. Cohen Military Family Clinic at Easter Seals.  Behavioral health care – Accessible services for Veterans and their families.  Some Veterans need extra support and care when leaving the military.  Easter Seals Veteran Staffing Network goes above and beyond helping these Veterans find not just jobs, but a stable community.   USAF Veteran psychologist Tracy Neal-Walden serves as senior vice president and director of the clinic.  On her staff, Jessica Dunham: "I provide individual, couples, and family therapy services to Veterans and their families.  Treatment includes delivery of EBPs (CBT, CBT-D, CBT-1, PE, CPT, EMDR, IRT) covering a wide range of mental health conditions, including primarily depression, anxiety, post-traumatic stress, adjustment issues, grief and loss, family issues, transition challenges, relationship problems, and children's behavioral problems.  Anyone who has served in the U.S. Armed Forces, regardless of role, discharge status, or combat experience is eligible for care.  Family members include parents, siblings, spouses/partners, children, caregivers or others.  All Veterans and their families are eligible for treatment, regardless of insurance or ability to pay.  Intake screenings are completed same day via phone, with a follow-up initial appointment scheduled within one week."  We were particularly pleased with the extent to which the clinic has embraced tele-behavioral health, as well as their commitment to establish collaborative research-practice partnerships to improve the adoption and dissemination of research that will lead to a continuous evolution of mental health services.  "We pay ourselves the highest tribute" (Thurgood Marshall).  Aloha,

Pat DeLeon, former APA President – Division 42 – November, 2017

 

Sent from my iPhone

Division 42 Winter column

“IN RECOGNIZING THE HUMANITY OF OUR FELLOW BEINGS,”

            Serving The Nation:  This fall I had the opportunity to attend the American Academy of Nursing 2017 Leadership Luncheon during which Sheila Burke moderated the inspirational panel discussion “Aspire to Achieve.”  During her career, Sheila has held a number of key leadership positions including chief of staff for U.S. Senator Robert Dole and is currently on the Board of Regents of the Uniformed Services University (USU).  The two panelists were Mary Wakefield and Sylvia Trent-Adams.  Mary served as Acting Deputy Secretary of HHS under President Obama and Sylvia was Acting USPHS Surgeon General.  A key message delivered by both of the speakers was the importance of constantly focusing upon one’s underlying mission.  Ask -- What is best for the patient or targeted program/population?  Not -- How can I advance my own profession?  Nursing and psychology have much to bring to the public policy table.  Yet, both professions still have to educate others by being actively involved in solving real societal problems.

            In what was perhaps one of the most visionary developments for APA during the past year, Interim CEO Cynthia Belar established the Office of Director of Military and Veterans Health Policy and appointed Heather O’Beirne Kelly, who has worked for APA for nearly two decades, as its first director.  This decision was widely supported by our public sector colleagues and especially those working for the Department of Veterans Affairs (VA) which is the largest employer (and trainer) of psychologists.  Having served for nearly four decades on Capitol Hill, we have been extremely impressed by the extent to which Heather has been able to capitalize upon this opportunity to expand psychology’s collective contributions to the wellbeing of our nation’s Veterans and, perhaps equally importantly, the Congress’s appreciation of the profession.  It is without question, a national public health tragedy that the VA still reports that every day 20 Veterans commit suicide; a clinical situation for which psychology and nursing have considerable expertise to offer.

            “It was an honor to attend The Science of Veteran Suicide: VA Research in Prevention and Intervention at the U.S. Capitol, hosted by the Friends of VA Medical Care and Health Research (FOVA) and the APA.  It was a special privilege to meet the new VA Deputy Secretary, Thomas Bowman, and receive the most up-to-date vision of the VA in caring for Veterans at risk for suicide.  The state of the science on Veteran suicide prevention provided by key VA scientists was especially relevant to me as a Ph.D. student in the Daniel K. Inouye Graduate School of Nursing at USU, as an active duty USAF Officer, and as a Veteran of OEF/OIF.  The presentation highlighted current work related to the critical factors of traumatic brain injury, sleep disorders, primary care encounters, and smartphone apps in the prevention of Veteran suicides.  Key findings presented on the association between sleep disturbance and suicide offer a potential biological intervention target for presenting suicide among affected Veterans.  The association of TBI, hopelessness, and suicide found among combat Veterans also offer an avenue for interrupting the negative psychological processes which contribute to suicidal ideation.

“From the prevention perspective, decreasing isolation and engaging Veterans is being undertaken by the VA through innovative smartphone apps which provide instant access to emotional regulation tools outside the clinic.  Overall an emphasis is being placed by the VA on developing trusting collaborative relationships between Veterans and providers to focus on ways to cope with the underlying feelings of hopelessness and loss of purpose during life transitions.  The big takeaway from this presentation is that Veteran suicide prevention is a multi-faceted issue which requires a biopsychosocial scientific approach and the collaborative efforts of the VA, DOD, and our whole society.  Veterans will always carry the physical and psychological wounds of war, but we all carry the responsibility of ensuring they do not endure this burden alone and without hope” (Maj. Sarah Huffman, USAF).

            A subsequent Capitol Hill event Heather also facilitated: “I was sincerely moved by the documentary film, Served Like a Girl.  Although I had heard of the Ms. Veteran America pageant, I had no idea that it arose from homelessness among female Vets, 55,000 even today.  Viewing the film with the pageant’s founder, the film director, and three of the featured Veterans was especially meaningful.  During the post-film Q&A session, MAJ. Jaspen Boothe, the founder of the pageant and Final Salute Inc. (http://www.finalsaluteinc.org/ and http://www.msveteranamerica.org/) explained why she chose a pageant as her organization’s primary event.  After serving honorably and battling cancer, MAJ. Boothe was released from active duty and quickly realized the staggering shortage of social services available to female veterans.  Vowing to ‘never leave a fallen comrade behind,’ she started the Ms. Veteran American pageant because she recognized that many Veterans miss the ‘tribe’ mentality when their military service is over.  She needed to create a ‘tribe’ that would welcome any female Veteran to be supported, encouraged, and reminded that she still had so much to offer, and to remind society that women are Veterans too.  The personal stories of tragedy and triumph featured in the film are incredibly thoughtful, heartbreaking, and heartwarming at the same time.  I encourage everyone to view a screening of the film or watch it on PBS next year.  And remember that women have truly been serving in combat for decades” (Capt. Michelle Binder, USAF).  Several psychologists were present, including former APA President Ron Fox, former APA Congressional Science Fellow Andrea Solarz, and Veterans advocate Nate Ainspan.

            Easter Seals has a long and admirable history of advocating for and providing exceptional services to ensure that all people with disabilities or special needs have equal opportunities to live, learn, work, and play in their communities.  CDR Eric Pauli of the GSN faculty and I had the opportunity to attend the Opening Celebration of the Steven A. Cohen Military Family Clinic at Easter Seals.  Behavioral health care – Accessible services for Veterans and their families.  Some Veterans need extra support and care when leaving the military.  Easter Seals Veteran Staffing Network goes above and beyond helping these Veterans find not just jobs, but a stable community.   USAF Veteran psychologist Tracy Neal-Walden serves as senior vice president and director of the clinic.  On her staff, Jessica Dunham: “I provide individual, couples, and family therapy services to Veterans and their families.  Treatment includes delivery of EBPs (CBT, CBT-D, CBT-1, PE, CPT, EMDR, IRT) covering a wide range of mental health conditions, including primarily depression, anxiety, post-traumatic stress, adjustment issues, grief and loss, family issues, transition challenges, relationship problems, and children’s behavioral problems.  Anyone who has served in the U.S. Armed Forces, regardless of role, discharge status, or combat experience is eligible for care.  Family members include parents, siblings, spouses/partners, children, caregivers or others.  All Veterans and their families are eligible for treatment, regardless of insurance or ability to pay.  Intake screenings are completed same day via phone, with a follow-up initial appointment scheduled within one week.”  We were particularly pleased with the extent to which the clinic has embraced tele-behavioral health, as well as their commitment to establish collaborative research-practice partnerships to improve the adoption and dissemination of research that will lead to a continuous evolution of mental health services.  “We pay ourselves the highest tribute” (Thurgood Marshall).  Aloha,

Pat DeLeon, former APA President – Division 42 – November, 2017

 

“THIS COUNTRY WILL NOT BE A PERMANENTLY GOOD PLACE FOR ANY OF US…”

 Developing a Visionary Perspective:  After nearly four decades of involvement at the federal policy level, we have come to appreciate how those who serve in higher office (whether within the Congress, the Administration, or their national professional associations) often develop an intuitive understanding of the "waves of change" and how their interests and expertise must continue to evolve in order to remain relevant and "cutting edge."  Former APA Presidents Suzanne Bennett Johnson and Susan McDaniel emphasized the importance of psychology affirmatively embracing interprofessional integrated care.  Psychologist Peter Kaufmann, former Acting Director of the Office of Behavioral and Social Sciences Research at the National Institutes of Health and former President of the Society of Behavioral Medicine, recently transitioned to the University of Colorado's College of Nursing as Associate Dean of Research.  He finds that nursing faces challenges similar to those of psychology with respect to research and practice, yet both can learn from one another.  Colleagues invested in mental and/or behavioral health must appreciate the fundamental importance of regularly interacting with the other disciplines (e.g., nursing, clinical pharmacy, social work, physician assistants, and medicine) which are essentially working with the same patients or systems/organizations; notwithstanding our different professional training backgrounds.  Fundamental change evolves from collective past experiences and challenges.

            Two of Susan's 2016 Presidential Initiatives exemplify this commitment to increasing psychology's role in interprofessional integrated care.  "The first initiative took a year to accomplish: developing a meeting of Presidents and CEOs or Government Relations people of all the primary care and mental health professional associations (including family medicine, pediatrics, general internal medicine, psychology, psychiatry, social work, nurse practitioners, nurses, physician assistants, etc.).  We called it the Integrated Primary Care Alliance.  Eighty-three leaders from 28 associations met at the APA Tower Conference Center in April for two days, to work on inter-professional approaches to integrated primary care with regard to: advocacy, education, research methodologies, team-based care, and healthcare disparities.  Many of these leaders had never met each other, and few had been to APA.  More than a handful said this was the best meeting they had ever attended!

            "My second Interprofessional initiative was to develop a curriculum for an Interprofessional seminar for integrated primary care that will be taught early in the graduate training of all health professionals.  Psychology often does clinical training and research with other disciplines after receiving foundational education.  Other health professionals often have earlyseminars or classroom training together.  We typically get on the Interprofessional train a bit late.  Integrated primary care seems a perfect vehicle for such a seminar for psychology graduate students to learn withother health professionals about issues such as population health, healthcare financing, collaboration, the science of teamwork, etc. – topics that all disciplines need to learn and would usefully be learned together.

"To accomplish this task, we convened a group of talented expert educator psychologists who know integrated primary care and were already involved in Interprofessional teaching at the early graduate level.  This crackerjack group was co-chaired by Ron Rozensky and Jeff Goodie, with the able assistance of Catherine Grus from the Education Directorate.  We met once, but had many phone calls and emails before and after the meeting.  Once the curriculum was in solid draft form, we sent it to members of the Integrated Primary Care Alliance for feedback.  After incorporating their suggestions, the curriculum was posted to the APA web-site for anyone to access free of charge.  Check it out!  (http://www.apa.org/education/grad/curriculum-seminar.aspx).  I wish all psychology students (practice, science, applied) were required to have an Interprofessional seminar early in their career, before applying any of it in practice or on research teams."  The era of perhaps comfortable, but unfortunately isolated professional silos is rapidly passing.  Those fortunate to work within visionary systems of health care delivery and/or educational institutions will find themselves increasingly exposed to exciting challenges and unprecedented opportunities.

Exciting Opportunities to Contribute:  Under the leadership of Dean Carol Romano, former Chief Nurse Officer for the U.S. Public Health Service, the Daniel K. Inouye Graduate School of Nursing (GSN) at the Uniformed Services University (USU) of the Department of Defense has recently initiated graduate student clinical placements in American Samoa.  Located in the South Pacific, midway between Hawaii and New Zealand, this site was chosen in 1872 as a coaling station for the U.S. Navy.  After the attack on Pearl Harbor on December 7, 1941, naval activity there increased significantly.  On January 11, 1942, a Japanese submarine surfaced off the coast of Tutuila and fired 15 shells from its deck gun at the Naval Station, most landing harmlessly in the bay.  This fire was not returned and it turned out to be the only Japanese attack on American Samoa during World War II.

American Samoa is a U.S. territory, covering seven islands and atolls.  Its current population approximates 55,500 with a land mass of 76.8 square miles, slightly more than Washington, DC.  It is noted for having the highest rate of military enlistment of any U.S. state or territory.  Today, health care is provided by the Department of Health (DOH), the Lyndon B. Johnson tropical medical center, a VA clinic, and a federally qualified community health center.  Traditional private practice is essentially non-existent.  With an extreme shortage of health professionals of all disciplines, as is all too common throughout rural America, health disparities are rampant.

            "Lt. Christopher Johnson (U.S. Navy) and I, Major Douglas Taylor (U.S. Army), were the first Graduate School of Nursing students from USU to complete a clinical rotation in American Samoa.  It was a three-and-a-half week rotation, the first of a new partnership between the USU and the Department of Health of American Samoa.  Professors Jill Schramm, Eric Pauli, and several other faculty members recognized the military and healthcare educational value of this experience.  They worked with American Samoan partners, Sandra King-Young, DOH Director Motusa Tuileama To'atolu Nua (retired US Army), and others to establish a Memorandum of Understanding (MOU) signed personally by the Governor of American Samoa and the President of USU.  Lt. Johnson is a Women's Health and Family Nurse Practitioner student and I am a Psychiatric Mental Health Nurse Practitioner student.  Interestingly, Mrs. King-Young served as an American Samoan Fellow in the office of the late U.S. Senator Daniel K. Inouye.  In our judgment, this clinical experience was critical to our military mission, health education, and without a doubt, our personal growth.

           "The mission of a military health officer is ensuring a Ready Medical Force and a Medically Ready Force.  The medically ready force ensures our Service Members are ready for combat, but the ready medical force ensures that, as a health professional, I am ready to deploy and engage in medical care anywhere in the world.  Our clinical rotation to American Samoa expanded our ability to effectively meet the mission of a ready medical force.  The United States projects its presence in many ways and one such way is supporting, building, and contributing to the health stability of a region.  I have to be ready to engage local leaders, local media, and local health providers.  American Samoa provided a real-life testing of these skills.

"On our first day, jet lag in full force, we met with the Governor and Lt. Governor (a Veteran himself) and were surprised to find both news reporters and camera crew waiting to interview us (http://samoanews.com/visiting-medical-practitioners).  My training from Army Captains Career Course and media training from Operation Bushmaster (a field training exercise at USU) kicked in, and Lt. Johnson and I successfully navigated a media event, redirecting questions like 'Will the U.S. military do anything about the supply shortages on the island?' back to our clinical mission.  Lastly, each day on the island, we engaged with local health providers, providing education and mentorship – ensuring that our presence had a lasting change to island health care.

            "As a health professional, cultural competence is essential to providing relevant mental health treatment.  On this trip, I learned that major depressive disorder can present incredibly similar in American Samoa as it does in my practice at home.  I also learned about differences, such as how the American Samoan culture emphasizes the 'We' instead of 'Me' and that multiple members of the family will show up for an appointment.  I'm thinking specifically of Joan (not her real name) who was brought in by her two younger sisters for being 'forgetful.'  When she was called into my office, her sisters came in with her.  At first, I assumed that it would be more culturally appropriate to include her family in the interview with her.  However, this assumption proved wrong and, in fact, Joan opened up much more when we were alone.  I learned that I had to be careful not to impose my beliefs of privacy, but also not to overcompensate by acting on misunderstood cultural norms.  I definitely still have much to learn in the practice of identifying cultural similarities and differences in the therapeutic relationship.  However, I know I am better at it for having served even so briefly in American Samoa.

            "Lastly, I grew as a person while in American Samoa and this can only be attributed to the people I met.  In particular, one person stands out as both an inspiration and hero.  Mrs. Mara Brown is the director at the Juvenile Detention Center.  I had the opportunity to meet her and the three counselors who work at her facility.  Prior to her arrival, the youth who passed through the detention center cells rarely completed high school.  Since she took over, 100% of the youth graduate from high school.  She turned the detention center from a focus on punishment to a focus on rehabilitation and recovery.  Two of her youth have gone on to join the military, one the postal service in Hawaii, and others have become productive members of the American Samoan community.  Often times, she and her counselors will work twelve-hour days or over the weekend without compensation.  It was amazing to see how one dedicated individual attained the right job, built the right team, and accessed the right resources to help the most vulnerable in our society.  I was able to share some of my knowledge with her and her staff during a two-hour education session on suicide assessment and prevention.  It was by far the most important work I did on the island and one of the most fulfilling moments of my professional life.  I am beyond thankful for the opportunity to practice in American Samoa.  I know I am better for it and I am confident that the people we met valued our presence."  Hopefully, the psychology, public health, and other medical school specialties at USU will soon follow the leadership of the GSN.

            Substantive Change Takes Time:  In 1982, the Institute of Medicine called for: "(G)reater interdisciplinary collaboration within the scientific community and more communication between it and clinical practitioners….  Interdisciplinary collaboration is not an end in itself; rather, it is a means to a higher goal – solving a problem….  (I)t should be possible to construct a reasonably unified biobehavioral science pertinent to health and disease, with major applications in all the health professions and by the public at large."  "(T)o live in unless we make it a reasonably good place for all of us to live in."  Aloha,

Pat DeLeon, former APA President – Division 29 – October, 2017

 

Sent from my iPhone

ALOHA - D29 column

“THIS COUNTRY WILL NOT BE A PERMANENTLY GOOD PLACE FOR ANY OF US…”

            Developing a Visionary Perspective:  After nearly four decades of involvement at the federal policy level, we have come to appreciate how those who serve in higher office (whether within the Congress, the Administration, or their national professional associations) often develop an intuitive understanding of the “waves of change” and how their interests and expertise must continue to evolve in order to remain relevant and “cutting edge.”  Former APA Presidents Suzanne Bennett Johnson and Susan McDaniel emphasized the importance of psychology affirmatively embracing interprofessional integrated care.  Psychologist Peter Kaufmann, former Acting Director of the Office of Behavioral and Social Sciences Research at the National Institutes of Health and former President of the Society of Behavioral Medicine, recently transitioned to the University of Colorado’s College of Nursing as Associate Dean of Research.  He finds that nursing faces challenges similar to those of psychology with respect to research and practice, yet both can learn from one another.  Colleagues invested in mental and/or behavioral health must appreciate the fundamental importance of regularly interacting with the other disciplines (e.g., nursing, clinical pharmacy, social work, physician assistants, and medicine) which are essentially working with the same patients or systems/organizations; notwithstanding our different professional training backgrounds.  Fundamental change evolves from collective past experiences and challenges.

            Two of Susan’s 2016 Presidential Initiatives exemplify this commitment to increasing psychology’s role in interprofessional integrated care.  “The first initiative took a year to accomplish: developing a meeting of Presidents and CEOs or Government Relations people of all the primary care and mental health professional associations (including family medicine, pediatrics, general internal medicine, psychology, psychiatry, social work, nurse practitioners, nurses, physician assistants, etc.).  We called it the Integrated Primary Care Alliance.  Eighty-three leaders from 28 associations met at the APA Tower Conference Center in April for two days, to work on inter-professional approaches to integrated primary care with regard to: advocacy, education, research methodologies, team-based care, and healthcare disparities.  Many of these leaders had never met each other, and few had been to APA.  More than a handful said this was the best meeting they had ever attended!

            “My second Interprofessional initiative was to develop a curriculum for an Interprofessional seminar for integrated primary care that will be taught early in the graduate training of all health professionals.  Psychology often does clinical training and research with other disciplines after receiving foundational education.  Other health professionals often have early seminars or classroom training together.  We typically get on the Interprofessional train a bit late.  Integrated primary care seems a perfect vehicle for such a seminar for psychology graduate students to learn with other health professionals about issues such as population health, healthcare financing, collaboration, the science of teamwork, etc. – topics that all disciplines need to learn and would usefully be learned together.

“To accomplish this task, we convened a group of talented expert educator psychologists who know integrated primary care and were already involved in Interprofessional teaching at the early graduate level.  This crackerjack group was co-chaired by Ron Rozensky and Jeff Goodie, with the able assistance of Catherine Grus from the Education Directorate.  We met once, but had many phone calls and emails before and after the meeting.  Once the curriculum was in solid draft form, we sent it to members of the Integrated Primary Care Alliance for feedback.  After incorporating their suggestions, the curriculum was posted to the APA web-site for anyone to access free of charge.  Check it out!  (http://www.apa.org/education/grad/curriculum-seminar.aspx).  I wish all psychology students (practice, science, applied) were required to have an Interprofessional seminar early in their career, before applying any of it in practice or on research teams.”  The era of perhaps comfortable, but unfortunately isolated professional silos is rapidly passing.  Those fortunate to work within visionary systems of health care delivery and/or educational institutions will find themselves increasingly exposed to exciting challenges and unprecedented opportunities.

Exciting Opportunities to Contribute:  Under the leadership of Dean Carol Romano, former Chief Nurse Officer for the U.S. Public Health Service, the Daniel K. Inouye Graduate School of Nursing (GSN) at the Uniformed Services University (USU) of the Department of Defense has recently initiated graduate student clinical placements in American Samoa.  Located in the South Pacific, midway between Hawaii and New Zealand, this site was chosen in 1872 as a coaling station for the U.S. Navy.  After the attack on Pearl Harbor on December 7, 1941, naval activity there increased significantly.  On January 11, 1942, a Japanese submarine surfaced off the coast of Tutuila and fired 15 shells from its deck gun at the Naval Station, most landing harmlessly in the bay.  This fire was not returned and it turned out to be the only Japanese attack on American Samoa during World War II.

American Samoa is a U.S. territory, covering seven islands and atolls.  Its current population approximates 55,500 with a land mass of 76.8 square miles, slightly more than Washington, DC.  It is noted for having the highest rate of military enlistment of any U.S. state or territory.  Today, health care is provided by the Department of Health (DOH), the Lyndon B. Johnson tropical medical center, a VA clinic, and a federally qualified community health center.  Traditional private practice is essentially non-existent.  With an extreme shortage of health professionals of all disciplines, as is all too common throughout rural America, health disparities are rampant.

            “Lt. Christopher Johnson (U.S. Navy) and I, Major Douglas Taylor (U.S. Army), were the first Graduate School of Nursing students from USU to complete a clinical rotation in American Samoa.  It was a three-and-a-half week rotation, the first of a new partnership between the USU and the Department of Health of American Samoa.  Professors Jill Schramm, Eric Pauli, and several other faculty members recognized the military and healthcare educational value of this experience.  They worked with American Samoan partners, Sandra King-Young, DOH Director Motusa Tuileama To’atolu Nua (retired US Army), and others to establish a Memorandum of Understanding (MOU) signed personally by the Governor of American Samoa and the President of USU.  Lt. Johnson is a Women’s Health and Family Nurse Practitioner student and I am a Psychiatric Mental Health Nurse Practitioner student.  Interestingly, Mrs. King-Young served as an American Samoan Fellow in the office of the late U.S. Senator Daniel K. Inouye.  In our judgment, this clinical experience was critical to our military mission, health education, and without a doubt, our personal growth.

           “The mission of a military health officer is ensuring a Ready Medical Force and a Medically Ready Force.  The medically ready force ensures our Service Members are ready for combat, but the ready medical force ensures that, as a health professional, I am ready to deploy and engage in medical care anywhere in the world.  Our clinical rotation to American Samoa expanded our ability to effectively meet the mission of a ready medical force.  The United States projects its presence in many ways and one such way is supporting, building, and contributing to the health stability of a region.  I have to be ready to engage local leaders, local media, and local health providers.  American Samoa provided a real-life testing of these skills.

“On our first day, jet lag in full force, we met with the Governor and Lt. Governor (a Veteran himself) and were surprised to find both news reporters and camera crew waiting to interview us (http://samoanews.com/visiting-medical-practitioners).  My training from Army Captains Career Course and media training from Operation Bushmaster (a field training exercise at USU) kicked in, and Lt. Johnson and I successfully navigated a media event, redirecting questions like ‘Will the U.S. military do anything about the supply shortages on the island?’ back to our clinical mission.  Lastly, each day on the island, we engaged with local health providers, providing education and mentorship – ensuring that our presence had a lasting change to island health care.

            “As a health professional, cultural competence is essential to providing relevant mental health treatment.  On this trip, I learned that major depressive disorder can present incredibly similar in American Samoa as it does in my practice at home.  I also learned about differences, such as how the American Samoan culture emphasizes the ‘We’ instead of ‘Me’ and that multiple members of the family will show up for an appointment.  I’m thinking specifically of Joan (not her real name) who was brought in by her two younger sisters for being ‘forgetful.’  When she was called into my office, her sisters came in with her.  At first, I assumed that it would be more culturally appropriate to include her family in the interview with her.  However, this assumption proved wrong and, in fact, Joan opened up much more when we were alone.  I learned that I had to be careful not to impose my beliefs of privacy, but also not to overcompensate by acting on misunderstood cultural norms.  I definitely still have much to learn in the practice of identifying cultural similarities and differences in the therapeutic relationship.  However, I know I am better at it for having served even so briefly in American Samoa.

            “Lastly, I grew as a person while in American Samoa and this can only be attributed to the people I met.  In particular, one person stands out as both an inspiration and hero.  Mrs. Mara Brown is the director at the Juvenile Detention Center.  I had the opportunity to meet her and the three counselors who work at her facility.  Prior to her arrival, the youth who passed through the detention center cells rarely completed high school.  Since she took over, 100% of the youth graduate from high school.  She turned the detention center from a focus on punishment to a focus on rehabilitation and recovery.  Two of her youth have gone on to join the military, one the postal service in Hawaii, and others have become productive members of the American Samoan community.  Often times, she and her counselors will work twelve-hour days or over the weekend without compensation.  It was amazing to see how one dedicated individual attained the right job, built the right team, and accessed the right resources to help the most vulnerable in our society.  I was able to share some of my knowledge with her and her staff during a two-hour education session on suicide assessment and prevention.  It was by far the most important work I did on the island and one of the most fulfilling moments of my professional life.  I am beyond thankful for the opportunity to practice in American Samoa.  I know I am better for it and I am confident that the people we met valued our presence.”  Hopefully, the psychology, public health, and other medical school specialties at USU will soon follow the leadership of the GSN.

            Substantive Change Takes Time:  In 1982, the Institute of Medicine called for: “(G)reater interdisciplinary collaboration within the scientific community and more communication between it and clinical practitioners….  Interdisciplinary collaboration is not an end in itself; rather, it is a means to a higher goal – solving a problem….  (I)t should be possible to construct a reasonably unified biobehavioral science pertinent to health and disease, with major applications in all the health professions and by the public at large.”  “(T)o live in unless we make it a reasonably good place for all of us to live in.”  Aloha,

Pat DeLeon, former APA President – Division 29 – October, 2017

 

IF YOU PLAY IT SAFE IN LIFE

A National Vision:  In December, 2013, following the service of Chairman Ron Rozensky, I was very fortunate to be appointed by Health and Human Services (HHS) Secretary Kathleen Sebelius to her Advisory Committee on Interdisciplinary, Community-Based Linkages (ACICBL), which provides policy and program development guidance for a number of the health professions training programs administered by the Health Resources and Services Administration (HRSA).  During his term as Chair of ACICBL, Ron noted that they co-signed a letter to Congress supporting the inclusion of funding for interprofessional healthcare in the Affordable Care Act (ACA) and their Annual Report to Congress stressed the importance of behavioral health integrated care.  "Having psychologists on this key federal advisory committee is an important mechanism that supports our voice being in the room when critical policy for tomorrow's interprofessional healthcare systems is being crafted."  This August, ACICBL issued its 15^th Annual Report to the Secretary and the U.S. Congress.  My term has now concluded; however, I am confident that rural America, our nation's Native Americans, and psychology will be well represented by Jacqueline Gray who will continue to serve on ACICBL.

            "The United States healthcare system strives to deliver safe and effective care, while also promoting innovations in procedures, medications, and technology.  Despite its strengths, the system is expensive and inefficient.  As a result, the health status of the U.S. population lags behind that of many other developed countries.  Furthermore, the system must now respond to changing conditions, including an aging population, an increase in chronic health conditions, and ongoing disparities in health outcomes that show the benefits of the healthcare system are not accessible to all.  There is a greater emphasis on primary and preventive care, along with a shift toward value-based services.

            "These changes impact the healthcare workforce.  However, this workforce faces several challenges, including a shortage of qualified practitioners, poor geographic distribution of practitioners that limits access to services, and an increasing average age of both current practitioners and the faculty who teach new students.  Meanwhile, healthcare organizations are transitioning toward an interprofessional team-based model of care, in which traditional health professionals work alongside community health workers or other providers, bringing together complementary skills toward the goal of improving patient care.  All of these factors point to an urgent need to adjust health policies, develop new methods of education, and increase investment in healthcare workforce training to promote interprofessional education and practice.

            "There has also been increasing discussion on improving training methods.  Traditional training criteria involve the completion of a set number of training hours or types of care experiences.  However, educators in many professions are examining models in which students must demonstrate their competence in fundamental skills, knowledge, and attitudes to become certified to practice.  This competency-based training allows for greater individualization in the design and evaluation of learning experiences (ACICBL, 2017)."

            The report further notes that the nation's healthcare system has traditionally focused on providing acute care within a hospital or similar clinical setting.  The aim of this approach is to preserve or restore health in the event of an illness or injury.  Acute care is, by definition, episodic and tends to treat only the current problem.  As such, it tends to be uncoordinated, inefficient, and expensive, often failing to address underlying health conditions or to help patients reduce preventable health risks.  In sharp contrast, the healthcare envisioned by President Obama's ACA, as well as the "Triple Aim" proposed by the former Administrator of the Centers for Medicare and Medicaid Services (CMS) Donald Berwick, emphasizes improving the experience of care, improving the health of populations, and reducing per capita costs simultaneously.  To succeed in this transformation, there must be a conscious shift away from traditional professional educational "silos" and equally importantly, developing respect by the next generation of practitioners for each profession's unique perspective.  To accomplish these goals, training for students in the health professions will need to incorporate the value of teamwork and include collaborative experiences with other health professionals.  This visionary approach represents a fundamental, if not unprecedented, shift in orientation from the status quo.

            APA Education Directorate's Catherine Grus: "Interprofessional training experiences should be provided to health professions students early in their training to help mitigate the formation of professional stereotypes and continue on through their clinical rotations.  It is equally important to provide opportunities for practicing health professionals to enhance their skills in interprofessional collaborative practice so that when the next generation enters the healthcare workforce they will have role models."

            Not surprisingly, ACICBL's first Policy Recommendation is: "Congress revise the eligibility requirements for Title VII, Part D, programs.  Eligibility should not be limited to specific health professions schools in isolation.  To promote interprofessional education, applicants should be permitted to develop the strongest consortia available to them, based on their access to local health professions schools, the strength of available partners, and the needs of the community."

            In a recent "letter to the editor" for a nursing journal, a director of a Nurse Practitioner program commented: "To me, the overarching health care system is like an umbrella with the different spokes representing various disciplines such as Psychology, Nursing, Social Work, Medicine, Therapies (physical, occ, rehab), Nutrition, etc.  The handle is held by and belongs to the patient as 'captain of the ship.'  After all, whose life is it anyway?"  She went on to comment on the number of times the term "medical" was used when instead should have been "health."  "I don't think nursing will be recognized as an autonomous profession until the word 'health' is substituted for 'medicine'".

            The Illinois Vision:  "With the passage by both Houses of the Illinois State Legislature of Senate Bill #2187 on May 29^th and 30^th of 2014, and the signature of then-Governor Pat Quinn on June 25, 2014, the Clinical Psychologist Licensing Act was expanded to give licensed clinical psychologists, with advanced, specialized training in Clinical Psychopharmacology and Medicine, the opportunity to apply to the Illinois Department of Financial and Professional Regulation for licensure as a 'prescribing psychologist.'  Our legislation served as a signal that Illinois was interested in repairing a broken healthcare system.  The new statute opened up access to mental health care for the most poorly served citizens throughout our state.

            "The passage of an RxP law significantly advanced the field of psychology, as we become only the fourth state (after Indiana, New Mexico and Louisiana), and the first northern, industrial state, in the nation to pass a prescriptive authority statute.  While Guam passed its RxP legislation in 1998, it is a U.S. Territory.  Iowa (2016) and Idaho (2017) quickly followed Illinois' passage.  Uniquely, in Illinois, licensed clinical psychologists, as well as psychology graduate and undergraduate students, can embark on their studies to become prescribing psychologists.  The Illinois law contains three levels of required training: * seven undergraduate basic science courses; * the Master's in Clinical Psychopharmacology with the capstone Psychopharmacology Exam for Psychologists-2 (PEP-2); and, * a series of rotations through nine medical specialties over a period of 14 months (minimum) – 28 months (maximum).

            "With the hard work and persistence of IPA leadership, staff, and a vigorous and ever-growing group of dedicated IPA members, as well as the persistence of our lobbyists, administrative attorneys, and state legislative champions (Senator President Pro-Tem, Don Harmon, in particular), the final rules for the RxP law were approved on September 12, 2017 – more than three years after SB #2187 was signed into law.

            "After spending these years implementing the tenets of our legislation, I like to say that Illinois RxP is currently in its 'toddler' stage.  There are more than 150 Illinois licensed clinical psychologists who are currently studying to become licensed prescribing psychologists.  Of those 150, at least 25 have completed their Master's degrees in Clinical Psychopharmacology as well as their required series of seven undergraduate basic science courses; have taken their capstone exam (PEP); and are now poised to enter their medical rotations.  In addition, there are 75 undergraduate psychology majors at the largest state University, the University of Illinois, Champaign-Urbana, who have chosen the 'pre-prescribing psychology' concentration, which adds the seven statute-required basic science classes to their traditional undergraduate psychology curriculum.  Major medical center and hospital systems, as well as local community hospitals, are working with us to provide the required rotation opportunities.

            "As we approach 2021, Illinois psychologists and our many third party supporters (medical center CEO's, psychiatric medical directors, social service organizations, elder care agencies, primary care physicians) will be preparing to go back to our state legislature to lobby for the removal of some of our initial statutory constraints.  Like nurse practitioners, physician assistants, and optometrists before us, the plan is for us to continue to return to the state legislature every five years until we can practice without statutory constraint.

"There is palpable excitement among our psychologist colleagues.  We have a vision of a future in which our training, our experience, and our comprehensive competencies will give us the opportunity to meet the mental and behavioral health needs of so many of our community's most underserved populations.  Our expertise is already in great demand.  Meeting that demand will give us tremendous personal and professional satisfaction (Beth Rom-Rymer)."  "You've decided that you don't want to grow anymore."  Aloha,

Pat DeLeon, former APA President – Division 55 – October, 2017

 

Sent from my iPhone

Division 55 column

“IF YOU PLAY IT SAFE IN LIFE”

A National Vision:  In December, 2013, following the service of Chairman Ron Rozensky, I was very fortunate to be appointed by Health and Human Services (HHS) Secretary Kathleen Sebelius to her Advisory Committee on Interdisciplinary, Community-Based Linkages (ACICBL), which provides policy and program development guidance for a number of the health professions training programs administered by the Health Resources and Services Administration (HRSA).  During his term as Chair of ACICBL, Ron noted that they co-signed a letter to Congress supporting the inclusion of funding for interprofessional healthcare in the Affordable Care Act (ACA) and their Annual Report to Congress stressed the importance of behavioral health integrated care.  “Having psychologists on this key federal advisory committee is an important mechanism that supports our voice being in the room when critical policy for tomorrow’s interprofessional healthcare systems is being crafted.”  This August, ACICBL issued its 15^th Annual Report to the Secretary and the U.S. Congress.  My term has now concluded; however, I am confident that rural America, our nation’s Native Americans, and psychology will be well represented by Jacqueline Gray who will continue to serve on ACICBL.

            “The United States healthcare system strives to deliver safe and effective care, while also promoting innovations in procedures, medications, and technology.  Despite its strengths, the system is expensive and inefficient.  As a result, the health status of the U.S. population lags behind that of many other developed countries.  Furthermore, the system must now respond to changing conditions, including an aging population, an increase in chronic health conditions, and ongoing disparities in health outcomes that show the benefits of the healthcare system are not accessible to all.  There is a greater emphasis on primary and preventive care, along with a shift toward value-based services.

            “These changes impact the healthcare workforce.  However, this workforce faces several challenges, including a shortage of qualified practitioners, poor geographic distribution of practitioners that limits access to services, and an increasing average age of both current practitioners and the faculty who teach new students.  Meanwhile, healthcare organizations are transitioning toward an interprofessional team-based model of care, in which traditional health professionals work alongside community health workers or other providers, bringing together complementary skills toward the goal of improving patient care.  All of these factors point to an urgent need to adjust health policies, develop new methods of education, and increase investment in healthcare workforce training to promote interprofessional education and practice.

            “There has also been increasing discussion on improving training methods.  Traditional training criteria involve the completion of a set number of training hours or types of care experiences.  However, educators in many professions are examining models in which students must demonstrate their competence in fundamental skills, knowledge, and attitudes to become certified to practice.  This competency-based training allows for greater individualization in the design and evaluation of learning experiences (ACICBL, 2017).”

            The report further notes that the nation’s healthcare system has traditionally focused on providing acute care within a hospital or similar clinical setting.  The aim of this approach is to preserve or restore health in the event of an illness or injury.  Acute care is, by definition, episodic and tends to treat only the current problem.  As such, it tends to be uncoordinated, inefficient, and expensive, often failing to address underlying health conditions or to help patients reduce preventable health risks.  In sharp contrast, the healthcare envisioned by President Obama’s ACA, as well as the “Triple Aim” proposed by the former Administrator of the Centers for Medicare and Medicaid Services (CMS) Donald Berwick, emphasizes improving the experience of care, improving the health of populations, and reducing per capita costs simultaneously.  To succeed in this transformation, there must be a conscious shift away from traditional professional educational “silos” and equally importantly, developing respect by the next generation of practitioners for each profession’s unique perspective.  To accomplish these goals, training for students in the health professions will need to incorporate the value of teamwork and include collaborative experiences with other health professionals.  This visionary approach represents a fundamental, if not unprecedented, shift in orientation from the status quo.

            APA Education Directorate’s Catherine Grus: “Interprofessional training experiences should be provided to health professions students early in their training to help mitigate the formation of professional stereotypes and continue on through their clinical rotations.  It is equally important to provide opportunities for practicing health professionals to enhance their skills in interprofessional collaborative practice so that when the next generation enters the healthcare workforce they will have role models.”

            Not surprisingly, ACICBL’s first Policy Recommendation is: “Congress revise the eligibility requirements for Title VII, Part D, programs.  Eligibility should not be limited to specific health professions schools in isolation.  To promote interprofessional education, applicants should be permitted to develop the strongest consortia available to them, based on their access to local health professions schools, the strength of available partners, and the needs of the community.”

            In a recent “letter to the editor” for a nursing journal, a director of a Nurse Practitioner program commented: “To me, the overarching health care system is like an umbrella with the different spokes representing various disciplines such as Psychology, Nursing, Social Work, Medicine, Therapies (physical, occ, rehab), Nutrition, etc.  The handle is held by and belongs to the patient as ‘captain of the ship.’  After all, whose life is it anyway?”  She went on to comment on the number of times the term “medical” was used when instead should have been “health.”  “I don’t think nursing will be recognized as an autonomous profession until the word ‘health’ is substituted for ‘medicine’”.

            The Illinois Vision:  “With the passage by both Houses of the Illinois State Legislature of Senate Bill #2187 on May 29^th and 30^th of 2014, and the signature of then-Governor Pat Quinn on June 25, 2014, the Clinical Psychologist Licensing Act was expanded to give licensed clinical psychologists, with advanced, specialized training in Clinical Psychopharmacology and Medicine, the opportunity to apply to the Illinois Department of Financial and Professional Regulation for licensure as a ‘prescribing psychologist.’  Our legislation served as a signal that Illinois was interested in repairing a broken healthcare system.  The new statute opened up access to mental health care for the most poorly served citizens throughout our state.

            “The passage of an RxP law significantly advanced the field of psychology, as we become only the fourth state (after Indiana, New Mexico and Louisiana), and the first northern, industrial state, in the nation to pass a prescriptive authority statute.  While Guam passed its RxP legislation in 1998, it is a U.S. Territory.  Iowa (2016) and Idaho (2017) quickly followed Illinois’ passage.  Uniquely, in Illinois, licensed clinical psychologists, as well as psychology graduate and undergraduate students, can embark on their studies to become prescribing psychologists.  The Illinois law contains three levels of required training: * seven undergraduate basic science courses; * the Master’s in Clinical Psychopharmacology with the capstone Psychopharmacology Exam for Psychologists-2 (PEP-2); and, * a series of rotations through nine medical specialties over a period of 14 months (minimum) – 28 months (maximum).

            “With the hard work and persistence of IPA leadership, staff, and a vigorous and ever-growing group of dedicated IPA members, as well as the persistence of our lobbyists, administrative attorneys, and state legislative champions (Senator President Pro-Tem, Don Harmon, in particular), the final rules for the RxP law were approved on September 12, 2017 – more than three years after SB #2187 was signed into law.

            “After spending these years implementing the tenets of our legislation, I like to say that Illinois RxP is currently in its ‘toddler’ stage.  There are more than 150 Illinois licensed clinical psychologists who are currently studying to become licensed prescribing psychologists.  Of those 150, at least 25 have completed their Master’s degrees in Clinical Psychopharmacology as well as their required series of seven undergraduate basic science courses; have taken their capstone exam (PEP); and are now poised to enter their medical rotations.  In addition, there are 75 undergraduate psychology majors at the largest state University, the University of Illinois, Champaign-Urbana, who have chosen the ‘pre-prescribing psychology’ concentration, which adds the seven statute-required basic science classes to their traditional undergraduate psychology curriculum.  Major medical center and hospital systems, as well as local community hospitals, are working with us to provide the required rotation opportunities.

            “As we approach 2021, Illinois psychologists and our many third party supporters (medical center CEO’s, psychiatric medical directors, social service organizations, elder care agencies, primary care physicians) will be preparing to go back to our state legislature to lobby for the removal of some of our initial statutory constraints.  Like nurse practitioners, physician assistants, and optometrists before us, the plan is for us to continue to return to the state legislature every five years until we can practice without statutory constraint.

“There is palpable excitement among our psychologist colleagues.  We have a vision of a future in which our training, our experience, and our comprehensive competencies will give us the opportunity to meet the mental and behavioral health needs of so many of our community’s most underserved populations.  Our expertise is already in great demand.  Meeting that demand will give us tremendous personal and professional satisfaction (Beth Rom-Rymer).”  “You’ve decided that you don’t want to grow anymore.”  Aloha,

Pat DeLeon, former APA President – Division 55 – October, 2017