“IF LIFE IS FAIR WHY DOES ROSES HAVE THORNS”
I have now served two terms on the National Institute of Medicine (NAM) Board on Children, Youth, and Families. This has been a fascinating opportunity to work with colleagues from a number of diverse disciplines on behalf of our nation’s children. Psychology is very fortunate that former APA Congressional Fellow Natacha Blain serves as Director of the Board, as the behavioral sciences have much to offer to these critical deliberations. This summer the Board released the proceedings of its workshop Training the Future Child Health Care Workforce to Improve Behavioral Health Outcomes for Children, Youth, and Families.
“Childhood diagnoses of cognitive, affective, and behavioral disorders are increasing in both absolute numbers and as a proportion of the total childhood population in the United States, and they are imposing a large and growing burden on children, youth, and families. However, the adoption of evidence-based interventions that have proven effective in preventing and treating behavioral health disorders in children has been slow. A contributing factor for this slow adoption may be that current training in many fields involving the behavioral health of children is falling short of meeting their needs.” Highlights of the proceedings:
The workforce involved in promoting children’s cognitive, affective, and behavioral health is broad and varied, including pediatricians, adult and child psychiatrists, family medicine physicians, obstetricians and gynecologists, nurses, social workers, community and public health professionals, and parents who have been trained to fill professional roles. Nevertheless, there is a workforce crisis due to an increased demand for behavioral health services, too few workers to meet the demand, a poorly distributed workforce, a need for additional training, an increased emphasis on integrated team-based care and treatment of co-occurring disorders, and a lack of systematic workforce data collection. Overall, the expected shortage of trained professionals will continue to be substantial through 2025, notwithstanding that currently over 900,000 licensed professionals work in behavioral health. “The total shortage in the selected behavioral health occupations is projected to be about a quarter million workers. In addition, the workforce is aging, more workers are needed in rural areas, the workforce needs to become more diverse, and people serving specialized populations need more specialized training.”
APA was represented by Doug Tynan who emphasized that all mental health providers need to receive training in delivering effective, evidence-based therapies in primary care settings – an underlying tenant of President Obama’s Affordable Care Act (ACA). Former APA President Susan McDaniel presented on Interprofessional training bringing together Psychology Post-doctoral fellows and pediatric and family medicine residents and fellows. She described the two-year curriculum that includes seminars, experiential exercises, supervision, and collaborative practice in their integrated primary care clinics. At the end of her presentation a leader in pediatrics stood up and said: “This is amazing! Why isn’t this implemented all over the country?” Why not indeed? One projection that I fundamentally disagree with is: “(S)hortages will continue to be substantial… in all the professions except behavioral health nurse practitioners and physician assistants.” As the nation’s health care environment continues to evolve towards integrated primary care systems (e.g., the ACA’s Accountable Care Organizations and Patient-Centered Medical Homes) we expect that these two disciplines will become increasingly important in providing necessary care and policy development.
It is exciting to work with colleagues who appreciate the “bigger picture.” Under the leadership of former USPHS chief nurse Dean Carol Romano, the USU Daniel K. Inouye Graduate School of Nursing has placed one of their DNP graduate students at the Lana’i Federally Qualified Community Health Center (LCHC). CEO Diana Shaw: “We recently formed a relationship with USU bringing with it a shared opportunity for learning and new experiences. U.S. Navy LCDR Kayla R. Horton started her internship with LCHC this month. She is excited to be with us and is learning and sharpening her skills as a future APRN in a rural, remote diverse setting. This experience is unique and provides her with access to a full range of family practice issues and the use of tele-medicine – especially services that she might not get in her military career, such as working with a medically underserved population on a small rural island. Kayla is also exposed to the cultural diversity of our community, which will add enhanced cultural sensitivity to her arsenal of health care tools. From our perspective, we are gaining additional experience with our workforce development program and honing our contribution to the educational preparation of health care professionals by allowing faculty and students to participate in our activities and live within our small community. Overall our joint efforts and combined resources work to develop, improve, and sustain the delivery of outstanding medical, dental, nursing, and clinical care and preventive medicine.”
Over the nearly four decades of working with Senator Inouye, I came to appreciate that substantive change always takes time and is usually based upon foundations that have been built by often unappreciated visionaries. In March, 2010, then-U.S. Army Surgeon General Eric Schoomaker, currently on the USU faculty, testified before the Senator regarding the status of Army Medicine. “I am in awe at what these selfless servants have done over the past years – their accomplishments have been quietly, effectively, powerfully successful. While we have experienced our share of crises and even tragedies, despite eight years of continuous armed conflict for which Army Medicine bears a heavy load, every day our Soldiers and their Families are kept from injuries, illnesses, and combat wounds through our health promotion and prevention efforts; are treated in cutting-edge fashion when prevention fails; and are supported by an extraordinarily talented medical force.”
A number of his underlying themes were reflected in the ACA and the NAM proceedings. ”The first strategic theme – Maximize Value in Health Services – is built on the belief that providing high quality, evidence-based services is not only right for our Soldiers and Families; it results in the most efficient use of resources within the healthcare system, thus delivering value to not only our Patients, but indeed, the Nation. In fact, what we really want to do is move from a healthcare system to a system for health…. This requires focusing on the clinical outcome for the patient and the community and maintaining or even reducing the overall resource expenditure needed to achieve this objective. It has occurred through adoption of evidence-based practices and reducing unwarranted practice variation.” He stressed the importance of improving physical and psychological health promotion and prevention, the value of the Patient-Centered Medical Home approach, and the appropriateness of his Mental Health Advisory Team’s recommendations to develop military-specific models for identifying and addressing “provider fatigue” as the military equivalent of compassion fatigue. Focusing upon evidence-based practice, he noted the Virtual Behavioral Health Pilot (aka Comprehensive Behavioral Health Integration) being conducted at Schofield Barracks and Ft. Richardson. “To transform from a healthcare system to a system for health, we need to change the social contract. No longer should we be paid for building widgets (number of clinic visits or procedures), rather, we should be paid for preventing illness and promoting healthy lifestyles.” Personally, I have the deepest appreciation for the service and dedication of former HPA President and APA Congressional Fellow Debra Dunivin during her tenure in the U.S. Army. [Elmo]. Aloha,
Pat DeLeon, former APA President – HPA – January, 2018
