ALOHA - Division 42 column

“TIME IS ON THE SIDE OF CHANGE” -- TELEHEALTH

            On April 27, 2004 President George W. Bush opined: “(T)here’s a lot of talk about productivity gains in our society, and that’s because companies and industries have properly used information technology….  And yet the health care industry hasn’t touched it, except for certain areas.  And one area that has is the Veterans Administration [VA].”  In our judgment, the continual advances occurring within the communications and technology fields will ultimately transform health care in an unprecedented fashion.  Will our nation’s behavioral and mental health care providers, and their training institutions, embrace the challenges and opportunities that are on the horizon?

            Winifred Quinn, Director, Advocacy & Consumer Affairs, Center to Champion Nursing in America of the AARP Public Policy Institute:  “Older adults with complex care needs want to independently live with dignity and limit stress on family caregivers.  Telehealth interventions, such as remote patient monitoring, offer the potential to improve access to care and the quality of care, while reducing strain on family caregivers.  For example, the Visiting Nurse Association of Nebraska is providing people with tablets and simple bio-metric devices that allow the consumers to record and transmit their vital signs to a remote team of nurses.  This set of tools is also being used to educate people about their own health literacy.  The combination of the technology and the remote clinical team is also helping to reduce unnecessary hospitalizations and to control costs – for the consumer and the overall system.”

            Hawaii Health Systems Corporation, East Hawaii Region:  “Hilo Medical Center (HMC), a safety-net hospital on the Big Island of the State of Hawaii, delivers a full range of services and programs to the uninsured, underinsured, and vulnerable populations.  To address the growing problem of Behavior Health patients in the Emergency Room awaiting a psychiatric evaluation before final disposition, the hospital initiated a telehealth program in the ER on May 15, 2018.  HMC currently has only one psychiatrist who evaluates and admits acute Behavioral Health patients which is inadequate for the population on the island.  The telehealth program has successfully evaluated 50+ patients since inception using qualified remote physicians.  The technical set up is very minimal using a video cart.  The remote physician documents on a separate screen, which the patient is not able to view, and once the document is completed it will electronically file directly into HMC’s Electronic Health Record (EHR)” (Chris Takahashi).

            Experiences from the Front Lines:  The Department of Defense (DOD), with considerable support from the U.S. Congress, has been systematically developing a robust telehealth capacity, especially in the behavioral and mental health arena.  This was a high personal priority for Ron Blanck while serving as Commander of the Walter Reed Army Medical Center and continued during his service as the U.S. Army’s 39th Surgeon General – a futuristic vision which each of his successors have actively pursued.  Ron is currently the Chair of the Board of Regents of the Uniformed Services University (USU) from which two of my psychiatric mental health colleagues recently retired as mental health program chairs.

            “My experience with telepsychiatry health began in 2006 while I was Active Duty Army.  I established the first policies and procedures for telepsychiatry for the Western Region Medical Command.  Our mission was to provide telepsychiatric support and consultation to military installations that either did not have or had limited psychiatric resources.  In 2011, I developed the first telepsychiatric capacity in Iraq.  This allowed psychiatric providers to reach Service Members at multiple bases throughout Iraq and Kuwait, minimizing travel and risk to both patients and providers.

            “Since retiring from the Army, I started a telepsychiatry consulting company and currently provide telepsychiatric services to two rural healthcare systems in Washington State, although I am located in Virginia.  I am leveraging a collaborative care model that incorporates primary care providers and social workers into the care process.  I provide consultation to primary care providers, psychiatric evaluation and medication management, continuing education to both providers and nursing staff, and inpatient consultation to attending providers and nursing staff.  The success of this model has been predicated on incorporating behavioral health into the continuum of primary care.  Having access to, and documenting in, the organization’s EMR system has been another essential factor in the success of this model.

            “Finally, improving access to care for those in underserved areas has been incredibly rewarding.  Since starting telepsychiatry services with these facilities 18 months ago, mental health visits to the Emergency Department and Primary Care have significantly reduced and no-show rates are consistently below 10%, well below the national average of 20+% in community mental health.

            “Telepsychiatry and more broadly telebehavioral health are here to stay and are invaluable resources to support underserved populations.  Medicaid and Medicare now reimburse for services and it is only a matter of time before all payers cover these services.  Synchronizing our efforts as behavioral health providers that include comprehensive services is a step in the right direction in improving access to care and a viable solution in beginning to address the mental health crisis in this country” (U.S. Army Lt. Col. (Ret.) Jess Calohan).

            And from my other DNP colleague:  “I have just recently started to use telehealth services with patients down here in South Eastern North Carolina (e.g., Blue Cross/Blue Shield, Medicare, and Tricare).  I am currently in the first phase of use with select patients who are stable in care and/or have difficulty commuting to the practice (e.g., elderly, physically impaired, psychologically avoidant or frequent travelers).

            “Best Practice Strategies:  1. My vision for practice requires that I physically see the patient (at least) quarterly and we can employ the telehealth option in between physical appointments.  2. Have the patient bring technology (e.g., laptop or tablet) to our session to ensure it works before going live in future sessions.  3. Use a reputable video conferencing software package (e.g., Cisco’s WebEx) which incorporates administrative and technical safeguards that meet HIPAA requirements.  4. Specify in my clinical documentation that the session is a telehealth encounter for insurance purposes.  5. Establish an alternate medium (commonly telephone) as a failsafe option in the event technology breaks down on either end of the connection.  6. Be mindful of a crisis intervention plan in the event you encounter an imminent safety issue during the telehealth encounter.  7. Obtain formal training (e.g., https://telehealth.org/telebehavioral-health-certificate/) to learn legal and practical nuances associated with telehealth.  8. Not all pharmacies support electronic submission of Schedule 2 medications (e.g., psychoactive stimulants and benzodiazepines) so it is important to work that problem before starting the telehealth option because without a solution the patient will have to come into the practice anyway to pick up a physical script.  The irony in my area is that the only pharmacy that does not accept an e-script for schedule 2 medications is Naval Medical Center Camp Lejeune.  9. If the mental health provider takes the time to structure up the process and provide real time oversight, the administrative and education based aspects of telehealth implementation can be championed by a medical assistant.  Finally, 10. We also have a patient portal (patient to provider secure email) that provides additional structure and support to the telehealth option.  I no longer allow patients to call the front desk of the practice for questions.  They are all directed to the patient portal.  This way I can ‘cut and paste’ the patient’s concerns directly into the EMR.

            “General Observations:  1. Millennials tend to adapt to the medium quicker than older generations.  2. Geriatric patients tend to be more easily frustrated with the telehealth option and require more than one education session to adapt to the medium.  3. Telehealth is markedly easier (not impossible) to navigate for traditional medication management as compared to psychotherapy.  4. While initial evaluations are commonly done via the telehealth option all across the country, I have not done this yet.  While I appreciate that it is the ‘least worst option’ when you think about providing the service to geographically isolated patients, I personally think something is lost in translation when you conduct an evaluation via telehealth when it comes to rapport development and diagnostic fidelity.  5. There are certain populations who generally don’t respond well to the telehealth option.  In my experience people with poorly managed paranoia, delusions, hallucinations, substance use disorder, and cognitive impairment don’t take to it well.  For these patients telehealth can be an option once you achieve some degree of crude target symptom stabilization.  6. Getting fellow mental health providers on the (telehealth) train has been a challenge.  I commonly find that healthcare providers are more resistant to the telehealth option than the actual patient.  Telehealth is a strategic solution to several national problems that exist within our current healthcare delivery system.  Either we are on the train or under it.  Academia is already moving toward distance education.  The healthcare delivery system needs to follow that lead.  7. There is a lot of misinformation out there as it relates to the ‘rules of the road’ for safe – effective – legal telehealth.  I would recommend that before a practice embarks on this journey that they consult a specialist that understands the technologies, legalities, and established standards of care” (U.S. Navy Commander (Ret.) Sean Convoy).

            An Educated View:  During his nearly 15 year tenure directing the APA Ethics Office, Steve Behnke saw the ethics of telehealth evolve.  “Telehealth gives us a wonderful example of ethics from a developmental perspective, with the VA and DOD leading the way.  Reflecting upon my work with colleagues in both agencies, I consistently found that these folk were – and remain – on the cutting edge of the technology.  Competence is the cornerstone of ethics and these colleagues have the competence both in the technological aspects of delivering telehealth interventions and in the clinical understanding of which populations may benefit most from these services.  I am pleased that the APA Ethics Office partnered with the Association of State and Provincial Psychology Boards (ASPPB) to enhance competent and ethical practice in all areas of psychology, including telehealth.  VA and DOD psychologists have an advantage because their unique circumstances allow them to deal with jurisdictional challenges that may be obstacles for other psychologists, but ASPPB has been working diligently to allow greater flexibility in crossing jurisdictional lines.  I am personally excited about the future of telehealth and look forward to a day when financial resources, physical distance, and other impediments to meeting with a mental health professional are diminished or non-existent factors in receiving services.”

            Reflections:  Over the past several years, we have been extraordinarily impressed by the pioneering efforts of Marlene Maheu and her colleague Ken Drude to utilize the APA annual convention platform in their efforts to educate psychology as to the nuances of telehealth.  We expect that they will continue to do so and accordingly, we would urge those interested in the future to participate in their ongoing continuing education workshops.  (Associate Justice Ruth B. Ginsburg, 2009).  Aloha.     Pat DeLeon, former APA President – Division 42 – July, 2018

THE IMPORTANCE OF VISION:

The next iteration of healthcare in our nation will feature team-based, interprofessional clinical services within organized systems of care. This approach represents one of the underlying foundations of President Obama's Affordable Care Act (ACA), as well as numerous recommendations by the National Academy of Medicine (NAM) of the National Academies of Sciences, Engineering, and Medicine. APA appreciates the long-term significance of this evolution, which was a high personal priority for former APA President Susan McDaniel. Jim Diaz-Granados, Executive Director of the Education Directorate: "The Education Directorate recognizes the value of interprofessional education and training (IPE). This is evidenced by our active participation in a number of interprofessional organizations." The increasing utilization of telehealth (i.e., telepsychology), as well as other transformational advances (apps, virtual realities, social networks, etc.) that are occurring within the communications and technology fields will ultimately revolutionize healthcare. The Association of State and Provincial Psychology Boards (ASPPB) proposed "E-Passport," based upon the enactment of an Interjurisdictional Compact (PSYPACT) by the various state legislatures, is the future. Our sincerest appreciation for the most impressive vision of their CEO Steve DeMers.

For psychology to effectively engage in these uncharted waters, it is critical that our State Associations provide critical leadership by exposing their members to our colleagues in a wide range of healthcare disciplines, such as Advanced Practice Registered Nurses (APRNs), Clinical Pharmacists, Physician Assistants (PAs), Optometrists, Clinical Social Workers, etc. prior to needing to work collaborative with them in the state legislative and administrative arenas. The Health Resources and Services Administration (HRSA) recently projected that the supply of primary care NPs will increase by 30%, from 55,400 in 2010 to 72,100 in 2020; primary care PAs will increase by 58%, from 27,700 to 43,900 over the same period. Fortunately, we are increasing aware of academic colleagues who are working within the training institutions of other healthcare disciplines, beyond that of medicine.

Karen Pellegrin: "It's a great time to be a psychologist in a College of Pharmacy. Over a decade ago, the Institute of Medicine [now NAM] identified working in interdisciplinary teams as one of the core competencies essential for all healthcare professionals. More recently, accreditors of pharmacy programs and other health education programs have made interprofessional education a requirement. At the Daniel K. Inouye College of Pharmacy at the University of Hawaii at Hilo, being the only clinical psychologist on the faculty gives me so many opportunities to introduce pharmacy students to key aspects of human behavior. The first cohort of pharmacy students has begun taking coursework in our new certificate programs. As program coordinator for the Healthcare Leadership Certificate program, I teach them about the Yerkes-Dodson law of human performance, actions leaders can take to improve performance at the individual and organization levels, how organizational culture can be measured and improved, and cognitive-behavioral approaches to managing their personal finances (so that they can pay off their student loans and save enough to be able to retire some day!)."

Developing these relationships is so important I might consider donating to the American Psychological Foundation (APF) in recognition of the first one or two State Associations that understand its significance. Update: Beth Rom-Rymer reports that the prescribing license announcement just appeared on the website of the Illinois Department of Financial and Professional Regulation. An application is expected in the very near future. Aloha,

Pat DeLeon, former APA President – Division 31 – June, 2018



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ALOHA - Div 31 column

THE IMPORTANCE OF VISION:

            The next iteration of healthcare in our nation will feature team-based, interprofessional clinical services within organized systems of care.  This approach represents one of the underlying foundations of President Obama’s Affordable Care Act (ACA), as well as numerous recommendations by the National Academy of Medicine (NAM) of the National Academies of Sciences, Engineering, and Medicine.  APA appreciates the long-term significance of this evolution, which was a high personal priority for former APA President Susan McDaniel.  Jim Diaz-Granados, Executive Director of the Education Directorate: “The Education Directorate recognizes the value of interprofessional education and training (IPE).  This is evidenced by our active participation in a number of interprofessional organizations.”  The increasing utilization of telehealth (i.e., telepsychology), as well as other transformational advances (apps, virtual realities, social networks, etc.) that are occurring within the communications and technology fields will ultimately revolutionize healthcare.  The Association of State and Provincial Psychology Boards (ASPPB) proposed “E-Passport,” based upon the enactment of an Interjurisdictional Compact (PSYPACT) by the various state legislatures, is the future.  Our sincerest appreciation for the most impressive vision of their CEO Steve DeMers.

            For psychology to effectively engage in these uncharted waters, it is critical that our State Associations provide critical leadership by exposing their members to our colleagues in a wide range of healthcare disciplines, such as Advanced Practice Registered Nurses (APRNs), Clinical Pharmacists, Physician Assistants (PAs), Optometrists, Clinical Social Workers, etc. prior to needing to work collaborative with them in the state legislative and administrative arenas.  The Health Resources and Services Administration (HRSA) recently projected that the supply of primary care NPs will increase by 30%, from 55,400 in 2010 to 72,100 in 2020; primary care PAs will increase by 58%, from 27,700 to 43,900 over the same period.  Fortunately, we are increasing aware of academic colleagues who are working within the training institutions of other healthcare disciplines, beyond that of medicine.

            Karen Pellegrin: “It’s a great time to be a psychologist in a College of Pharmacy.  Over a decade ago, the Institute of Medicine [now NAM] identified working in interdisciplinary teams as one of the core competencies essential for all healthcare professionals.  More recently, accreditors of pharmacy programs and other health education programs have made interprofessional education a requirement.  At the Daniel K. Inouye College of Pharmacy at the University of Hawaii at Hilo, being the only clinical psychologist on the faculty gives me so many opportunities to introduce pharmacy students to key aspects of human behavior.  The first cohort of pharmacy students has begun taking coursework in our new certificate programs.  As program coordinator for the Healthcare Leadership Certificate program, I teach them about the Yerkes-Dodson law of human performance, actions leaders can take to improve performance at the individual and organization levels, how organizational culture can be measured and improved, and cognitive-behavioral approaches to managing their personal finances (so that they can pay off their student loans and save enough to be able to retire some day!).”

Developing these relationships is so important I might consider donating to the American Psychological Foundation (APF) in recognition of the first one or two State Associations that understand its significance.  Update: Beth Rom-Rymer reports that the prescribing license announcement just appeared on the website of the Illinois Department of Financial and Professional Regulation.  An application is expected in the very near future.  Aloha,

Pat DeLeon, former APA President – Division 31 – June, 2018

ALOHA - D55

“THE WILL OF THE PEOPLE IS THE BEST LAW”

            The Buckeye State – Continuing to Set the Agenda:  Ted Strickland was the first psychologist to be elected to the U.S. House of Representatives and when elected Governor of Ohio, he was also the first psychologist to serve in that position.  Former APA President Ron Levant recently shared with us a report on the ongoing efforts in his adopted State to obtain prescriptive authority (RxP).  In his various roles within the APA governance, Ron has always been supportive of this particular agenda, seeing it as a natural expansion of psychology’s role within the overall healthcare arena.  The late-Ron Fox -- former APA President, founding Dean of the Wright State Professional School, and the Grandfather of the RxP movement -- used to muse about how his Ohio academic nursing colleagues appreciated that there were many ways to accomplish one’s ultimate objective.  They had obtained a major foundation grant to expand their clinical outreach capacities, given the significant healthcare needs throughout the rural areas of the state.  Then, with the active endorsement of the foundation staff, Ron reported that they informed the Governor that unless they could have prescriptive authority, their grant funding would not be released.  The Governor concurred and the first step was RxP authority for the nursing students supervised by the university faculty.  As these students graduated, their clinical authority continued to expand, given the high quality of needed care being provided.

One must appreciate that substantive change takes time; often times far longer than one might initially expect.  It was actually back in 1995 when the Ohio Nurses Association (ONA) formally sought legislation providing their Advanced Practice Nurses (APRNs) with prescriptive authority, under the leadership of Margaret Wheatley, who was their first African-American President.  From a policy perspective, the Ohio nurses’ creative geographical approach nicely paralleled OPA’s efforts to begin psychology’s RxP within the State’s prison system, similar to an earlier effort attempted by the late-Chuck Faltz in the State of California.  As clinicians, APRNs now possess this clinical responsibility, under various conditions, throughout the nation and within the federal healthcare delivery systems, especially within the Department of Veterans Administration (VA).

Brad Potts is serving as the current Ohio Psychological Association (OPA) Advocacy Chair and has been working on the RxP initiative for the past decade, along with his colleagues Jerry Strauss who has been at it for over two decades, and Angela Miller, who is chair of their RxP Committee.  Both Brad and Angela are graduates of the Alliant psychopharmacology program.  This legislative session three hearings have been held on their current bill, H.B. 326, with testimonies received from Ruth Roe-Navarrete, who is a prescribing psychologist at Wright Patterson Air Base, Marlin Hoover, a prescribing psychologist from New Mexico (and who was instrumental to the Illinois Psychological Association’s recent legislative success), and Jerry.

Brad: “In addition to their broad clinical experience both were able to testify about helping train medical students how to prescribe psychotropic medications.  Supportive testimony was also provided from the University of Findlay Pharmacy program about their Masters in Psychopharmacology that they have approved and are prepared to launch once the Ohio bill passes.  For the past six months we have worked to address a series of issues raised by the opposition.  That work is now done and we have a solid piece of legislation.  I think it is the strongest bill we have had.  Our interactions with lawmakers have been largely positive and our current stance is that we are cautiously optimistic, especially with Michael Ranney’s steady calming guidance.”

Jerry:  “The APRNs in Ohio started their venture for independence and prescriptive authority in 1988.  The bill for RxP finally passed for them on 1/12/2000.  The very last state to pass the law for APRNs.  When I testified on our bill, I cited the DoD Demonstration Project and other empirical evidence demonstrating safe, effective, and judicious prescribing practices by prescribing psychologists.  Channel 6 in Columbus Ohio interviewed me after the testimony and aired the interview in Ohio, West Virginia, and parts of Indiana and Pennsylvania.  I have been participating in each interested party meeting between OPA, the Ohio Psychiatric Physicians Association/Ohio State Medical Board, and our bill’s sponsors.  Each of these meetings has been positive in our favor.  I guess those responsibilities should fall to the grandfather of RxP in Ohio and I will continue to play a role until our bill is written into law in our state.”

Kathy McNamara, another long time Ohio colleague who was formerly at Wright State University and now lives on the Hawaiian island of Maui, recently retired from the VA after nearly four decades of service.   Her thoughts on the importance of the profession obtaining this clinical responsibility in order to serve our nation’s Veterans:  “The development with VA pharmacists prescribing occurred even before I retired.  I recall my disbelief that our VA pharmacists – with no formal training in psychological issues or mental health treatment – could prescribe psychotropics and VA psychologists still could not.  The recruitment ads for VA pharmacists include reference to both their contributions to interdisciplinary practice (in a collaborative way) and to the fact that ‘Clinical Pharmacy Specialists’ have ‘authority to prescribe and monitor medication therapies.’  My own psychopharmacology training program included pharmacists – and I learned a significant amount from those lectures, and have great respect for pharmacists – but I am disappointed in how reticent our own VA psychologists have been to think outside the box and move this forward.  In the VA, structure always supersedes function: creating a title for some of the VA psychologists who become ‘Clinical Psychology Specialists’ with a scope of practice to prescribe (or even as a first step, advise in primary care staffing of patients about how to integrate therapy and medication) can go a long way.  I am just so appreciative of Heather Kelly’s persistence in the legislative arena.”  We would rhetorically ask: “Will our next generation of VA psychologists listen to the vision of their senior VA, now retired, colleagues Kathy and Jerry?  Or, will they be content with the status quo, allowing Jerry to continue flying a helicopter around the state?”

            The Importance of Developing an Interprofessional Orientation:  At the national level, pharmacy has established The Board of Pharmacy Specialists which currently certifies specialists in eight different areas (e.g., ambulatory care, pediatrics, psychiatric pharmacy).  The number of specialty certified pharmacy practitioners has grown quite dramatically in recent years as the complexity of patient management increases.  It is possible to find specialists by geographical region through the Board’s website.  Pharmacy has been steadily expanding its scope-of-practice on both the federal and state level, commensurate with its doctoral level of educational training.  As a result, an increasing number of states allow pharmacists to modify and initiate medication protocols.  In 2003 there were approximately 4,000 board certified specialists in clinical pharmacy.  By 2014 these numbers had increased to almost 22,000.  As Brad and Kathy have indicated, and as experienced by Linda Campbell during the original Georgia Psychological Association efforts in the very beginning of the RxP movement – not to mention her recent interprofessional community care efforts – Colleges of Pharmacy have been extraordinarily supportive of psychology’s psychopharmacology quest.

            Team-based, interprofessional care, capitalizing upon the potential contributions of the advances occurring within the communications and technology fields (i.e., telehealth), is the future for our nation’s healthcare environment.  We are entering a transformational era.  In November, 2013 the Health Resources and Services Administration (HRSA) released its report Projecting the Supply and Demand for Primary Care Practitioners Through 2020.  “Demand for primary care services is projected to increase through 2020, due largely to aging and population growth and, to a much lesser extent, the expanded insurance coverage implemented under the Affordable Care Act, which includes a number of investments that strengthen the primary care workforce….  The supply of NPs and PAs, however, is projected to grow rapidly and could mitigate the projected shortage of physicians if NPs and PAs continue to be effectively integrated into the primary care delivery system.  In order for this integration to occur, patient and health system acceptance is necessary and the dissemination of more effective models of workforce deployment must continue.  New models that allow for an increased role of NPs and PAs in the provision of primary care services, such as patient-centered medical homes that emphasize team-based care, have the potential to help address the projected shortage of primary care physicians….  Aging and population growth are projected to account for 81 percent of the change in demand between 2010 and 2020.”  The supply of primary care NPs is projected to increase by 30%, from 55,400 in 2010 to 72,100 in 2020.  Will prescribing psychologists actively engage in the public policy (i.e., political) process in order to became participants in shaping their own professional destiny?

Increasing Signs of Bipartisanship on Behalf of Our Nation’s Veterans:  On May 24, 2018 the U. S. House of Representatives passed the National Defense Authorization Act for FY’ 2019 (H.R. 5515) by a vote of 351-66.  In this legislation was a provision proffered by Heather O’Beirne Kelly, Director of the APA Office of Military and Veterans Health Policy, to Hawaii’s Congresswoman Tulsi Gabbard, herself a Veteran.  “GAO Audit of TRICARE….  There is evidence that mental health providers from the East and West regions received new contracts that include a proposed 30% discount off… CHAMPUS rates.  With the limited options and resources that TRICARE beneficiaries currently have, these discounts will further jeopardize the mental health of military members, veterans, and their families who rely on TRICARE for their basic needs.  Therefore, the committee directs the Comptroller General of the U.S. Government Accountability Office (GAO) to conduct a study of the Defense Health Agency’s (DHA) oversight of the transition of TRICARE managed care support contractors for its TRICARE regions” (Ulysses S. Grant).  Aloha,

Pat DeLeon, former APA President – Division 55 – June, 2018

EACH TIME A MAN STANDS UP FOR AN IDEAL

With Experience Comes A Renewed Focus: It is intriguing to see some of psychology's historical trail blazers, now, later on in their careers, becoming engaged in broader, international agendas. Barbara Van Dahlen, Founder and President of Give an Hour, recently signed a memorandum of understanding (MOU) with the United Kingdom's Ministry of Defence, pursuant to their Global Summit on Mental Health Culture Change scheduled for London. This MOU will allow the United Kingdom Ministry of Defence to adopt Give an Hour's signature public health initiative, the Campaign to Change Direction, to ensure that all within the British Military "Know the Five Signs of Emotional Suffering." The Ministry of Defence: "We recognize the importance of mental fitness and want to ensure it's emphasized on par with physical fitness." Indeed, the Give an Hour model, which Barbara developed from the simple idea of asking mental health professionals to "give an hour" of their time each week to provide free mental health care to those who serve and their families, is now expanding to serve other populations – including at-risk teens, at risk-women and girls, survivors of gun violence, and victims of natural and man-made disasters – here at home and abroad.

Former APA President Alan Kazdin has been increasingly grappling with how to transform our historical office-based, individually-oriented approach exponentially in order to expand quality psychological care to those most in need – appreciating that the status quo is drastically inadequate to meet the nation's (and world's) pressing needs. "Our focus on treatment needs to begin with the concern about scalability and reaching people in need of services. New treatments, evidence-based or not, will not be very useful if they cannot reach people in need. We begin with the view that most people in need of psychological services receive nothing. That is, standard care or 'treatment as usual' for the vast majority of our citizens (more than 70%) is no treatment. Disseminating treatments to all mental health professionals, while clearly important, does not address the salient issue; namely, people in need of care do not usually see mental health professionals. They do not go to treatment at least in that form. We must consider what treatments can reach the people rather than how people reach the treatments. There are tried models of delivery we could use now (e.g., task shifting, best-buy interventions; disruptive innovations, social networks) to deliver the treatments psychologists and others have worked so hard to develop and evaluate."

Evolving Opportunities -- Bipartisanship and Vision: On May 23, the U.S. Senate passed by a vote of 95-0 bipartisan legislation to fund a critical Tribal Housing initiative (S. 1333). The Tribal HUD-VA (Supportive Housing) initiative will provide rental and housing assistance to homeless and at-risk homeless Veterans. The Chairman and Ranking Member of the Senate Veterans Affairs Committee noted: "It is critical that we work to strengthen resources and opportunities for those who have courageously served our country. This legislation will bring certainty to an important housing program for Native American Veterans, who serve in our nation's Armed Forces in higher numbers than any other ethnic group." "Tribal members in New Mexico and throughout Indian Country have a proud history of military service, and they have served our nation with valor and distinction. Unfortunately, Native Veterans are disproportionally affected by homelessness and this is simply unacceptable… I am deeply grateful that we can honor all our Veterans with passage of this important bipartisan legislation that ensures that Native service men and women have full access to well-deserved housing resources when they return home." Those of our colleagues working with this special population appreciate that Native Americans serve in the military at a higher percentage than any other ethnic demographic. And, that their healthcare needs are extraordinarily significant.

The following day, the U. S. House of Representatives passed the National Defense Authorization Act for FY' 2019 (H.R. 5515) by a vote of 351-66. "The Committee remains concerned about the high rate of suicides in the reserve component and specifically, within the Army National Guard. The Committee is aware of numerous efforts by the Chief of the National Guard Bureau to increase access and resources for Guardsmen to receive behavioral health treatment and support. The Committee also supports the establishment of a more integrated and holistic approach to resilience and fitness across the National Guard to better assess and improve the operational readiness of Guardsmen by carrying out pilot programs as required. Therefore, the Committee directs… a report to the House Committee on Armed Services not later than 1 March, 2019 on the effectiveness of National Guard Bureau behavioral health programs like resiliency, suicide prevention, and other mental health outreach efforts."

The House also included: "Comprehensive Women's Health for Active Duty. The committee recognizes that as the population of women in the military increases and more women seek additional opportunities in direct combat units and throughout the joint force, it is critical that women's health is addressed comprehensively to optimize health and readiness. The committee notes the efforts of Navy Medicine with the establishment of the Women's Health Clinical Community and the piloting of a comprehensive clinic at Naval Medical Center, San Diego, to address the complex needs of the Active Duty female population. Guided by feedback from clinical and non-clinical stakeholders and evidence-based research, the comprehensive women's health clinic addresses women's health in a patient-centered manner integrating perinatal, women's health, mental health, and force readiness. As the Military Health System transitions military treatment facilities from the services to the Defense Health Agency, the committee encourages the inclusion of similar health clinics where appropriate to improve the readiness of women in the force."

A Continuing and Steady Focus: It is important for the next generation of our colleagues, and especially those who will be serving within the public sector, to appreciate that their clinical services are never provided in a clinical or policy (i.e., political) vacuum. One aspect to be considered, and hopefully addressed, is society's ever-slowly changing appreciation for the expertise of non-physician healthcare providers and the impact of continuing gender stereotypes. We recently attended the George Washington University School of Nursing press conference: "On May 8, 2018 I attended a press conference. The Woodhull Study Revisited: Nurses' Representation in Health News Media, at the National Press Club in Washington, DC. In 1998, the original study examined journalists' use of nurses as a source in print media. Diana Mason and her research team replicated the original study, conducted a qualitative study of journalists' experiences with nurses in print media, and analyzed the top 50 schools of nursing tweets. The researchers found nurses to be consistently underrepresented in health news stories. Nurses were seldom the source for topics related to health policy, care, or research.

"In 1998, nurses were the primary source in four percent of health-related articles, but only two percent in September, 2017. Nursing and the nursing profession are, however, now mentioned in 13%. Today, twenty years later, nurses were still only mentioned rarely in articles on research (9%), policy (4%), the Affordable Care Act (4%), and Business (3%). In addition, the researchers found that journalists do not understand the overall role, work, and education of nurses. Journalists do not know how to find nurses and have limited time to look for them. Nurses and their associations are not actively engaging with journalists. Over 79.8% of the tweets coming from schools of nursing were inward-facing and only 1.15% were followed by journalists. Nursing represents the largest group of health professionals (approximately 3.5 million, almost 90% of whom are women). Not surprisingly, regardless of profession, men were quoted roughly twice as often as women (65% and 34% respectively). Men were in 72% of media images and women in 48%. Interestingly, women also continue to be underrepresented in newsrooms (24%). My experience at the press conference in this historical building was very rewarding. I was able to meet key nurse leaders and learn about the research at George Washington University and even invite one of nursing's 'living legends' to participate at a forthcoming health policy class as the Uniformed Services University" (Maj. Theresa Bedford, USAF, GSN). "He sends forth a tiny ripple of hope." (Robert Kennedy, University of Cape Town, 1966). Aloha,

Pat DeLeon, former APA President – Division 18 – June, 2018



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ALOHA - Division 18 column

“EACH TIME A MAN STANDS UP FOR AN IDEAL….”

            With Experience Comes A Renewed Focus:  It is intriguing to see some of psychology’s historical trail blazers, now, later on in their careers, becoming engaged in broader, international agendas.  Barbara Van Dahlen, Founder and President of Give an Hour, recently signed a memorandum of understanding (MOU) with the United Kingdom’s Ministry of Defence, pursuant to their Global Summit on Mental Health Culture Change scheduled for London.  This MOU will allow the United Kingdom Ministry of Defence to adopt Give an Hour’s signature public health initiative, the Campaign to Change Direction, to ensure that all within the British Military “Know the Five Signs of Emotional Suffering.”  The Ministry of Defence: “We recognize the importance of mental fitness and want to ensure it’s emphasized on par with physical fitness.”  Indeed, the Give an Hour model, which Barbara developed from the simple idea of asking mental health professionals to “give an hour” of their time each week to provide free mental health care to those who serve and their families, is now expanding to serve other populations – including at-risk teens, at risk-women and girls, survivors of gun violence, and victims of natural and man-made disasters – here at home and abroad.

Former APA President Alan Kazdin has been increasingly grappling with how to transform our historical office-based, individually-oriented approach exponentially in order to expand quality psychological care to those most in need – appreciating that the status quo is drastically inadequate to meet the nation’s (and world’s) pressing needs.  “Our focus on treatment needs to begin with the concern about scalability and reaching people in need of services.  New treatments, evidence-based or not, will not be very useful if they cannot reach people in need.  We begin with the view that most people in need of psychological services receive nothing.  That is, standard care or ‘treatment as usual’ for the vast majority of our citizens (more than 70%) is no treatment.  Disseminating treatments to all mental health professionals, while clearly important, does not address the salient issue; namely, people in need of care do not usually see mental health professionals.  They do not go to treatment at least in that form.  We must consider what treatments can reach the people rather than how people reach the treatments.  There are tried models of delivery we could use now (e.g., task shifting, best-buy interventions; disruptive innovations, social networks) to deliver the treatments psychologists and others have worked so hard to develop and evaluate.”

Evolving Opportunities -- Bipartisanship and Vision:  On May 23, the U.S. Senate passed by a vote of 95-0 bipartisan legislation to fund a critical Tribal Housing initiative (S. 1333).  The Tribal HUD-VA (Supportive Housing) initiative will provide rental and housing assistance to homeless and at-risk homeless Veterans.  The Chairman and Ranking Member of the Senate Veterans Affairs Committee noted: “It is critical that we work to strengthen resources and opportunities for those who have courageously served our country.  This legislation will bring certainty to an important housing program for Native American Veterans, who serve in our nation’s Armed Forces in higher numbers than any other ethnic group.”  “Tribal members in New Mexico and throughout Indian Country have a proud history of military service, and they have served our nation with valor and distinction.  Unfortunately, Native Veterans are disproportionally affected by homelessness and this is simply unacceptable…  I am deeply grateful that we can honor all our Veterans with passage of this important bipartisan legislation that ensures that Native service men and women have full access to well-deserved housing resources when they return home.”  Those of our colleagues working with this special population appreciate that Native Americans serve in the military at a higher percentage than any other ethnic demographic.  And, that their healthcare needs are extraordinarily significant.

The following day, the U. S. House of Representatives passed the National Defense Authorization Act for FY’ 2019 (H.R. 5515) by a vote of 351-66.  “The Committee remains concerned about the high rate of suicides in the reserve component and specifically, within the Army National Guard.  The Committee is aware of numerous efforts by the Chief of the National Guard Bureau to increase access and resources for Guardsmen to receive behavioral health treatment and support.  The Committee also supports the establishment of a more integrated and holistic approach to resilience and fitness across the National Guard to better assess and improve the operational readiness of Guardsmen by carrying out pilot programs as required.  Therefore, the Committee directs… a report to the House Committee on Armed Services not later than 1 March, 2019 on the effectiveness of National Guard Bureau behavioral health programs like resiliency, suicide prevention, and other mental health outreach efforts.”

The House also included: “Comprehensive Women’s Health for Active Duty.  The committee recognizes that as the population of women in the military increases and more women seek additional opportunities in direct combat units and throughout the joint force, it is critical that women’s health is addressed comprehensively to optimize health and readiness.  The committee notes the efforts of Navy Medicine with the establishment of the Women’s Health Clinical Community and the piloting of a comprehensive clinic at Naval Medical Center, San Diego, to address the complex needs of the Active Duty female population.  Guided by feedback from clinical and non-clinical stakeholders and evidence-based research, the comprehensive women’s health clinic addresses women’s health in a patient-centered manner integrating perinatal, women’s health, mental health, and force readiness.  As the Military Health System transitions military treatment facilities from the services to the Defense Health Agency, the committee encourages the inclusion of similar health clinics where appropriate to improve the readiness of women in the force.”      

A Continuing and Steady Focus:  It is important for the next generation of our colleagues, and especially those who will be serving within the public sector, to appreciate that their clinical services are never provided in a clinical or policy (i.e., political) vacuum.  One aspect to be considered, and hopefully addressed, is society’s ever-slowly changing appreciation for the expertise of non-physician healthcare providers and the impact of continuing gender stereotypes.  We recently attended the George Washington University School of Nursing press conference:  “On May 8, 2018 I attended a press conference.  The Woodhull Study Revisited: Nurses’ Representation in Health News Media, at the National Press Club in Washington, DC.  In 1998, the original study examined journalists’ use of nurses as a source in print media.  Diana Mason and her research team replicated the original study, conducted a qualitative study of journalists’ experiences with nurses in print media, and analyzed the top 50 schools of nursing tweets.  The researchers found nurses to be consistently underrepresented in health news stories.  Nurses were seldom the source for topics related to health policy, care, or research.

“In 1998, nurses were the primary source in four percent of health-related articles, but only two percent in September, 2017.  Nursing and the nursing profession are, however, now mentioned in 13%.  Today, twenty years later, nurses were still only mentioned rarely in articles on research (9%), policy (4%), the Affordable Care Act (4%), and Business (3%).  In addition, the researchers found that journalists do not understand the overall role, work, and education of nurses.  Journalists do not know how to find nurses and have limited time to look for them.  Nurses and their associations are not actively engaging with journalists.  Over 79.8% of the tweets coming from schools of nursing were inward-facing and only 1.15% were followed by journalists.  Nursing represents the largest group of health professionals (approximately 3.5 million, almost 90% of whom are women).  Not surprisingly, regardless of profession, men were quoted roughly twice as often as women (65% and 34% respectively).  Men were in 72% of media images and women in 48%.  Interestingly, women also continue to be underrepresented in newsrooms (24%).  My experience at the press conference in this historical building was very rewarding.  I was able to meet key nurse leaders and learn about the research at George Washington University and even invite one of nursing’s ‘living legends’ to participate at a forthcoming health policy class as the Uniformed Services University” (Maj. Theresa Bedford, USAF, GSN).  “He sends forth a tiny ripple of hope.”  (Robert Kennedy, University of Cape Town, 1966).  Aloha,

Pat DeLeon, former APA President – Division 18 – June, 2018

VISION AND INCREMENTAL STEPS TOWARDS “IPE”

During her APA Presidency, Susan McDaniel's highest priority was facilitating the evolution of psychology, both nationally and internationally, into the healthcare arena and developing an appreciation for the long-term importance of actively engaging in interprofessional care, especially during the profession's early training experiences. Susan's visionary 2016 "Interprofessional Education for Integrated Primary Care" conference brought together 83 leaders from 28 primary care associations in the APA building. Education Directorate Executive Director Jim Diaz-Granados: "The Education Directorate recognizes the value of interprofessional education and training (IPE). This is evidenced by our active participation in a number of interprofessional organizations." During this year's graduation ceremonies at the Uniformed Services University (USU), Psychology Professor Tracy Sbrocco marched with the Graduate School of Nursing faculty during the Academic Processional along with her colleagues, Jeanette Witter and Layne Bennion, who had quickly joined her. Traditionally, psychology faculty have "lined up" with the Medical School, where their Department is administratively located. Tracy's comment: "IPE." Although perhaps not evident to many, this symbolic step represents a major institutional change.

I have been personally pleased with the extent to which APA has been highly supportive of inviting the USU military graduate students ("Learning to Care for Those in Harm's Way"), in both nursing and psychology, to participate in their conferences. Most recently, thanks to Acting Science Directorate Executive Director Howard Kurtzman: "The first annual Technology, Mind, and Society Interdisciplinary Conference was a huge success! I was one of the honored and privileged attendees. The conference opened with a reception and poster session – perfect for mingling with the other conference attendees. At the finale of the conference, I realized the value of the opening reception, because during the conference there were far fewer opportunities to socialize with this intriguing mixture of interdisciplinary professionals from all over the world. The keynote speakers were outstanding. The opening keynote speaker – Cynthia Breazeal – definitely set the tone with her energy and enthusiasm about Social Robotics and Human Behavior. I found it challenging to choose between the concurrent paper sessions and symposiums because many of the topics were relevant and timely for where I am in my research trajectory. The conference was jam-packed with intellectually stimulating activities from start to finish. It was exciting and refreshing to be surrounded by so many clinicians, researchers, and educators that shared my passion for technology, patient engagement, and healthcare policy. I cannot wait to present a poster/paper session next year" (Tonya Spencer, Maj, USAF, GSN graduate student).

"'We evolved as a social species to harvest social information from the environment and come to a consensus on what to do, and that underlies the substrate on which society was built,' said Alex Pentland near the beginning of his lecture. He described the idea people's success depends on their ability to exploit opportunities in their environments; that if you succeed in doing so, variation allows for domination and success. He anchored his talk on the notion of social foraging. He consults and conducts analyses for big international companies; he puts tracking badges on their employees to a) discover silos and break them and – when working for drug companies – he tracks employees to b) better predict which of their biochemists will critically contribute to the next breakthrough drug. Who's the next rock star? Drug companies typically rate and attempt to predict which employees will succeed; they hire him to do this more effectively, largely unaware of how their employees spend their days. He found that the employees rated highest by the drug company also had the most diverse communications with near perfect correlations. Yet each of these companies has strict productivity guidelines. Their employees are supposed to talk to their colleagues and their boss and focus on productivity and work. Yet the most successful biochemists broke the rules, wasted their time talking to the sales teams. This supports the argument for social foraging: Pentland discussed it as this idea that the most successful people are those most skilled at exploiting ideas within the community and outside that group. 'Tremendously important, the structure of communication.'

"As his lecture expanded, it became clear how starkly the data laid out entrenched social problems. Does the community talk to each other? How much does the community talk to other members, to others outside the community? These questions predict crime, poverty, and lack of opportunity with astounding accuracy. How remarkably stratified the world's cities are" (Kevin Barry, 1st Lt, USA, Psychology graduate student).

The Importance of PSYPACT: During his tenure as CEO of the Association of State and Provincial Psychology Boards (ASPPB), Steve DeMers contributed to numerous advances for the profession of psychology. His most recent accomplishment has been the creation of their proposed "E-Passport" which, with the enactment of an Interjurisdictional Compact (PSYPACT) by the state legislatures, would allow the provision of psychological services via electronic means across jurisdictional boundaries, without additional licensure. Heather O'Beirne Kelly, Director of the APA Office of Military and Veterans Health Policy, reports that the VA has recently issued a federal rule which allows VA healthcare providers to practice via telehealth across state lines, pre-empting previous state licensing and telehealth restrictions. This new initiative allows VA providers, including psychologists, to offer care and Veterans to receive care, from any location. The previous regulations allowed Veterans to receive care via virtual technology in their homes but required that telehealth providers be located in a VA facility. Mental and behavioral healthcare providers continue to be the most frequent federal utilizers of this maturing technology. The healthcare environment of the future, including within the private sector, will be dramatically transformed by the advances occurring within the communications technology field.

Generational and Geographical Perspectives on RxP: "You will be glad to know that my cohort mates, Matt Moosey (Army), Marcus Van-Sickle (Navy), and Andrea (Dre) Weiss (Air Force) have all enrolled in a Masters of Pharmacology program to complete the RxP requirements. I'm pretty proud of their dedication to the cause. Aloha" (Sarah McCreight, Maj, US Army). And, "Although I am 70, I am still actively practicing in a La Clinica de Familia CMHC/FQHC Adult and Children's Services. I have had Doctoral Nurse Practitioner students, from the New Mexico State University Nursing Program, who have been placed with me for psychiatric practicum supervision for the last four semesters. In addition, the University of New Mexico School of Medicine, Department of Psychiatry and Behavioral Sciences, began placement of second year Psychiatric Residents with us as part of the Rural Psychiatry Program, during this spring semester. Small steps of progress" (Thomas Thompson, Medical and Neuropsychology-Prescribing Psychologist – New Mexico). "With the signing of 201-34, now Public Law 34-78, Guam Governor Eddie Calvo and Guam legislators have brought full and direct access to NP and other APRN care to the territory's patients…. (T)hank you for partnering with AANP to bring quality, accessible health care to your patients…. We encourage you to connect with one of the AANP NP Organization Members in your state or territory to get involved and support legislative changes in your state!" (AANP). Aloha,

Pat DeLeon, former APA President – HPA – June, 2018



Sent from my iPhone

ALOHA - HPA

VISION AND INCREMENTAL STEPS TOWARDS “IPE”

            During her APA Presidency, Susan McDaniel’s highest priority was facilitating the evolution of psychology, both nationally and internationally, into the healthcare arena and developing an appreciation for the long-term importance of actively engaging in interprofessional care, especially during the profession’s early training experiences.  Susan’s visionary 2016 “Interprofessional Education for Integrated Primary Care” conference brought together 83 leaders from 28 primary care associations in the APA building.  Education Directorate Executive Director Jim Diaz-Granados: “The Education Directorate recognizes the value of interprofessional education and training (IPE).  This is evidenced by our active participation in a number of interprofessional organizations.”  During this year’s graduation ceremonies at the Uniformed Services University (USU), Psychology Professor Tracy Sbrocco marched with the Graduate School of Nursing faculty during the Academic Processional along with her colleagues, Jeanette Witter and Layne Bennion, who had quickly joined her.  Traditionally, psychology faculty have “lined up” with the Medical School, where their Department is administratively located.  Tracy’s comment: “IPE.”  Although perhaps not evident to many, this symbolic step represents a major institutional change.

            I have been personally pleased with the extent to which APA has been highly supportive of inviting the USU military graduate students (“Learning to Care for Those in Harm’s Way”), in both nursing and psychology, to participate in their conferences.  Most recently, thanks to Acting Science Directorate Executive Director Howard Kurtzman: “The first annual Technology, Mind, and Society Interdisciplinary Conference was a huge success!  I was one of the honored and privileged attendees.  The conference opened with a reception and poster session – perfect for mingling with the other conference attendees.  At the finale of the conference, I realized the value of the opening reception, because during the conference there were far fewer opportunities to socialize with this intriguing mixture of interdisciplinary professionals from all over the world.  The keynote speakers were outstanding.  The opening keynote speaker – Cynthia Breazeal – definitely set the tone with her energy and enthusiasm about Social Robotics and Human Behavior.  I found it challenging to choose between the concurrent paper sessions and symposiums because many of the topics were relevant and timely for where I am in my research trajectory.  The conference was jam-packed with intellectually stimulating activities from start to finish.  It was exciting and refreshing to be surrounded by so many clinicians, researchers, and educators that shared my passion for technology, patient engagement, and healthcare policy.  I cannot wait to present a poster/paper session next year” (Tonya Spencer, Maj, USAF, GSN graduate student).

            “‘We evolved as a social species to harvest social information from the environment and come to a consensus on what to do, and that underlies the substrate on which society was built,’ said Alex Pentland near the beginning of his lecture.  He described the idea people’s success depends on their ability to exploit opportunities in their environments; that if you succeed in doing so, variation allows for domination and success.  He anchored his talk on the notion of social foraging.  He consults and conducts analyses for big international companies; he puts tracking badges on their employees to a) discover silos and break them and – when working for drug companies – he tracks employees to b) better predict which of their biochemists will critically contribute to the next breakthrough drug.  Who’s the next rock star?  Drug companies typically rate and attempt to predict which employees will succeed; they hire him to do this more effectively, largely unaware of how their employees spend their days.  He found that the employees rated highest by the drug company also had the most diverse communications with near perfect correlations.  Yet each of these companies has strict productivity guidelines.  Their employees are supposed to talk to their colleagues and their boss and focus on productivity and work.  Yet the most successful biochemists broke the rules, wasted their time talking to the sales teams.  This supports the argument for social foraging: Pentland discussed it as this idea that the most successful people are those most skilled at exploiting ideas within the community and outside that group.  ‘Tremendously important, the structure of communication.’ 

            “As his lecture expanded, it became clear how starkly the data laid out entrenched social problems.  Does the community talk to each other?  How much does the community talk to other members, to others outside the community?  These questions predict crime, poverty, and lack of opportunity with astounding accuracy.  How remarkably stratified the world’s cities are” (Kevin Barry, 1^st Lt, USA, Psychology graduate student).

            The Importance of PSYPACT:  During his tenure as CEO of the Association of State and Provincial Psychology Boards (ASPPB), Steve DeMers contributed to numerous advances for the profession of psychology.   His most recent accomplishment has been the creation of their proposed “E-Passport” which, with the enactment of an Interjurisdictional Compact (PSYPACT) by the state legislatures, would allow the provision of psychological services via electronic means across jurisdictional boundaries, without additional licensure.  Heather O’Beirne Kelly, Director of the APA Office of Military and Veterans Health Policy, reports that the VA has recently issued a federal rule which allows VA healthcare providers to practice via telehealth across state lines, pre-empting previous state licensing and telehealth restrictions.  This new initiative allows VA providers, including psychologists, to offer care and Veterans to receive care, from any location.  The previous regulations allowed Veterans to receive care via virtual technology in their homes but required that telehealth providers be located in a VA facility.  Mental and behavioral healthcare providers continue to be the most frequent federal utilizers of this maturing technology.  The healthcare environment of the future, including within the private sector, will be dramatically transformed by the advances occurring within the communications technology field.

            Generational and Geographical Perspectives on RxP:  “You will be glad to know that my cohort mates, Matt Moosey (Army), Marcus Van-Sickle (Navy), and Andrea (Dre) Weiss (Air Force) have all enrolled in a Masters of Pharmacology program to complete the RxP requirements.  I’m pretty proud of their dedication to the cause.  Aloha” (Sarah McCreight, Maj, US Army).  And, “Although I am 70, I am still actively practicing in a La Clinica de Familia CMHC/FQHC Adult and Children’s Services.  I have had Doctoral Nurse Practitioner students, from the New Mexico State University Nursing Program, who have been placed with me for psychiatric practicum supervision for the last four semesters.  In addition, the University of New Mexico School of Medicine, Department of Psychiatry and Behavioral Sciences, began placement of second year Psychiatric Residents with us as part of the Rural Psychiatry Program, during this spring semester.  Small steps of progress” (Thomas Thompson, Medical and Neuropsychology-Prescribing Psychologist – New Mexico).  “With the signing of 201-34, now Public Law 34-78, Guam Governor Eddie Calvo and Guam legislators have brought full and direct access to NP and other APRN care to the territory’s patients….  (T)hank you for partnering with AANP to bring quality, accessible health care to your patients….  We encourage you to connect with one of the AANP NP Organization Members in your state or territory to get involved and support legislative changes in your state!” (AANP).  Aloha,

Pat DeLeon, former APA President – HPA – June, 2018