THE ADVENT OF TECHNOLOGY

Technology's Contribution To Health Care Reform:  As President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act (PPACA) [P.L. 111-148], is being steadily implemented, the concerns raised from a number of vantage points can be seen as a testament to his vision, as well as to the magnitude of change involved.  Change is always unsettling, especially for those comfortable with the status quo.  One of the underlying objectives of PPACA is to focus the unprecedented advances occurring within the communications and technology fields directly upon the health care environment, as they are already impacting every other segment of our economy.  This can be seen with the significant resources provided for Comparative Clinical Effectiveness Research (i.e., determining objectively what services work, for what symptoms, and under what conditions); ensuring that all providers have ready access to electronic health records, thus providing the capacity to compare outcomes across patients and diagnoses (Health Information Technology (HIT)); and increasing the applicability of telehealth care, so that one's geographical location will no longer be a barrier to receiving quality care.  There can be no question that central to effectively utilizing this technology are critical and complex licensure issues.  Perhaps the underlying question is: Whether our nation looks at providing necessary health care as representing a societal responsibility or an individual patient/provider decision?

            Organized psychology appreciates the importance of being proactive.  In February, the APA Council of Representatives approved the creation of a Telepsychology Task Force, co-chaired by Linda Campbell and Fred Millan, that will be comprised of four APA representatives, four ASPPB representatives, and two APAIT representatives.  One of the issues that the task force will face is inter-jurisdictional practice/licensure mobility.  Their first meeting is scheduled for mid-July. Judy Hall, National Register Executive Officer: "The National Register of Health Service Providers in Psychology (NR) is uniquely positioned to serve as the primary licensure mobility credential for psychologists in the United States, Canada, and beyond.  We are by far the largest credentialing organization for psychologists, with 11,000 members; have standards and credentialing procedures that are well established and are widely approved by licensing boards to expedite licensure mobility.  To date, we have verified credentials to licensure boards for more than 1,300 Registrants.  The NR is ranked by both early career and more senior psychologists as one of the most valuable benefits, both for the here-and-now value and as an insurance policy for those who may apply for additional licenses later in their careers.  For a list of jurisdictions approving the National Register, seewww.nationalregister.org."

            Health Resources and Services Administration (HRSA):  APA's Debra Baker shared with us the report released this Spring by HRSA: "Health Licensing Board Report To Congress."  Requested by the FY'2010 Senate Appropriations bill, the report updated efforts being made on licensure portability and the level of cooperation between health licensing boards, the best models for such cooperation, and the barriers to cross-state licensing arrangements.  HRSA focused on physicians and nurses since in its view these are: "the two professional groups for which there is the most information on alternative approaches to overcoming licensing barriers to cross-state practice."  Utilizing funding from FY' 2006, HRSA created its licensure portability grant program which has subsequently funded projects submitted by the Federation of State Medical Boards (FSMB) and the National Council of State Boards of Nursing (NCSBN), as well as the State of Wisconsin Department of Regulation and Licensing.

            "Licensure portability is seen as one element in the panoply of strategies needed to improve access to quality health care services through the deployment of telehealth and other electronic practice services (e-care or e-health services) in this country.  But licensure portability goes beyond improving the efficiency and effectiveness of electronic practice services.  Overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals in order to address workforce needs and improve access to health care services, particularly in light of increasing shortages of healthcare professionals.  It is also seen as a way of improving the efficiency of the licensing system in this country so that scarce resources can be better used in the disciplinary and enforcement activities of state boards, rather than in duplicative licensing processes."

            Those involved in the licensing process of both medicine and nursing are seeking ways to simplify the licensing process for those members of their professions who are interested in obtaining licenses in more than one state, although they have taken different strategic approaches to date.  Nursing has developed a far reaching mutual recognition model under which practice across state lines would be allowed, whether physical or electronic, unless the individual practitioner is under discipline or a monitoring agreement that restricts practice across state lines.  This approach requires each state to enter into an interstate compact, called the Nurse Licensure Compact.  This was first implemented on January 1, 2000 by Maryland, Texas, Utah, and Wisconsin.  Currently 24 states participate.

            Medicine has been encouraging states to adopt the model of expedited endorsement.  This is a method of setting criteria to approve the valid license of another state.  The process accepts a license issued in one state that was verified and sets requirements for endorsing a license granted in another state.  Idaho, Iowa,Michigan, Nevada, New Mexico, North Carolina, Oregon, and Rhode Island currently have adopted the expedited endorsement process.

Some state authorities are clearly uncomfortable with accepting the licensing process of another state.  Concerns expressed include: not every state board requires criminal background checks and state boards are ultimately responsible for maintaining public protection within the state.  Control/lack of authority; lack of uniform standards; cost/loss of revenue; fear among unions and state professional associations that this could facilitate strike breaking; a general misunderstanding about the process among practitioners; and the lack of independent evaluations have all been noted as potential barriers.  A number of these concerns can be satisfactorily addressed, especially as the broader provider community becomes more clinically comfortable with the use of advanced technology (HIT) in their daily practices.  To place this evolution in perspective, at the time the Obama Administration began its successful quest for health care reform, their goal was to bring physician HIT utilization up from five percent to 90 percent by 2019 and hospital utilization to 70 percent during the same time frame, with their estimate being that only 1.5 percent of hospitals had a comprehensive electronic system available in all units.

For over a century, health care in theUnited States has primarily been regulated by the states.  Such regulation includes the establishment of licensure requirements and enforcement of standards of practice for health providers.  The licensure authority is administered with the goal of ensuring that health care professionals are academically qualified, competent, and mentally and physically fit to provide the activities covered by the license.  "As the U.S. health system evolves to meet the changing needs of consumers, traditional methods of healthcare delivery are being transformed.  No longer do the patient and the provider need to be in the same location to receive quality health services.  Telehealth (telecommunications and information) technologies are being used to provide healthcare services in a more efficient and effective manner to address the shortages and maldistribution of healthcare professionals that result in lack of access to quality healthcare services, whether due to geographic, economic, or other social factors.  Telehealth services are increasingly becoming part of the mainstream of healthcare.  For these reasons, the number of physicians and the number of other health providers practicing across state boundaries have increased in recent years.  This trend is expected to continue in the foreseeable future."

The purpose of licensing health care professionals is to protect the public from incompetent or impaired practitioners.  A licensure system must be able to administer and enforce its standards.  The basic standards for medical and nursing licensure have become largely uniform across all states.  Physicians and nurses must graduate from nationally approved educational programs and pass national licensure examination.  However, there are significant differences in administrative and filing requirements among the states.

The American Bar Association Health Law Section in its 2008 report proposed a model for allowing the cross-state licensure of physicians, which was approved by the ABA House of Delegates.  The Federal Communications Commission (FCC) released its National Broadband Plan in 2010 urging states to revise licensure requirements to enable "e-care."  Noting that current licensure requirements limited practitioners' ability to treat patients across state lines, which hindered access to care, the FCC urged increased collaboration.  And, if the states failed to develop reasonable licensing policies to facilitate electronic practice over the next 18 months, it recommended that Congress ensure that Medicare and Medicaid beneficiaries are not denied the benefits of "e-care."  Some have already called for the federal government to enact national licensure.  In our view, the states still have time to demonstrate vision.  "You know I feel all right."  Aloha,

Pat DeLeon, former APA President – Division 18 column – June, 2011

 

WHERE HAVE ALL THE FLOWERS GONE?

 The Robert Wood Johnson Foundation (RWJ) is the nation's largest philanthropy devoted solely to the public's health.  Their efforts focus upon improving both the health of everyone in America, and their health care – how it's delivered, how it's paid for, and how well it does for patients and their families.  By investing in improving systems through which individuals receive health care and in fostering environments that promote health and prevent disease and injury, RWJ expects to achieve comprehensive, meaningful, and timely change.  Creating leverage for change is RWJ's greatest asset.  Annually RWJ issues its Anthology, which this year focused upon Improving the Health and Health Care of Vulnerable Populations.  For those colleagues interested in learning about the gradual evolution of our nation's health policy, these publications provide a fascinating glimpse into the vision of the foundation world, where only a few psychologists have ever been involved.  Ruby Takanishi, President of the Foundation for Child Development; Judith Rodin, President of the Rockefeller Foundation; and Anne Peterson, formally of the W.K. Kellogg Foundation, being notable exceptions.

            The Vulnerable Populations portfolio was created in 2003 and has developed a special niche by identifying and supporting innovative programs at the intersection of health and the social factors that influence health – factors such as education, housing, race, class, and income.  As such, it provides a unique opportunity to dramatically change how services are delivered, while at the same time helping individuals, families, and communities make progress towards better health and a healthier society.  Helping real people and moving towards a healthier society are laudable goals which are "possible, but not always easy."

            A concerted effort has been made by RWJ to go beyond supporting creative individual efforts which address national needs, by also nurturing the most promising among them with the hope and expectation that they can become strong enough to "enter the mainstream" of society's expectations.  One example would be RWJ's commitment since the 1970s to fund a range of projects advancing Nurse Practitioners.  The Nurse-Family Partnership program, in which public health nurses visit young, low-income, first-time mothers in their homes, is a RWJ-funded initiative that may be ready to enter the mainstream.  Starting in 1979, support was provided for a new approach to improving the health of babies and their mothers.  In the 31 years since its first grant, RWJ has provided nearly $27 million to build evidence about the effectiveness of this approach and to support its replication.  In 2002, the Edna McConnell Clark Foundation, along with other foundations and corporate funders, supported a major expansion of the program.  President Obama's Patient Protection and Affordable Care Act (PPACA) authorized $1.5 billion for states that adopt home-visitation programs that serve young, low-income mothers.

RWJ's initial nurse practitioner efforts focused upon increasing the access of people living in rural areas and inner cities to non-hospital based care.  These became the forefront of a movement that lead to the widespread acceptance of nurse practitioners as recognized health care professionals.  One might say that the Foundation supported a "disruptive innovations" approach by sponsoring a less costly group of health professionals who could carry out many of the functions performed by a more costly, and often inaccessible group, namely physicians.  The underlying philosophical question remains, however: Why do some initiatives evolve into mainstream concepts while others do not?  Perhaps it is because they are picked up initially by change agents who influence the rest of society until a critical mass of individuals find it is in their best interest to adopt an innovation.  Are there "take-off points" when the accretion of small advances reach the point where change becomes unstoppable?  Or, as APA convention speaker Malcolm Gladwell proposed, by taking one step at a time, does an innovation affect enough people to reach a "tipping point," from which it then naturally races through the population?

            Four elements were highlighted in theAnthology which are seen as necessary to move foundation-funded ideas into the mainstream.  1.) The idea is seen by a substantial portion – or at least an influential portion – of the population as a potential solution to a pressing problem.  2.) The political system is receptive to the adoption of new ideas – especially when legislation is the means of spreading them.  3.) The evidence is strong that an idea is workable and perhaps cost-effective.  And, 4.) Committed advocates keep the idea in the forefront and fight for its widespread adoption.  The RWJ President enumerated five key tools available to philanthropy: Communicating, Convening, Coordinating, Connecting, and Counting (plus a sixth, Cash) – her "Five Cs."  From our experience within the public policy arena over the years, we would especially agree with the view that those who wish to implement significant change must: "Stick with good ideas for a long time.  An inhospitable political climate can suddenly become inviting, as the passage of health care reform in 2010 demonstrates."

            Each of the Vulnerable Population projects has direct application to psychology and the behavioral sciences.  Caring Across Communities explored the need for mental health services among probably the most vulnerable population in our nation, children with mental health problems born to refugees or immigrants.  Generally, this population is not welcome in the medical care system.  If undocumented, they are pretty much precluded from getting care except in public hospitals, free clinics, and community health centers.  They are more likely to live in poverty, be poorly educated, and lack health insurance coverage.  "Despite laws and regulations requiring parity in coverage of mental and physical health services under employer-sponsored health plans, such parity does not in fact exist.  Not to mention the stigma associated with mental illness, which would discourage many people from seeking services for themselves and their children.  Moreover there are all of the cultural barriers, of which language is the most obvious and perhaps the easiest to resolve."

Studies show that one out of every five school children in America is now either the child of an immigrant or an immigrant him or her self.  Problems such as post traumatic stress disorder (PTSD) appear to be particularly prevalent in this population, close to 20% for those immigrants who experienced violence before arriving.  School officials begin to see the effects of PTSD in problems that range from rising individual disciplinary cases to a 25% high school dropout rate for foreign-born pupils nationwide.  North Carolina officials reported 59% of their immigrant children are suffering from symptoms of anxiety, about one-third are dealing with PTSD, and 9% have had thoughts of suicide – while the rates of treatment are appallingly low.  Many refugees and their children have witnessed horrors unimaginable to most Americans.  The parents resettled in the U.S. primarily for their children and yet they face a school system with little understanding of what they or their children have gone through.

            Another impressive initiative, the Alaskan Native Dental Health Aide and Therapist program, is, in our judgment, highly analogous to psychology's prescriptive authority (RxP) quest.  "How to deliver health care services to individuals residing in extremely remote areas?" has long been a challenge for health policy experts.  Professional (and at times social) isolation remains a major challenge for rural America. Alaska is a huge and highly isolated region with what can be considered extraordinary inhospitable weather.  The model proposed by RWJ and others (most notably the Rasmuson and Kellogg Foundations) to address the pressing dental needs of rural Alaska was to provide a limited amount of training to members of the local communities who then could provide basic necessary services to their neighbors (akin to China's barefoot doctors).  The oral health crisis in Alaska has sparked numerous comparisons with the TB epidemic of the 1950s.  Nationwide, tooth decay is the most common chronic childhood disease, interfering with daily activities for an estimated 4 to 5 million children and adolescents annually.  The Indian Health Service (IHS) estimates that untreated lesions exist in 68% of American Indian and Alaskan Native adolescents, compared with 24% of other children in the nation.  One-third of Alaskan Native children report missing some days of school each year due to dental pain.

In 2001 the Alaska Native Tribal Health Corporation, the nation's largest tribal health organization, proposed it's Dental Health Aide Program, based upon the principles underlying community health aides.  At the time there was no appropriate training program in the U.S. since every attempt to introduce such a program had been steadfastly resisted for nearly a century by organized American dentistry.  The World Health Organization (WHO) 2003 report indicated that by that time 42 countries around the world – including Canada, Great Britain, Australia, and New Zealand – had relied for years on such midlevel providers to educate patients, apply sealants, and perform basic dental procedures, from fillings to extractions, and even root canals.  The training for the Alaskan Native providers was conducted in New Zealand.  As the graduates began providing services, the ADA and the Alaska Dental Society filed a joint lawsuit in the state court, accusing the dental therapists of practicing dentistry without a license and mounted a major public relations campaign proclaiming "second class dental care."  In June, 2007 the Alaska Superior Court ruled that the dental health therapists were legal under a federal statue, although we understand that even today there are strict limitations on where they can, in fact, practice.  Organized dentistry's opposition to alternative providers has continued, notwithstanding the dental extender provisions contained in PPACA, as well as increasing financial support from the foundation world.  The underlying policy arguments are: Whether these providers represent an alleged public health hazard?  Or, Are they providing access to quality care?  Not surprisingly, all of the objective evidence supports their continued contribution to the health and well being of the Alaskan Native population and as a result, their probable expansion into the federally qualified community health center network which also continues to report significant difficulty in accessing dental care for their patients.

Throughout the RWJ's impressive history of "making a real difference" there have been at least four reoccurring themes: 1.) Supporting independent quality research to provide an evidence-base that will be widely accepted.  2.) Communications are a key to making research relevant to policy makers and the public.  3.) Answering issues of concern to policy makers.  And, 4.) Policy impact definitely requires a long-term vision.

            This Spring, AARP and RWJ facilitated an impressive Congressional briefing by the House and Senate Nursing Caucuses following up on the Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health.  A campaign for action was described with the goal of having Regional Action Coalitions functioning in all 50 states by 2012.  RWJ has already committed $10 million for the campaign which will systematically focus upon building a 21^st century nursing workforce with the skills and knowledge Americans need; increasing the influence of nurses in high levels of health care, policy, business, and community decision making; and removing artificial barriers to nursing being allowed to clinically function to the fullest extent of its training.  Former HHS Secretary Donna Shalala has been actively involved.  Perhaps the most interesting development at the briefing was the public recognition by the President and CEO of the Association of American Medical Colleagues that the time for such change has arrived.  Subsequently, Major General Patricia Horoho was nominated by DoD Secretary Robert Gates to serve as the Surgeon General of the U.S. Army.  When confirmed, she will be the first nurse and first female to serve in that position since the establishment of the Army Medical Corps in 1775.  Times are a-changing.  "When will we ever learn?  When will we ever learn?"  Aloha,

Pat DeLeon, former APA President – Division 42 – June, 2011

 

VISION FOR THE FUTURE – THE IMPORTANCE OF INVOLVEMENT

The Department of Health and Human Services:  In presenting her Fiscal Year 2012 budget, Secretary Sebelius (HHS) expressed her enthusiasm for effectively implementing President Obama's landmarkPatient Protection and Affordable Care Act (PPACA) in a timely fashion.  "In President Obama's State of the Union address he outlined his vision for how the United Statescan win the future by out-educating, out-building and out-innovating the world so that we give every family and business the chance to thrive.  His 2012 budget is the blueprint for putting that vision into action and making the investments that will grow our economy and create jobs.  At the Department of Health and Human Services [HHS] this means giving families and business owners better access to health care and more freedom from rising health costs and insurance abuses.  It means keeping America at the cutting edge of new cures, treatments and health information technology.  It means helping our children get a healthy start in life and preparing them for academic success.  It means promoting prevention and wellness to make it easier for families to make healthy choices.  It means building a health care workforce that is ready for the 21^st century health needs of our country.  And it means attacking waste and fraud throughout our department to increase efficiency, transparency and accountability.  Our 2010 budget does all of this."

            Visionary health psychologist Susan McDaniel and APA Executive Officer Norm Anderson have long been urging our colleagues to become more personally involved in educating society's leaders and the public regarding the importance of the psychosocial-economic-cultural gradient of quality health care, as well as the increasingly emerging scientific and clinical evidence supporting the critical nature of the social determinants of health.  The Secretary clearly has a similar vision.  Her budget redirects and increases funding within the Centers for Disease Control and Prevention (CDC) targeted towards reducing chronic disease.  Rather than splitting funding and making separate grants for heart disease, diabetes, and other chronic diseases, she has proposed one comprehensive grant that will allow States to address chronic disease more effectively.  Similarly, the prevention resources within SAMHSA would be redirected to fund evidence-based interventions and better respond to evolving needs.  States and local communities would benefit from the additional flexibility while funds would still be competed and directed toward proven interventions.

We would rhetorically ask: How many of our colleagues who are primarily in private practice share Division President Glenn Ally's vision and have developed collaborative relationships with their local state or county health authorities?  Glenn, along with two other medical psychologists, works closely with his local Community Mental HealthCenter; other Louisiana medical psychologists in private practice work with their Children's and State Psychiatric Hospitals, not to mention serving on numerous State Boards and Committees/Commissions.  It is only by becoming active community participants and visionary leaders that psychology will ultimately be well positioned to effectively engage in the policy discussions that determine local plans for implementation of PPACA on a collegial and equal basis with other health care disciplines, interested stakeholders, and government and business community leaders.  The President's vision provides the Administration and States with considerable flexibility to develop local strategies for successfully meeting broad-reaching national objectives.  As Jim Quillin keeps reminding us, "All politics are local."

            The HHS Secretary further pointed out that PPACA expands access to affordable coverage to millions of Americans and strengthens consumer protections to ensure individuals have coverage when they most need it.  Focusing upon ensuring access to quality, culturally competent care for vulnerable populations: "The budget includes $3.3 billion for the Health Centers Program, including $1.2 billion in mandatory funding provided through the Affordable Care Act Community Health Center Fund, to expand the capacity of existing health center services and create new access points….  (This) will enable health centers to serve 900,000 new patients and increase access to medical, oral, and behavioral health services to a total of 24 million patients."  Her Innovation Center, in coordination with private sector partners wherever possible, will pursue new approaches that not only will improve quality of care, but also lead to cost savings for Medicare, Medicaid, and CHIP.  We suspect that very few of our colleagues truly appreciate the long term implications for their daily practices of the PPACA established Patient-Centered Outcomes Research Institute which will be funding research and getting relevant, high quality information to patients, clinicians, and policy-makers, so that they can make informed health care decisions.  The Institute of Medicine (IOM) estimates that almost 40% of Americans possess only "basic" or "below-basic" health literacy skills.  Thus, their ability to make informed decisions without concerted assistance will become increasingly difficult as the volume and complexity of data available to them increases.  The Patient-Centered Outcomes Research Trust Fund will fund this independent Institute and related HHS activities.  Approximately $620 million will be allocated during the coming year as investments in core patient-centered health research activities and to disseminate research findings, train the next generation of patient-centered outcome researchers, and improve data capacity.

            The HHS budget also includes $78 million for the Office of the National Coordinator for Health Information Technology to accelerate health information technology (HIT) adoption and promote electronic health records (EHRs) as tools to improve the health of individuals and transform the health care system.  One focus will be assisting health care providers in becoming meaningful users of health information technology.  One of the Secretary's priorities should be of particular interest to APA.  Her budget provides HRSA with $163 million for Health Workforce Diversity programs to improve the diversity of the nation's health workforce and improve care to vulnerable populations.  These funds will support training programs and scholarship opportunities for students from disadvantaged backgrounds who are enrolled in health professions and nursing programs.

            The Department of Defense:  "As this year's Military Nurse Fellow, I was thrilled to attend the Senate Committee on Appropriations defense subcommittee hearing on the DoD Fiscal Year 2012 Health Programs.  During this hearing, Senators heard testimony from the Nurse Corps Chiefs and the Surgeons General from the Army, Air Force, and the Navy.  Not at all surprising was a universal concern voiced by the Senators regarding the behavioral health of our troops and their families.  The Surgeons General and the Nurse Corps Chiefs all mentioned during their testimony that preserving the psychological health of service members and their families is one of the greatest challenges the services face today.  The military is not immune to mental health issues or concerns; behavioral health issues affect military members and their families just as they affect the civilian community, perhaps even more so.

            "Tragically, the wars in Iraq andAfghanistan have produced a group of combat veterans who face a lifelong struggle to cope with the severe physical and psychological traumas of war.  The invisible scars of war cut deep and transcend through military members to their families who are desperately trying to assist their loved ones to cope.  The military health system as a whole strives to provide the very best ongoing healthcare for military members and their families including mental health services and support.  It is clear that early identification of mental health risks through surveillance, education, and training is a key component in helping to mitigate behavioral health and stress related issues.  The Army has developed an approach to strengthen their soldiers' and families' behavioral health and emotional resiliency through a campaign to align various behavioral health programs.  The long term goals of this Comprehensive Behavioral Health System of Care is to protect and restore the psychological health of soldiers and their families and prevent adverse psychological and social outcomes like family violence, DUIs, drug and alcohol addiction, and suicide.

            "Citing that no one is immune to the stresses and strains of life, the Air Force testimony identified that one important aspect of patient-centered preventive care includes preserving the mental health and well-being of service members and improving their resilience.  Initiatives have been developed to support and train front line supervisors to recognize when an individual may be having difficulties.  Counseling services have also been expanded beyond traditional avenues.  Other initiatives aimed at addressing behavioral health and resiliency included utilizing a targeted approach that recognizes different risk groups.  An overarching theme identified was the utilization of 'best practice' programs to help service members become more resilient.  An example of this is teaching the afflicted to realize that seeking help is a sign of strength, not a sign of weakness.

            "The Navy keyed in on the fact that service members and their families are usually mentally and emotionally strong at baseline, but the long conflict (war) and other related deployment challenge this resilience.  Thus, the Navy implemented programs for early detection of stress injuries, which includes focusing on leadership's role in monitoring the health of their people.  Additionally, the programs include providing leaders with tools they may employ when service members are experiencing mild to moderate symptoms and the utilization of multidisciplinary expertise for members more seriously affected.

            "It is evident from the testimony that psychological health issues cut across all walks of life.  Programs that support, prevent, diagnose, mitigate, and treat behavioral health issues are paramount to ensuring the optimal health of our communities, whether civilian or military.  The services are working hard to change the 'culture' and are striving to ensure military members are a healthy, fit and resilient force!" (Lt. Col. Maureen Charles, USAF).

            The Department of Agriculture:  The U.S. Department of Agriculture recently announced a $25 million grant to the Collegeof Agriculture at the University of Hawaii in order to develop obesity prevention strategies among native populations in the Pacific Region, thereby continuing its commitment to meet the rising challenge of obesity in our nation.  The Secretary: "We know that in order to win the future, we have to win the race to educate our children.  That means that our kids must be healthy so they can learn and thrive.  Improving childhood nutrition remains a key priority of the Obama Administration as we work to ensure our kids are ready to out-compete in an increasingly globalized world."  This five year initiative will use a community-based participatory research approach that engages communities to prioritize obesity prevention strategies.  Researchers will work with the communities to develop community needs assessments and establish sustainable nutrition and health-promoting programs.  Specifically, the team will identify specific environmental factors leading to childhood obesity in selected schools and daycare facilities.  Intervention strategies will be attuned to culturally-specific needs and goals, and focus on physical activity, nutritional intake, and the amount of sleep children get each night.  This is a health psychologist's dream.

            The implications of the similar visions expressed by the leadership of these three federal Departments should be quite exciting for psychology, as long as our practitioners, scientists, and educators are actively engaged in shaping the specifics of the implementation strategies as they gradually unfold.  The behavioral sciences have much to contribute to these important national agendas and our visionaries have provided a solid scientifically-based foundation for their success.  Involved we must be.  Aloha,

Pat DeLeon, former APA President – Division 55 – May, 2011

 

INTEGRATED CARE -- MICHAEL, ROW YOUR BOAT ASHORE

            From a national public policy perspective, it is becoming increasingly evident that our nation is steadily evolving towards embracing an integrated, primary care-oriented health care delivery system.  The enactment of President Obama's landmarkPatient Protection and Affordable Care Act [PPACA] is unquestionably the most dramatic indication.  This law provides the various States and the Administration with considerable flexibility to reach national objectives, as it is systematically implemented over the next five to ten years.  The legislation is fundamentally patient-centered and not provider-centric.  Psychology must appreciate that the clinical services our practitioners provide are, in today's political and policy world, deemed to be health care services.  Accordingly, how the nation addresses the complexities of that environment will have a direct and profound impact upon the profession's future (i.e., practice, education, and research).  Substantive change evolves over time and is almost always based upon foundations established by visionaries from the past.  We would urge that psychology pay careful attention to the views expressed by those Institute of Medicine (IOM) participants who have, and frequently still are serving as health policy appointees within the Bush and Obama Administrations.  Their focused attention upon curtailing the ever-escalating cost of health care and bringing data-based, scientific knowledge to the daily delivery of care is unprecedented.  The advances occurring within computer sciences and related communications fields make their vision achievable.

            Movement Towards Integrated Care:  Five years ago the State ofMassachusetts joined Hawaii in enacting legislation which took a significant step towards guaranteeing that all of its citizens would have access to necessary health care.  Recently, due primarily to ever-escalating costs, it is considering replacing its fee-for-service system with an increasingly capitated approach that is very similar to President Obama's Accountable Care Organization (ACO) initiative (which many have suggested is founded upon President Nixon's HMO vision).  The underlying concept is to provide pre-set payments to organized teams of health care providers which would be responsible for all of the care required by a group of patients, with the possibility of bonuses for keeping people healthy.  Currently 98% of Mass.residents are insured with the Senate President acknowledging: "We did access first.  Now we have to figure out how we afford that."  The Governor's proposal builds upon a consensus among leaders from the state's insurance and hospital industries, medical society, and legislature who served on a special state commission.  Fee-for-service "is a primary contributor to escalating costs and pervasive problems of uneven quality" the commission unanimously concluded.

            The Healthcare Imperative: Lowering Costs and Improving Outcomes:  The IOM has proposed lowering the nation's health care expenditures by 10% in 10 years, while improving patient health and the quality of care provided.  The Congressional Budget Office (CBO) estimates that federal spending on health care will double in the next decade, consuming 27% of the budget by 2020.  The overarching IOM vision is to have 90% of clinical decisions being supported by accurate, timely, and up-to-date clinical information by 2020.  To accomplish this, it will be necessary to develop a learning health system that is designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider and to drive the process of discovery to become a natural outgrowth of patient care, while ensuring innovation, quality, safety, and value in health care.  Evidence development must not be merely an occasional byproduct of health care, but instead evidence capture and analysis, as well as its application, must be systematically structured as an integral and natural component of the care process.

            An IOM workshop identified six domains of excess costs in health care: unnecessary services (volume), services delivered inefficiently, prices that are too high, excessive administrative costs, missed prevention opportunities, and fraud.  The participants concluded that each is an important contributor to excessive health care costs and the amount of excessive costs incurred from each is tremendous.  Excess costs stemming from waste and inefficiency in the nation's health care system was estimated by IOM to total between $750 billion and $785 billion in 2009.

Health care cost increases continue to outpace the price and spending growth rates for the rest of the economy by a considerable margin.  At $2.5 trillion and 17% of the GDP in 2009, health spending in our nation commanded twice the per capita expenditures of the average for other developed countries.  "Moreover, there are compelling signals that much of health spending does little to improve health, and, in certain circumstances, may be associated with poorer health outcomes."  Interestingly, the Peter G. Peterson Foundation which supported this workshop is primarily dedicated to the mission of increasing public awareness of the nature and urgency of key economic challenges threatening the nation's fiscal future, and accelerating action by identifying sensible, sustainable solutions.  It has committed significant resources and attention to the area of health care costs and solutions given health care's direct impact upon the economy.

            Without significant action, by 2050 Medicare and Medicaid expenditures will account for nearly a quarter of the entire U.S.economy.  In 2008, Medicaid spending accounted for approximately 21% of total state spending and represented the single largest component of state spending.  Similarly, in the private sector health care costs have contributed to slowing the growth in wages and jobs.  "While the United States has the highest per capita spending on health care of any industrialized nation – 50 percent greater than the second highest and twice as high as the average for Europe, it continually lags behind other nations on many healthcare outcomes, including life expectancy and infant mortality."

            A number of common themes surfaced.  The Cost and Outcome Challenges. * Health Cost Excesses with Personal, Institutional, and National Consequences.  * Health Outcomes Far Short of Expectations.  Racial disparities in access lead to poorer outcomes, lost productivity, and lower quality of life.  * Fragmented Decision Points, Inconsistent Principles, Political Distortions. The Drivers of the Shortfalls.  * Scientific Uncertainty.  The gap between practice needs and available guidance is growing.  * Perverse Economic and Practice Incentives. * System Fragmentation. * Opacity as to Cost, Quality, and Outcomes. * Changes in the Population's Health Status.  Since 48% of Medicare beneficiaries have at least three chronic conditions and 21% have five or more conditions, it has been estimated that approximately 60 million Americans have multiple morbidities, a number that is expected to increase to 81 million by 2020.  * Lack ofPatient Engagement in Decisions.  Almost 40% of Americans possess only "basic" or "below-basic" health literacy skills.  Thus, their ability to make informed decisions becomes increasingly difficult as the volume and complexity of data available to them increases.  * Under-Investment in Population Health.  Only about 6% of national health expenditures are spent on public and population health.  Levers to Address the Drivers.  * Streamlined and Harmonized Health Insurance Regulation.  * Administrative Simplification and Consistency.  * Payment Redesign to Focus Incentives on Results and Value.  There is a need to better target resources on those patients at highest risk of poor outcomes.  * Quality and Consistency in Treatment, with a Focus on the Medically Complex.  There are already more than 3,000 guidelines from more than 280 organizations registered with the National Guideline Clearinghouse, thus consistency in guideline recommendations is a concern.  * Evidence That Is Timely, Independent, and Understandable.  * Transparency Requirements as to Cost, Quality, and Outcomes.  * Clinical Records That Are Reliable, Sharable, and Secure.  * Data That Are Protected But Accessible for Continuous Learning.  * Culture and Activities Framed by Patient Perspective.  With 25% of Medicare expenditures attributed to unwanted variation in preference-sensitive care, it was noted by many of the participants that much of health care delivery has been shaped over the past generation with the primary convenience and interests of the clinician, not the patient, in mind.  * Medical Liability Reform.  And, * Prevention at the Personal and Population Levels.

As one should expect, there was considerable discussion surrounding the potential benefits of Comparative Effectiveness Research and Health Information Technology (i.e., electronic records and telehealth services).  One of the participants asserted that: "(E)nhancing the effectiveness and efficiency of the U.S.healthcare system was dependent upon maximizing the contributions of healthcare professionals who are not physicians.  She identified a number of current barriers which limit appropriate use of such providers, including federal and state laws and regulations; opposition from healthcare systems, professional medical groups, and managed care organizations; reimbursement and other payment policies; and exclusion from demonstrations proposed as part of health reform."

Psychology's Visionaries – Interdisciplinary Care:  "I have had the privilege of serving on the Board of Advisors of the Duke University School of Nursing for the last four years at the request of the Dean who is the current President of the Association for the Advancement of Nursing.  While I have always been a strong advocate of collaborative care, this experience is an education for me in the roles that nurses play in our emerging healthcare systems.  I have learned about the roles nurses play in Global Health, such as the Duke nurses who develop and staff clinics in rural Tanzania with others leading distance education programs in the British West Indies.  I have learned about the new professional degree for nurses, the Doctor of Nursing Practice (DNP).  At Duke, DNPs are being prepared to innovate and provide leadership in clinical service delivery, and to translate evidence into practice at the point of care.  I have learned about the innovative on-line educational programs now available to nurses.  I was able to attend a course for Nurse Informatacists on the Second Life platform.  I have learned about the science of nursing, and the role Ph.D. faculty play in advancing healthcare science and education.  Some nurses ARE psychologists, having earned their Ph.D. in psychology after attending nursing school; for example our immediate APA Past-President Carol Goodheart.  Carol truly appreciates the emerging data on the social determinants of health as well as the importance of the primary healthcare providers in our country: family (as defined by the patient) caregivers, for acute and chronic conditions, which was one of her impressive Presidential initiatives.  I have learned about how effective nursing organizations and their leadership are in their advocacy efforts, supporting their discipline and focused on better patient care.  There is a profound research-practice gap in all disciplines.  Researchers must come to understand the values and beliefs of particular clinicians in order to achieve wide dissemination.  Psychology has much to learn from our sister discipline of nursing, whether through interdisciplinary courses or collaborative research or advocacy" [Susan McDaniel, University of Rochester Medical Center].

Ensuring Culturally Sensitive Care:  "I Ola Lahui Rural Hawai'i Behavioral Health Program opened its doors in August of 2007 with the specific intention of developing an APA accredited internship program to helpHawai'i 'grow its own.'  With only four APA accredited internships in the state, many of the best and brightest have been forced to leaveHawai'i during their crucial training years.  On November 9^th, 2010 the I Ola Lahui Internship Program was approved as an APA accredited program beginning in December, 2009.  Since 2007, we have trained 10 psychologists with eight of them living and working in medically underserved areas.  We currently have five more in training.

"Native Hawaiians continue to have major health and socioeconomic concerns that are disproportionately greater than other ethnic groups in Hawai'i.  Native Hawaiians have the highest rate of untreated medical and psychological concerns, and those who do seek services rely primarily on state and federally sponsored programs for their health care.  Greater medical and psychological concerns coupled with disparities in income and education and the cultural distress experienced by Native Hawaiians have created an unprecedented demand for health and mental health services.  Further exacerbating the dire need for mental health treatment in underserved areas is the reluctance of patients to seek treatment due to the stigma of mental health problems.  Increased access to quality health care for Native Hawaiians and other medically underserved populations in Hawai'iis desperately needed to combat these health disparities.

"The idea of creating I Ola Lahui arose from the growing behavioral and mental health care needs of the medically underserved and people who reside in the rural communities of Hawai'i.  As with many medically underserved and rural communities across the U.S., those in Hawai'i face challenges in receiving quality medical and psychological services.  Often people do not access care, are offered limited care, or are referred to specialty health care services in urban areas miles away or even on another island in our state.  I Ola Lahui provides a sustainable source of behavioral health care that is tailored to the unique needs of this group.

"I Ola Lahui expresses our intent to improve the health and well being of our people.  It means, 'So that the people will live and thrive.'  The I Ola Lahui mission is to provide culturally-minded, evidence-based behavioral health care that is responsive to the needs of medically underserved and predominately Native Hawaiian rural communities.  In recognition of Hawai'i's urgent need for more quality mental health care, I Ola Lahui is committed not only to providing services, but also to investigating the effectiveness of the services we provide and to training future providers with the hope of increasing the number of doctoral level behavioral health providers and services available in the medically underserved and rural areas of Hawai'i.

"I Ola Lahui is designed to serve Native Hawaiians and other medically underserved groups through specialized training exclusively in Hawai'i's Native Hawaiian Health Care System (NHHCS) clinics, Federally Qualified Community Health Centers (FQCHCs), and related programs.  Although we, as an organization, aspire to have a significant impact upon the health and well being of all Native Hawaiians and other medically underserved groups living in rural areas, our mission is simple and based soundly in a real desire to improve the lives of the people in our islands.  We are honored that this year we had 70 applicants for the two internship slots we can offer" [Robin Miyamoto, former HPA President].  "Chills the body but not the soul, hallelujah…. Michael row the boat ashore, hallelujah."  Aloha,

Pat DeLeon, former APA President 

LEAVING ON A JET PLANE

            Over the next five to ten years, President Obama's landmark Health Care Reform legislation (the Patient Protection and Affordable Care Act [PPACA]) will be systematically implemented.  Psychology should appreciate that the law is fundamentally patient-oriented and not provider-centric.  The States and Administration have considerable flexibility to address overarching national objectives.  Increasing access to quality primary health care and making scientifically-based clinical decisions are central to its vision.  The 21^stcentury will be an era of educated consumers, interdisciplinary and integrated health service delivery systems, and an unprecedented utilization of communications technology (e.g., telehealth and electronic health records).

            Telehealth – Service Delivery Of The Future:  The HHS Budget notes that the Office of Telehealth is an integral component of its Improve Rural Healthcare Initiative, with the goal of expanding the use of telecommunications technologies to increase access to, and the quality of, healthcare provided to rural populations.  A major goal is to strengthen partnerships among rural health care providers, recruit and retain rural health care professionals, and modernize the health care infrastructure in rural (and urban) areas.  These technologies are not viewed as products or ends in themselves, but as the means to provide services at a distance and to overcome geographic, economic, and other social barriers to obtaining health care.  A related objective is to increase the number of states adopting a common licensure application and participating in mutual recognition of each other's licenses.  Evaluation activities will focus upon telehealth's economic impact, particularly on the implications for coverage by government and third party payers which are critical for its viability.

The APA Council of Representatives recently established a ten person Task Force on the Development of Telepsychology Guidelines, co-chaired by Linda Campbelland Fred Millan (ASPPB), in conjunction with the APA Insurance Trust.  The goal is to provide direction to psychologists as they navigate the numerous ethical, regulatory, legal, and practice issues in their increasing utilization of this exciting technology for the delivery of psychological care.  Nevada is the home of the U.S. Senate Majority Leader.  His colleague, Senator Sheldon Whitehouse has introduced legislation (S. 539), the Behavioral Health Information Technology Act, which would extend eligibility for psychologists and other behavioral health care providers to obtain federal assistance in moving into the rapidly evolving technological era.  APA'sMarilyn Richmond would appreciate your active support of this legislation.  "I'm leaving on a jet plane.  I don't know when I'll be back again.  Oh babe, I hate to go."  Aloha,

 

Pat DeLeon, former APA President – Nevada Psychological Association – April, 2011

STEADILY FORWARD IN UNCHARTED WATERS

            Over the next five to ten years psychology will experience the steady implementation of President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act [PPACA].  The President's vision is fundamentally patient-centered, rather than provider-centric, and provides the Department of Health and Human Services (HHS) and the States with considerable flexibility to meet overarching national goals.  From a public policy frame of reference, we will see the revitalization of the states as "living laboratories" of social reform.  It is estimated that at least 32+ million currently uninsured Americans will obtain primary care coverage by 2014, although some experts predict a significantly higher number of nearly 50 million.  With an aging provider workforce and concerted efforts in the newly elected House of Representatives to repeal ObamaCare at all costs, Who will be available to provide these necessary services? And, What role will psychology ultimately play?

            Accountable Care Organizations: What Are They?  The Accountable Care Organizations (ACOs) concept is among the most visible health care payment and delivery system models provided for in the now one-year old health reform law [P.L. 111-148].  ACOs have the dual purpose of realigning the provider payment system and retooling performance measurement approaches to ensure accountability; thereby, shifting health care practice from a volume and intensity-based system to one that supports coordinated, high quality, and cost-effective care.  Specifically, this section of the federal statute focuses upon promoting accountability for Medicare beneficiaries through voluntary participation in the Medicare Shared Savings Program (which will be created before January 1, 2012), via ACOs.  The law defines ACOs as provider-led organizations, which may include hospitals, that share with payers accountability for care quality and cost containment and address the continuum of care and specialty needs for a patient population (of at least 5,000).  Accountability is fostered primarily through cost and quality transparency and economic rewards shared by providers and payers when costs are reduced.  The initiative will be implemented in January, 2012 and the Centers for Medicare and Medicaid Services (CMS) regulations are scheduled to come out in the near future.  Providers, executives, and even health insurance companies are scrambling to design and establish ACOs, but structural details are still forthcoming.

            ACOs have been characterized as "the elusive unicorn – everyone seems to know what it looks like, but nobody's actually seen one."  Ultimately, the shape of ACOs will likely depend on a variety of factors including proposed CMS regulations and the related financing environment, relevant statutory definitions; and, in some cases, state practice acts.  High stakeholder demands for flexibility and regulation nimbleness – until we learn what works – indicate that the debate around which entities will qualify will likely be ongoing.  Leading experts do agree that four general models capture the essential elements of potential ACOs: an integrated delivery system, multi-specialty group practice, physician-hospital organization, and independent practice association.  Historically, whenever any complex legislation, such as PPACA, has been enacted, over the next couple of years the committees with jurisdiction will recommend bipartisan "technical fixes" in order to smooth the implementation process, based upon practical experiences.  Unfortunately, in the current Congressional climate such necessary legislative oversight seems unlikely.

            Exciting Opportunities For Psychology:  As the exact nature of ACOs is still evolving, it is important for organized psychology to affirmatively enter into the policy debate, at both the local and federal level, especially in determining the fate of non-physician providers and non-physician led practices.  Will the ACOs be broadly defined and horizontally-organized including behavioral health providers as equal partners (or leaders)?  Or, Will they take on a physician-dominated hierarchical structure?  As the four models above indicate, ACOs are not necessarily physician focused.  They address all facets of a patient's condition and foster shared accountability for overall quality and costs encompassing a larger range of providers.

            With respect to the quality and integration side of the equation, the opportunities for psychology are clear.  First, the role of the behavioral health provider will only become more essential.  Mental health and substance-use problems are the leading cause of combined disability and death of women and second highest in men in theUnited States.  Currently, only 7% of health care expenditures go to mental health treatment.  This, despite the fact that over 70% of people dually eligible for Medicare and Medicaid have mental illness.  Further, we know that 67% of adults and more than 92% of people with serious mental illness do not receive effective mental health and substance-use treatment.  This is due to multiple variables that affect success and acceptability of care, but these statistics highlight the type of patient who will be served in ACOs.  As with health homes (or "medical homes"), the ACO concept emphasizes prevention, early identification and intervention, chronic disease management, person-centered approaches, and implies adoption of evidence-based practice.  There are now several compelling examples of high value integrated care interventions targeting mental health and substance-use in elderly adults that include psychological interventions/supervision.  Two examples of cost-effective models with good outcomes include the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) and the Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) programs.

            Second, quality care depends upon access to the well-implemented, cost-effective best practices.  Psychologists can fill a knowledge and skill void here, in a number of ways.  They include: a.) recruiting, training, and retraining a competent behavioral health workforce; b.) developing and studying effective implementation and service delivery models including: c.) screening and assessment technology: instrument selection and construction, administration and interpretation, training, supervision, and research; d.) bridging science and service and facilitating the dynamic, iterative learning process resulting from their interplay; e.) client- and family-centered shared decision making: intervention design, training and supervision, and basic and applied research; f.) competency in developmental psychology across the lifespan; specifically in older adults and adults with psychiatric disabilities: training and supervision, development of selection tools and interventions, and conducting and translating research; g.) developing decisional algorithms for referral to specialty services; and, h.) implementing outcome-driven, culturally-informed, evidence-based intervention strategies.  In addition, high quality, multidisciplinary care and cross-training is rife with interest for psychologists in both practice and research fronts.  Some examples include: standardized screening, outcome measures, data collection, analysis and interpretation in the context of multiple literatures, training of staff on behavioral health evidence-based practices and process, patient engagement, and, of course, conducting research and translating findings into practice top the list of examples.  Finally, coordinating communication and treatment planning across a multidisciplinary team requires appreciation for the overlapping and unique knowledge bases and skill sets of each participating discipline and managing group dynamics in the context of delivering quality-based care.  Regardless of the fate (or face) of ACOs, it is clear that psychologists can and must play a critical role in their development and successful implementation.  ACOs are being developed within the policy context of reports by the Institute of Medicine (IOM) that excessive costs stemming from waste and inefficiency within the nation's health care system currently total between $750-$785 billion annually.

            Visionary Leadership:  Susan McDaniel of the University of Rochester Medical Center has long been in the forefront of psychology's evolution into integrated care.  "I have had the privilege of serving on the Board of Advisors of the Duke University School of Nursing for the last four years at the request of the Dean who is the current President of the Association for the Advancement of Nursing.  While I have always been a strong advocate of collaborative care, this experience is an education for me in the roles that nurses play in our emerging healthcare systems.  I have learned about the roles nurses play in Global Health, such as the Duke nurses who develop and staff clinics in rural Tanzania with others leading distance education programs in the British West Indies.  I have learned about the new professional degree for nurses, the Doctor of Nursing Practice (DNP).  At Duke, DNPs are being prepared to innovate and provide leadership in clinical service delivery, and to translate evidence into practice at the point of care.  I have learned about the innovative on-line educational programs now available to nurses.  I was able to attend a course for Nurse Informatacists on the Second Life platform.  I have learned about the science of nursing, and the role Ph.D. faculty play in advancing healthcare science and education.  Some nurses ARE psychologists, having earned their Ph.D. in psychology after attending nursing school (for example, our immediate APA Past-President Carol Goodheart).  I have learned about how effective nursing organizations and their leadership are in their advocacy efforts, supporting their discipline and focused on better patient care.  Psychology has much to learn from our sister discipline of nursing, whether through interdisciplinary courses or collaborative research or advocacy."  Aloha,

Sandra Wilkniss, APA/AAAS Congressional Fellow & Pat DeLeon, former APA President.  National Register – March, 2011

 

AN EXCITING OPPORTUNITY

            As President Obama's landmarkPatient Protection and Affordable Care Act [PPACA] [P.L. 111-148] is systematically implemented over the next 5-10 years, it is important that our State Associations appreciate that the law is fundamentally patient-centered, and not provider-centric, andfurther that the States have considerable flexibility to develop local approaches which address broad, often non-specific, national objectives.  Psychology is one of the nation's health care professions and as such, must increase its efforts to work collaboratively with other disciplines, engage patients in taking responsibility for their own health care, and begin utilizing the unprecedented advances occurring within the communications and technology fields (i.e., telehealth and virtual realities) to ensure data-based, high quality care.  Geographical boundaries (for example, in rural America) no longer are acceptable excuses for denying care.  State Associations must work with their legislatures and licensing boards to achieve licensure portability.

            The Robert Wood Johnson Foundation (RWJF) recently announced a new grant program Public Health Law Research: Making the Case for Laws That Improve Health.  RWJF seeks to build the evidence for, and strengthen the use of, regulatory, legal, and policy solutions to improve public health and help individuals lead healthier lives.  It is equally interested in identifying and ameliorating laws and legal practices that unintentionally harm health.  Critical questions: How does law influence health and health behavior?  Which laws have the greatest impact?  Can current laws be made more effective through better enforcement, or do they require amendment?  Preference will be given to applicants that are public entities or nonprofit tax-exempt (501(c)(3)) organizations.  Short-term study grants up to 18 months ($150,000 each); complex and comprehensive study grants up to 30 months ($450,000 each).  A total of $2.85 million will be available for this round of grants.

            The Call for Proposals focuses upon three topics: 1.) Effects of laws and legal practices on population health outcomes.  2.) Using innovative regulatory tools to promote health.  And, 3.) Effects of law, regulation, and policy on the performance of public health systems and the delivery of public health services.  Examples include: studies that will investigate the design and implementation of a new legal intervention or assess effects of an existing law or enforcement strategy on physical or mental health; exploring the impact of the criminal justice system on the health of communities; studies of the unintended effects of law on the incidence or prevention of chronic diseases; and, studies of the organization, financing, and delivery of public health services, including public mental and behavioral health services, and the effects of those services on public health.  One selection criterion is effective collaboration between public health, legal researchers, and practitioners.  We would suggest that this RWJF initiative provides an exciting opportunity for state psychological, nursing, and bar associations to collaboratively address some of society's most pressing needs.  Law and business remain the most common professional backgrounds of elected officials.  Early career exposure goes a long way towards encouraging professional respect for other disciplines.  This Spring, Hawaii Psychological Association was successful in having their prescriptive authority (RxP) legislation pass the State Senate on an 18-3-4vote.  With mutual respect comes legislative success.  Aloha,

 

Pat DeLeon, former APA President – Division 31 – March, 2011