TECHNOLOGICAL IMPERATIVE

 One direct consequence of the advent and steadily increasing presence of technology within the health care arena will be the need for psychology to finally seriously address the issue of licensure mobility.  The Department of Veterans Affairs (VA) recently announced its plan to increase veterans' access to mental health care by conducting more than 200,000 clinic-based, telemental health consultations by mental health specialties this fiscal year.  Earlier the VA indicated that it would no longer charge a copayment when veterans receive care in their homes from VA health professionals using video conferencing.  The Secretary: "Telemental health provides Veterans quicker and more efficient access to the types of care they seek.  We are leveraging technology to reduce the distance they have to travel, increase the flexibility of the system they use, and improve their overall quality of life.  We are expanding the reach of our mental health services beyond our major medical centers and treating Veterans closer to their homes."  Since the start of the VA Telemental Health Program, VA has conducted over 550,000 patient encounters. 

            The Fiscal Year 2013 budget request for the Office of Rural Health Policy, which is located within the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services, notes that there has been a significant Departmental focus on rural activities for over two decades.  Historically, rural communities have struggled with issues related to access to care, recruitment and retention of health care providers, and maintaining the economic viability of hospitals and other health care providers in isolated rural communities.  There are nearly 50 million people living in ruralAmerica who face ongoing challenges in accessing rural health care.  Rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than their urban counterparts.  Rural areas also continue to suffer from a shortage of diverse providers for their communities' health care needs and face workforce shortages at a greater rate than their urban counterparts.  Of the 2,052 rural counties in the nation, 77 percent are primary care health professional shortage areas (HPSAs), where APA's Nina Levitt reports that psychologists are eligible for the National Health Service Corps Loan Repayment Program which places health professionals in underserved rural communities.

HRSA's Telehealth Grants initiative is designed to expand the use of telecommunications technologies within rural areas, seeking to link rural health practitioners with specialists in urban areas, thereby increasing access and the quality of healthcare provided.  Telehealth offers important opportunities to improve the coordination of care in rural communities by linking its providers with specialists and other experts not available locally.  The strengthening of a viable rural health infrastructure is viewed as critical for long-term success, including facilitating distance education experiences.  The budget request for the office of rural health office once again proposed $11.5 million, which has subsequently been approved by the Senate Appropriation Committee, and thus allows the continuation of the Licensure Portability Grant initiative, in order to assist states in improving clinical licensure coordination across state lines.  This particular initiative builds on HRSA's 2011 Report to Congress indicating: "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….  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 health professionals. "

            For some colleagues, and particularly for those who are not comfortable with fundamental change, the relationship between telemental health and licensure mobility might seem to be a tenuous one.  And yet, we would suggest that they are intimately linked.  The public policy rationale for professional licensure is to protect the public from untrained and/or unethical practitioners, not to enhance the status or economic well-being of the profession.  Historically, and we would expect for the foreseeable future, licensure decisions and qualification criteria have been made at the individual state level, where each of the professions plays a major role in determining its requirements for membership and its scope of practice, albeit through the political process.  Within the federal system the governing statutes and implementing regulations generally require licensure in at least one state (regardless of practitioner geographical location) and facility approval (i.e., being credentialed).  As improvements in technology allow for increasingly higher quality utilization, the congressional committees with jurisdiction have been systematically "cleaning up" potential lingering statutory restrictions.  And, at both the state and federal level, expanding reimbursement paradigms are evolving.  APA estimates that 13 states now require private sector insurance companies to pay for telehealth services.  Over the years, we have not been aware of any objective evidence which suggests that the quality of care being provided via telehealth is in any way compromised.  To the contrary, as the VA, the Department of Defense (DoD), and the federal criminal justice system are demonstrating, access has been significantly enhanced and new state-of-the-art clinical protocols have been developed and implemented.

            A First Hand View -- From TriplerArmy Medical Center:  "I joined the Telebehavioral and Surge Support (TBHSS) Clinic in February, 2011 during its infancy.  At that time, the program was fully staffed with providers and support staff, making us 24 strong.  TBHSS provides healthcare access by connecting eligible beneficiaries to providers who are able to indentify and treat their clinical needs.  These services are provided through secured video technology which allows accessibility from remote locations worldwide.  I was very excited to have the opportunity to work in a clinic that has the ability to reach out to those off island, typically in areas where the demand for services is far greater than that of the availability.  To date, the clinic has been able to support Alaska,Texas, Korea, Japan, Okinawa, and American Samoa, as well as various sites on the island ofOahu and in the Continental United States.  As a provider, it was refreshing to be able to provide multiple services such as therapy, consultation, administrative evaluations, and both neuropsychological and psychological assessments. In addition, we provided surge support during different points within the ARFORGEN cycle whenever there was a need for augmented behavioral health resources.  In February, 2012 I was fortunate to be commissioned in the USPHS as a Lieutenant (0-3) and detailed to Tripler.  As a clinical psychologist, I was able to utilize all the skills within the Department of Psychology that I acquired from my time at TBHSS.  Recently, I had the honor to be promoted to the position of Clinical Director of TBHSS.  Returning back to my roots has been exciting as I get to work with individuals who have a passion and commitment to serve service members and their families.  My journey as a clinical psychologist civilian contractor to active duty clinical director has just begun and I am looking forward to the ongoing relationships that the TBHSS team forges with the different regions" [Sherry Gracey, Lt. USPHS].

            ASPPB:  We were very pleased to learn from Steve DeMers that the Association of State and Provincial Psychology Boards (ASPPB) was successful in its application this year for one of the licensure portability grants issued by HRSA.  ASPPB will receive approximately $1 million over the next three years to provide support for state psychology licensing boards addressing statutory and regulatory barriers to telehealth, focusing upon continuing the development and implementation of its Psychology Licensure Universal System (PLUS) initiative.  As an integral means of addressing the present barriers associated with telepsychology, ASPPB has developed an on-line application system, the PLUS, that can be used by any applicant who is seeking licensure, certification, or registration in any state, province, or territory in the United States or Canada that participates in the PLUS program.  This also enables concurrent application for the ASPPB Certificate of Professional Qualification in Psychology (CPQ) which is currently accepted by 44 jurisdictions and the ASPPB Interjurisdictional Practice Certificate (IPC).  All information collected by the PLUS is deposited and saved in the ASPPB Credentials Bank, a Credentials Verification & Storage Program (The Bank).  This information can then be subsequently shared with various licensure boards and other relevant organizations.  Therefore, streamlining future licensing processes.

            ASPPB is an active participant in the APA/ASPPB/APAIT Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, established by former APA President Melba Vasquez and co-chaired byLinda Campbell (APA) and Fred Millan (ASPPB).  The members have backgrounds, knowledge, and experience reflecting expertise in the broad issues that practitioners must address each day in the use of technology -- ethical considerations, mobility, and scope of practice.  Several of the meta-issues discussed to date center on the need to reflect broadness of concepts when incorporating telecommunications technologies and to provide guidance on confidentiality and maintaining security of data and information.  In addition, a number of meta-issues focus on the critical issue of interjurisdictional practice.  The underlying intent behind the proposed guidelines is to offer the best guidance to psychologists when they incorporate telecommunication technologies in the provision of psychological services, rather than be prescriptive. The Task Force met twice in 2011, June of 2012, and plans to meet once more this Fall.  Feedback on their recommendations will be sought at the Orlandoconvention, throughout the APA governance, and continuously from the membership at large.  Their goal is to have the guidelines adopted by APA as policy and approved by ASPPB and APAIT sometime in 2013.

            The U.S. Supreme Court:  As we all must be aware, this summer the U.S. Supreme Court upheld the underlying constitutionality of the President's landmark Patient Protection and Affordable Care Act of 2010 (ACA), including it's far reaching individual mandate provision, by a 5-4 vote.  For legal scholars, the most critical issue was probably the Court's deliberations regarding the federal government's power to regulate Commerce vs. its power to raise Taxes, as a government of limited and enumerated powers.  "We do not consider whether the Act embodies sound policies.  That judgment is entrusted to the Nation's elected leaders.  We ask only whether Congress has the power under the Constitution to enact the challenged provisions."

For health policy experts and practitioners, the Court's musings on our nation's health care system makes for particularly intriguing reading.  * "Everyone will eventually need health care at a time and to an extent they cannot predict, but if they do not have insurance, they often will not be able to pay for it.  Because state and federal laws nonetheless require hospitals to provide a certain degree of care to individuals without regard to their ability to pay, hospitals end up receiving compensation for only a portion of the services they provide.  To recoup the losses, hospitals pass on the cost to insurers through higher rates, and insurers, in turn, pass on the cost to policy holders in the form of higher premiums.  Congress estimated that the cost of uncompensated care raises family health insurance premiums, on average, by over $1,000 per year."  * "Indeed, the Government's logic would justify a mandatory purchase to solve almost any problem….  (M)any Americans do not eat a balanced diet.  That group makes up a larger percentage of the total population than those without health insurance.  The failure of that group to have a healthy diet increases health care costs, to a greater extent than the failure of the uninsured to purchase insurance….  (T)he annual medical burden of obesity has risen to almost 10 percent of all medical spending and could amount to $147 billion per year in 2008.  Those increased costs are born in part by other Americans who must pay more, just as the uninsured shift costs to the insured."  * "In enacting [ACA], Congress comprehensively reformed the national market for health-care products and services.  By any measure, that market is immense.  Collectively, Americans spent $2.5 trillion on health care in 2009, accounting for 17.6% of our Nation's economy.  Within the next decade, it is anticipated, spending on health care will nearly double.  The health-care market's size is not its only distinctive feature.  Unlike the market for almost any other product or services, the market for medical care is one in which all individuals inevitably participate."  * "Not allU.S. residents, however, have health insurance.  In 2009, approximately 50 million people were uninsured, either by choice or, more likely, because they could not afford private insurance and did not qualify for government aid."

            Bringing Psychology To The Table – State Leadership In Health Care Reform:  At this year's impressive State Leadership conference, Katherine Nordal exhorted our state association leaders to appreciate that: "We're facing uncharted territory with proposed new models of care delivery.  New financing mechanisms that we're going to have to understand and appreciate, and the ways that they are going to impact practice, whether it's private practice or institutional practice.  We know that the states are in the drivers' seat, and most of what happens about health care reform is going to happen back home.  We know that we can't do it alone.  Our advocacy depends on effective collaborations and effective partnerships.  We have to be ready to claim our place at the table.  We need to be involved at the ground level.  You've got to get involved in coalitions.  If we don't participate, then we abdicate our responsibility there and we let other people – physicians, nurses, social workers, MFTs, whoever – define what our future is going to be as a profession.  And that's just not an option for us.  If we're not at the table, it's because we're on the menu….  When you get home and you turn your focus to health care reform, I want you to remember that other groups don't automatically think about psychology and invite us to the table when they're having these discussions.  We have to identify health care reform initiatives that impact psychological practice and our patients and get involved in those in a proactive way.  If you wait…."  Aloha,

 

Pat DeLeon, former APA President – Division29 – August, 2012

 

EXCITING TIMES FOR THE PUBLIC SECTOR

  During this year's Senate Appropriations Committee hearings on the Fiscal Year 2013 budget, the three Department of Defense (DoD) Surgeon Generals and the Chiefs of the Service Nursing Corps noted the importance of quality mental health care, advances in technology (e.g., telehealth), and the critical psychosocial-cultural-economic gradient of care to the military and to its families.  Having personally observed these hearings over the years, the change in focus from previously almost exclusively acute care and "medical" issues, to the recognition of the importance of systems, holistic approaches, and patient-centered care represents a very nice evolution/maturation for which psychology and nursing can be justifiably proud.  Many of the underlying concepts, such as coordinated and integrated care, not to mention fundamental interdisciplinary respect, are at the foundation of President Obama's landmarkPatient Protection and Affordable Care Act.  I have come to particularly appreciate how critical the public sector's inherent emphasis upon systems of care --  in contrast to the private sector's often isolated (or silo-oriented) care -- is in fostering cost-effective, state-of-the-art, high quality care for beneficiaries.  This is the future and fortunately our training programs are becoming increasing responsive.  At lunch the other day, for example, I learned that Uniformed Services University of the Health Sciences (USUHS)  clinical psychology graduate student LT Chantal Meloscia, USN is enrolled/embedded in a Graduate School of Nursing advanced physiology course.  This core course for advanced nurse practitioners provides an in-depth understanding of the function and regulation of the body system to maintain homeostasis, with an emphasis on the integration of the structure and functional systems within the human body.  The course content ranges from cellular mechanisms to the major body organ systems, providing the basis for understanding physiologic derangements.  On average, nine USUHS psychology students will take this required course annually, serving as a foundation for a pharmacology class the following year taken through the medical school.

            United States Air Force (USAF):  National health care costs continue to rise at rates above general inflation and the DoD is not insulated from this growth as we purchase over 60% of our care from the private sector.   In times of war there are always significant advances in the field of medicine.  Today we are applying these lessons to shape future readiness and care.  Build patient-centered care.  At home, we continue to advance thePatient-Centered Medical Home (PCMH) to improve the delivery of peacetime healthcare.  The foundation of patient-centered care is trust, and we have enrolled 920,000 beneficiaries into team-based, patient-centered care.  Continuity of care has more than doubled with patients now seeing their assigned physician 80% of the time and allowing patients to become more active participants in their health care.  PCMH will be in place at all Air Force Medical Treatment Facilities (MTFs) by June of this year.  The implementation of PCMH is decreasing emergency room visits and improving health indicators.  We have also implemented pediatric PCMH, focusing on improving well child care, immunizations, reducing childhood obesity, and better serving special needs patients.

            Our personalized medicine project,Patient Centered Precision Care (PC2), which builds on technological and evidence-based genomic association, received final Institutional Review Board approval.  We enrolled the first 80 patients this year with a goal of enrolling 2,000 patients in this research.  It will allow us to deliver state-of-the-art, evidence-based, personalized health care incorporating all available patient information – the advancement of genome-informed personalized medicine.  We are also testing incorporation of smart-phones into our clinics to link case managers directly to patients.  Linking wireless and medical devices into smart phones allows the patient to transmit weight, blood pressure, or glucometer readings that are in high risk parameters, directly to their health team for advice and consultation.

            Safeguarding the well-being and mental health of our people while improving resilience is a critical Air Force priority.  We remain vigilant with our mental health assessments and consistently have Post-Deployment Health Reassessment completion rates at 80% or higher for Active Duty, Guard, and Reserve personnel.  We have implemented the Congressionally directed two-phased approach requiring members to complete an automated questionnaire, followed by a person-to-person dialogue with a trained privileged provider.  Whenever possible, these are combined with other health assessments to maximize access and minimize inconvenience for deployers.  Each deployer is screened for post-traumatic stress disorder (PTSD) four times per deployment including a person-to-person meeting with a provider.  Although our PTSD rates are rising, the current rate remains low at 0.8% across the Service.  Our mental health providers, including those in internships and residencies, are trained in evidence-based PTSD treatments to include Prolonged Exposure, Cognitive Processing Therapy, and Cognitive Behavioral Couples Therapy for PTSD.  Virtual Iraq/Afghanistan uses computer-based virtual reality to supplement Prolonged Exposure Therapy at 10 Air Force sites.  Diagnosis is still done through an interview, supported by screening tools and other psychological testing as clinically indicated.

            We are working closely with Air Force leadership to inculcate healthy behaviors.  Comprehensive Airmen Fitness focuses on building strength across physical, mental, and social domains.  While we experienced a drop in the active duty suicide rate in 2011, we remain concerned.  Guard and Reserve suicide levels have remained steady and low.  The major risk factors continue to be relationship, financial and legal problems.  No deployment or history of deployment associations has been found.  By summer of this year, we will embed behavioral health providers in primary care clinics at every MTF.  The Behavioral Health Optimization Program reduces stigma by providing limited behavioral health interventions outside the context of the mental health clinic, offering a first stop for those who may need counseling or treatment.  We are increasing our mental health provider manning over the next 5 years.

            This past year, the Air Force field-tested a new Electronic Health Record (EHR) during Aeromedical Evacuation (AE) missions.  Air Force nursing priority for 2011 was to further advanced research and evidence-based practice initiatives to improve patient safety and pain management during AE transport.  Our Informatics Fellowship is critical to prepare nurses to participate in the development and fielding of computer based information systems, such as the EHR.  Patient centered care is at the core of all we do; it is our highest priority.  Care for our patients crosses into both inpatient and outpatient arenas, and has been redefined with a more focused emphasis on providing healthcare to promoting health.  Embedded in our patient-centered care is an emphasis on resilience.  The Air Force is committed to strengthening the physical, emotional, and mental health of our Airmen and their families.  "You will know you're a military nurse when you visit the National Mall in Washington  D.C., and the Vietnam Veterans visiting The Wall tell you their stories of how nurses saved their lives, and then they thank you for serving.  Then you swallow the lump in your throat and blink back the tears in your eyes and continue doing what you were doing without missing a beat.…  You will know you're a military nurse when at the end of the day, at the end of the tour, or the career, you say, 'I'd do it all over again.'"

            U.S. Army Surgeon General Patricia Horoho noted: "Psychological health problems are the second leading cause of evacuation during prolonged or repeated deployments."  Division member Ray Folen and Becky Porter were with the Surgeon General at TriplerArmy Medical Center when she addressed 5,000 Army behavioral health providers throughout the world, utilizing video-conferencing.  "It was an impressive event, the first of its kind in my 28 years with the Army.  She is a most impressive visionary."  SG Horoho is the first non-physician and first woman selected for this leadership position in the history of the U.S. Army, dating back to 1775.

            A Wonderful Role Model:  "When I turned 70, I retired officially, but since I like to teach, I taught one course a term for free until I had to have my hips and right shoulder replaced at age 85 (the penalty for 50 years of pitching softball).  Now I come to my office every morning to do e-mail and play MURDER at noon.  Then I go home to have lunch with my wife and read the New York Times which is delivered to us, daily.  I still subscribe to 50 journals, including theChronicle of Higher Education and Sciencemagazine which come weekly; so I always have plenty to read.  We also go on Tuesday evenings to hear the Easy Street Jazz Band, which plays some of the same music I played when I played piano in bars weekends during my college years.  We have sung in the FirstBaptist Church for 65 years and enjoy that.  We have an excellent Korean woman organist and a fine choir director.  Our daughters and their husbands live nearby; so we get together with them frequently.  For Christmas, Karen gives us a scroll for one year of free computer consultation and Linda and Larry give us a scroll promising one year of free household maintenance.  (I'm no good at practical things).  One of my friends retired from Harvard and can only go in to hear lectures because he doesn't have an office.  So, at age 91, we feel lucky to be healthy and well cared for.  Best wishes!"  [Bill McKeachie, former APA President.  Regularly attending APA conventions since 1947].

Pat DeLeon, former APA President – Division 18 – July, 2012

 

THE TIMES THEY ARE A-CHANGIN’

The U.S. Army Surgeon General Patricia Horoho recently testified before the Senate Appropriations Committee: "Psychological health problems are the second leading cause of evacuation during prolonged or repeated deployments." The popular media reports that suicides among military members, on average of one per day, are the highest rate so far during a decade of war in Iraq andAfghanistan – and this year higher than the number of troops killed in combat. This clearly demonstrates an appreciation for the need for psychological services in a timely fashion. Reflecting upon my tenure on the U.S. Senate staff, I recall an August 2, 1978 memo from the then-Principal Deputy Assistant Secretary of the Department of Defense titled: Utilization of Psychologists in the Military Health Care System. VernonMcKenzie: "I have had my staff explore this question in some detail. We have concluded that there are utilization problems with respect to this group that require further consideration. We have tentatively concluded that there are several steps which might be taken which would improve the utilization of this professional group. Among these are the following…. Grant psychology departmental autonomy where the size and staffing of the hospital would justify…. Allow a psychologist, when he is senior and capable, to be the head of a mental health department…. Improve the promotion opportunities for senior psychologists…." SG Horoho is the first female and first nurse to be appointed to that critical position since the creation of Army Medicine in 1775.
Bob McGrath, a staunch supporter of psychology obtaining prescriptive authority from the beginning, estimates that currently there are 1600-1700 colleagues who have completed their advanced psychopharmacology training. This is an impressive figure. What I consider even more so, however, is the increasing interdisciplinary training efforts being developed by our academic colleagues as the nation evolves towards integrated care. For example, clinical psychology graduate student LT Chantal Meloscia, USN is enrolled/embedded in a Graduate School of Nursing Advanced Physiology course. This core course for advanced nurse practitioners provides an in-depth understanding of the function and regulation of the body system to maintain homeostasis, with an emphasis on the integration of the structure and functional systems within the human body. The course content ranges from cellular mechanisms to the major body organ systems, providing the basis for understanding physiologic derangements. On average, nine USUHS psychology students will take the required course annually serving as a foundation for a Pharmacology class the following year taken through the MedicalSchool.
Visionary Cynthia Belar announced a new APA Primary Care Fellowship which will develop an overall framework and strategy for promoting the engagement of psychologists in providing integrated mental and behavioral health services in primary care settings. This will involve outreach to physician specialty associations, interdisciplinary primary care organizations, and disease-specific groups to enhance collaboration and partnerships on programmatic and policy initiatives related to integrated health care. Exciting opportunities. For the times they are a-changin'. Aloha,

Pat DeLeon, former APA President – Division 31 – June, 2012

THE STEADY EVOLUTION

  As our nation's business leaders and elected officials seek to address the escalating cost of health care, there will undoubtedly be increasing emphasis upon utilizing the unprecedented advances occurring in computer technology to ensure that necessary, cost-effective care becomes readily available.  Chronic disease treatments account for over 75% of expenditures, with obesity being a major contributor.  Chronic pain affects 116 million adults; more than heart disease, cancer, and diabetes combined.  No single profession can reasonably claim exclusive clinical expertise for these conditions, for which the psychosocial-economic-cultural gradient of care is so critical.  To control costs and increase access, the economic incentives must be transitioned from our traditional fee-for-service and often isolated small practices, to an integrated, multi-disciplinary system, comprehensive enough to capitalize upon multi-provider and multi-discipline strengths, prevention opportunities, and cross patient-diagnosis comparisons.  Change is always unsettling.  Yet, future health delivery models will have much in common with the HMOs proposed by President Nixon and the Managed Care efforts of President Clinton.

            Within the past decade, nearly every health profession has enhanced the education of their graduates, their scope of clinical practice, and their numbers.  There are over 150,000 Advanced Nurse Practitioners (Doctors of Nursing Practice) and Physician Assistants providing quality primary care.  Notwithstanding medicine's historically expressed concerns, objective evaluations of these non-physicians consistently report extraordinary competence and satisfaction by patients.  Similar results exist for optometrists, physical therapists, psychologists, and clinical pharmacists.  With our aging population and expanding ability to quantify health care outcomes, we must embrace a health care delivery system that is dedicated to providing the highest possible quality of patient-centered care in a cost-effective manner.  The critical implementation decisions will be made at the local level.  Aloha,

 

PatDeLeon

 

The Council for Ohio Health Care Advocacy – June, 2012

 

INTERESTING PERSPECTIVE AT THE FEDERAL LEVEL

  DoD/VA Challenges and Exciting Opportunities:  Although I am no longer on the U.S. Senate staff, it is intriguing to reflect upon how psychology and the other health professions are viewed on Capitol Hill.  During her recent Senate testimony, the U.S. Army Surgeon General Patricia Horoho pointed out: "There are significant health related consequences of over ten years of war, including behavioral health needs, post-traumatic stress, burn or disfiguring injuries, chronic pain or loss of limb….  A decade of war in Afghanistan and Iraq has led to tremendous advances in the knowledge and care of combat-related physical and psychological problems.  Ongoing research has guided health policy, and multiple programs have been implemented in theatre and post-deployment to enhance resiliency, address combat operational stress reactions and behavioral health concerns….  For those who do suffer from PTSD, Army Medicine has made significant gains in the treatment and management of PTSD as well.  The DoD and VA jointly developed the three evidenced based Clinical Practice Guidelines for the treatment of PTSD, on which nearly 2,000 behavioral health providers have received training….  (Our) researchers develop strategies and advise policy makers to enhance and sustain mental fitness throughout a service member's career.  Psychological health problems are the second leading cause of evacuation during prolonged or repeated deployments.  (DoD) psychological health and resilience research focuses on prevention, treatment, and recovery of Soldiers and Families behavioral health problems, which are critical to force health and readiness.  Current psychological health research topic areas include behavioral health, resiliency building, substance use and related problems, and risk-taking behaviors."  Her considerable sensitivity to the critical importance of the behavioral sciences, including the psychosocial-cultural-economic gradient of care, undoubtedly reflects the fact that she is the first female and first non-physician Surgeon General in the history of the U.S. Army.

            In considering the Fiscal Year 2013 funding for the Department of Veterans Affairs (VA), the Senate Appropriations Committee voted 30-0 to recommend a $135.6 billion budget.  As of last Fall there were an estimated 22.2 million living veterans and their 34 million dependents (spouses and dependent children).  The VA Health Administration (VHA) operates a national healthcare delivery system consisting of 153 hospitals, 1,102 outpatient clinics and Vet Centers, 133 nursing homes, and 107 VA residential rehabilitation treatment programs.  VHA is the largest federal medical care delivery system in the nation.  The unemployment rate of male veterans between ages 18-24 is 29%; almost double that of their civilian peers with over 847,000 unemployed veterans.  A tragedy which strongly suggests that psychology has much to contribute.

The underlying vision for President Obama's Patient Protection and Affordable Care Act (P.L. 111-148) is the importance of providing high quality primary care through an interdisciplinary team approach, emphasizing integrated care.  It is anticipated that the various health care professions will ultimately learn to work collaboratively, in a cost-effective manner.  The Accountable Care Organization (ACO) and Medical Home provisions of the law are clear examples.  For many of psychology's practitioners this approach represents a fundamental change in their role and clinical orientation.  It will also require our educational systems to significantly modify their programs and expectations.  In many ways, over the years, VHA has championed this approach.  Accordingly, the Senate Appropriations Committee's expressed Interests/Concerns should be of considerable interest to those contemplating the future.

*  Licensing Requirements at DoD/VA Collocated Facilities:  In fiscal year 2012, the Committee directed the Department of Veterans Affairs and the Department of Defense to examine ways in which duplicative licensing requirements at collocated medical facilities might be eliminated.  The findings of this examination were required to be reported to the Committees on Appropriations of both Houses of Congress.  The Committee reiterates the expectation and importance that the VA submit this report.  Upon receipt of the report, the Department is directed to provide regular reports on progress made in implementing any recommendations to streamline duplicative licensing requirements.  An astute colleague working for VHA feels that the more DoD/VA operates like a business, the better off we will be.  Very few in either Department understand "cash flow" or have ever had to live month to month, week to week, and day to day having to make a payroll.  Those who have only worked in the public sector think they understand the "business model," but they have never had to make payroll.  Payroll is always assured and never something they have to concern themselves with.  The bottom line:  They care deeply about patients and each other, but they never really worry if an action they take or don't take might influence whether they will or won't get their next pay check.  Thus, they are comfortable allowing themselves the luxury of not doing what would be most cost-effective in the long run, especially if that would require fundamental change.  For example, embracing prescriptive authority for well trained non-physicians and eliminating bureaucratic hassles such as duplicative credentialing.

*  VA Nursing Academy:  The Committee commends the VA for addressing the nursing shortage through the VeteransAffairs Nursing Academy.  This pilot program established partnerships with competitively selected nursing schools to expand the number of teaching faculty in VA facilities and affiliated nursing schools in order to increase student enrollment in baccalaureate nursing programs.  The Committee notes the VA's realization of a net-positive value for the pilot overall and urges VA to continue its collaboration with the Department of Defense through the Uniformed Services University of the Health Sciences by providing nurse faculty and nursing students in the graduate nursing education programs through the external evaluation period.  Advanced Nursing Education:  The Committee urges the VA, in conjunction with accredited schools of nursing, to explore the development of a fast-track doctoral training program which would facilitate completion of a doctorate in nursing by qualified nurses employed within the VA network who possess a bachelor of science in nursing.  Nursing Research Program:  The Committee supports the Veterans Affairs Nursing Research Program, which facilitates research on the specific nursing needs of combat veterans and aging veterans.  The Committee strongly supports continuation of this program.  The Committee also encourages collaboration between VA nurses and recipients of Tri-Service Nursing Research Program awards in the exploration of research proposals that improve the health and well-being of their shared beneficiary population.

*  Rural America:  The Committee recognizes that the demand for VA services in rural areas will only increase and believes that the VA must do more to plan for and provide quality healthcare to veterans living in rural and highly rural areas.  Travel barriers, including long distances to VA medical facilities and lack of public transportation, make it difficult for the VA to serve rural veterans.  Also, lack of specialized care in rural areas, including mental healthcare, make it difficult for veterans to obtain quality care at home.  The VA is working to address these problems through a number of initiatives, including expanding the use and variety of telemedicine techniques, such as video consultations with practitioners, telephone healthcare monitoring and management, and audio-visual telemedicine diagnostic techniques.  The Committee encourages the VA to pursue leading-edge telemedicine technology and innovative rural health demonstration projects, and to incorporate promising advances into its rural health delivery system.  The Committee recognizes the ongoing challenges to recruit and retain highly qualified healthcare professionals, particularly mental health professionals, in rural areas.  Staffing shortages ultimately lead to higher out-of-pocket costs for veterans as well as decreased quality of care.  The Committee directs VHA to more thoroughly and aggressively evaluate and deploy innovative approaches to recruiting and retaining quality physicians, surgeons, mental health professionals, and other healthcare professionals in rural areas.  These potential approaches should include additional flexibility for rural facilities to enhance salary offers and to offer contract incentives to qualified applicants.  VA should investigate using innovative ways to rotate practitioners through rural areas, such as medical "circuit riders," fully staffed mobile clinics, and cooperative ventures using community hospitals or clinics as platforms for providing VA healthcare services.

*  Mental Health:  Access to VA's mental health services is imperative given the number of Iraq and Afghanistan war veterans suffering from combat related mental health problems.  The Committee remains very concerned about the ability of veterans suffering from combat related mental health conditions to access clinical care in a timely manner.  The Inspector General review found that first-time patients have not uniformly been provided timely mental health evaluations and existing patients often must wait beyond the desired date for appointments.  The Department recently announced that it would add an additional 1,600 mental health clinicians and 300 support staff as part of an ongoing review of mental health operations.  The Committee supports this effort.

There is clear Congressional recognition of the importance of providing high quality mental health and behavioral health care for DoD and VA beneficiaries.  There is demonstrable interest in developing highly innovative approaches for delivering care, especially in remote and rural areas.  We would ask: Whether the Congress or the Administration understands how psychology might meaningfully contribute to the underlying mission of DoD and the VA?

            The Patient-Centered Outcomes Research Institute (PCORI):  The Patient Protection and Affordable Care Act also established PCORI to conduct or commission research to provide information about the best available evidence to help patients and their health care providers make more informed decisions.  The intent is to give patients a better understanding of the prevention, treatment, and care options available, and the science that supports them.  The Institute Mission Statement: "PCORI helps people make informed health care decisions, and improves health care delivery and outcomes, by producing and promoting high integrity, evidence-based information that comes from research guided by patients, caregivers and the broader health care community."  It is an independent, non-profit organization governed by a 21-member Board of Governors.  During his APA Presidency, James Bray testified before the Institute of Medicine as to the importance of Comparative Clinical Effectiveness Research and psychology's potential contributions.  "Comparative effectiveness research is a critically important tool for advancing an evidence-based approach to health care decision-making.  However, the full public health benefits of such research will only be realized if behavioral, psychosocial, and medical interventions for the prevention and treatment of mental and physical health conditions are evaluated individually and in combination.  Even when strictly medical treatments are compared, it is important to expand the range of outcome measures to include behavioral and psychological outcomes, such as quality of life and adherence to treatment protocols."  In its initial research effort, PCORI proposed $120 million for these types of initiatives.  This Summer, $96 million will be made available for those engaged in patient-centered outcomes research.  PCORI maintains a broad scope of interest, rather than addressing specific disorders or conditions.  The underlying research agenda contemplates five broad areas: Assessment of prevention, diagnosis, and treatment options; Improving healthcare systems; Communication and dissemination research; Addressing disparities; and, Accelerating patient-centered outcomes research and methodological research.  Aloha,

 

Pat DeLeon, former APA President – Division 42 – June, 2012

 

PROACTIVITY IS INCREASINGLY CRITICAL

APA State Leadership Conference:  At this year's exciting event, Bringing Psychology to the Table: State Leadership in Health Care Reform, Katherine Nordalhighlighted the critical role of President Obama's Accountable Care Act (ACA) in furthering health care reform and the importance of action by psychology at the state level.  "We're facing unchartered territory with proposed new models of care delivery.  Again, different kinds of care delivery models than we've been used to working in before.  We're facing new financing mechanisms that we're going to have to understand and appreciate, and the ways that they are going to impact practice, whether it's private practice or institutional practice….  (W)e know that the states are in the drivers' seat and most of what happens about health care reform is going to happen back home….  There is also marketplace uncertainty for us….  (I)f you think you won't be affected by Medicare and Medicaid because you've opted out of those systems or you don't want to participate in those systems, you really need to think again.  Medicare and Medicaid contribute over 50% of all the funding for hospitals in this country.  I'm not talking about just mental health care; I'm talking about health care in this country.  Medicare and Medicaid and other public funds pay for about 58% of all mental health and substance abuse care in this country.  And we know that commercial carriers often times peg their rates to the Medicare rates.  So Medicare rates not only affect the income of private practitioners; they affect the income of agencies, they affect the income of hospitals, they affect incomes in federally qualified health centers [FQCHCs], community mental health centers and community health centers….  (D)espite all of this uncertainty, change is here.  And change is fairly inevitable….  So we have to be ready to claim our place at the table.  We need to be involved at the ground level….  If we don't participate, then we abdicate our responsibility there and we let other people… define what our future is going to be as a profession.  And that's just not an option for us."

            Health Care Reform:  The newly established Accountable Care Organization (ACO) provision of ACA reflects the Administration's commitment to ensuring that all Americans will have ready access to necessary high quality primary care services.  For many health policy experts, ACOs are functionally equivalent to the HMOs of President Nixon and the Managed Care efforts of President Clinton.  Sandra Wilkniss, former APA Congressional Fellow and currently on the staff of U.S. Senator Jeff Bingaman, reviewed the statutory language and implementing regulations for ACOs.  In neither were psychologists expressly enumerated.  Clinical management and oversight must be managed by a senior-level medical director who is a physician and is one of the ACO providers/suppliers; is physically present on a regular basis in any clinic, office, or other location participating in the ACO; and is board-certified and licensed in the State in which the ACO operates.  Public response: "A number of commenters recommended CMS include measures that are more inclusive of specialty care, pediatric care, and non-physician professionals, such as nurse practitioners and registered nurses.  Many of these commentaters noted that the proposed measures were heavily focused on primary care….  Response:  We believe that the final set of measures is appropriately focused and measures care furnished by a variety of providers including specialists, nurses, and nurse practitioners."  As Kathleen so eloquently urged, our practitioners mustbecome actively involved, especially at the local level, for the future of the profession.

            Addressing Society's Needs:  Over the years, we have been impressed by the extent to which our nation's elected officials actively support those who serve society.  Sallie Hildebrandt reports that more than 110,000 active-duty Army troops last year took antidepressants, sedatives and other prescription medications.  In 2008 the Rand Corporation's comprehensive study of the mental health and cognitive needs of returning service members and veterans found that nearly one-third of returning service members reported symptoms of a mental health or cognitive condition.  Approximately 18.5% of those who have returned from Afghanistan andIraq have PSTD or depression, with 19.5% experiencing a traumatic brain injury during deployment.  Half of those needing treatment seek it, but only slightly more than half who receive treatment receive minimally adequate (i.e., scientifically based) care.

Without question, as the U.S. Army Surgeon General Patricia Horoho testified: "For those who do suffer from PTSD, Army Medicine has made significant gains in the treatment and management of PTSD….  The DoD and VA jointly developed the three Evidenced based Clinical Practice Guidelines… on which nearly 2,000 behavioral health providers have received training.  (Our) researchers develop strategies and advise policy makers to enhance and sustain mental fitness throughout a service member's career.  Psychological health problems are the second leading cause of evacuation during prolonged or repeated deployments….  (Our) psychological health and resilience research focuses on prevention, treatment, and recovery of Soldiers and Families behavioral health problems, which are critical to force health and readiness."  General Horoho is the first female (and nurse) Surgeon General in the Army's history.  We would rhetorically ask: How is Hawaii Psychological Association reaching out to our military and veteran community, many of whom are being served by Hawaii's FQCHCs, in order to provide pro bono care and expertise?  From personal discussions, we know that our State's health centers are very interested in collaborating.

            An Interesting Evolution:  Elaine Rodino, while in full-time private practice, is exploring new frontiers.  "You asked that I send you some information about my new business venture.  This isSeniorPremierDating.com.  Our senior dating website is for people 50+ to connect with others for dating, companionship and house sharing.  As you know, the senior population is growing rapidly with the aging of baby boomers and the increasing longevity of existing seniors – all of whom are increasingly computer savvy.  Our site is different from existing sites in two specific ways, Humor and Psychology.  We will have short videos depicting senior dating scenarios that will be created and performed by Renee Taylor and Joseph Bologna.  Taylor and Bologna are Emmy Award winning writers and performers in theatre, film and TV.  Their work has always been about the foibles of relationships.  The psychological aspects of issues facing seniors dating will be presented by myself and by contributing psychologists.  Each contributor will write short articles on topics in their specialty areas such as aging issues, weight and sex, and also include a short statement about their practice and a link to their website.

            "At this point the site has a simple questionnaire for subscribers to complete.  Profiles of potential subscribers will be gathered beginning in June through email blasts to those potentially interested.  In August we will activate the site to accept subscribers and do matching.  We've done a lot of research and consultation for this project.  We have an extensive business plan and a hopeful financial projection for the next five years.  Colleagues interested in contributing articles or in learning more about our venture should contact us atERodino@aol.com."  Fundamental change is upon us.  Aloha,

Pat DeLeon, former APA President – HPA – June, 2012

 

WHEN I WAS A LITTLE BITTY BABY:

Reflecting with senior colleagues upon retirement, we heard personal stories of profound joy, sadness, complexity, and relief accompanying this new state for most of us.  Retirement for some is a delight.  Finally an opportunity to do what we want to, when we want to, where we want to, and how we want to!  Psychologists are highly conscientious, productive, high achieving, hard working folk.  Many of the shared "reflections" described having worked, almost excessively, for most of their lives.  What a relief when there are no bosses, systems, or organizations that dictate and limit how we spend our time.  On the other hand, that very absence of structure can trigger anxiety and doubt.  So for some, retirement is also like being in a room without walls.  Don Freedheim referred to being retired as being without an institution that frames our activities and guides how we spend our time.  Previously, as we went to grade school, attended universities, worked, met partners, had children and hobbies, and became grandparents we had rules of the institution to follow.  While we lived and worked in many different settings, all had rules, procedures, customs.  We are now on our own in retirement.  We finally have control of personal time.  There are no rules regarding what we should be doing.  What should rule-followers be doing when there are no rules to follow?  That is the question.  If we are not psychologists, who are we?  Just about all of us deal, though in individual fashions, with identity issues.

For some, deciding which activities are most personally meaningful is a huge challenge.  Many report not having enough time.  Opportunities to be involved in activities and tasks eventually become unending.  When Ruth retired: "I wanted for the first time in my life to do what I really wanted to do, and I learned that is difficult for me.  I thought this is now my time.  Whoops!!  My time for what?  I needed to stop doing and to hear myself… to pay attention to what I really wanted to do.  I know now more about what I do not want to do."  Visionary sage Gene Shapiro:  "If you possibly can, never retire!"

That is not to say that retired or mostly retired colleagues in their individually creative way aren't living full and varied lives.  Many (Jay Benedict) truly love being psychologists and don't really want to stop working.  Shortly after retiring from the U.S. Senate staff, Patnoticed he was no longer in the once all-important information loop and missed the action affecting psychology practice, education, and research.  Integral to his identity was being creative, innovative, and trail blazing.  Accordingly, he enthusiastically accepted the intriguing opportunity to mentor the next generation of practitioners (nursing, law, pharmacy, and psychology) in engaging in interdisciplinary (e.g., integrated), patient-centered practice from a university base.  Having "practiced" health policy for nearly four decades, he will now engage in shaping its theoretical/philosophical application.

            How our senior colleagues relate their experiences, reflects their activities and orientations while working.  Their look at retirement parallels work perspectives.  Ed Sheridan, an educational administrator (Dean and Provost) thoughtfully considers the many realistic and practical issues that require attention in preretirement and retirement, namely the need for collaboration and in-depth discussion with a partner about a multitude of life style preferences, health care concerns likely to arise, realistic appraisal of financial needs, etc.  Rod Baker, former VA chief psychologist, accustomed to employment in a large organization known for structure and "red tape" now follows his own path in retirement: "My definition of a 'good retirement'….  Doing what you want, as much as you want, and whenever you want.  And, if you are not doing that, you only have one person to talk to."

            Choices made by our colleagues regarding their retirement activities are varied, and naturally consistent with preretirement beliefs and values.  How important is it to continue working in some fashion as a psychologist?  Many in the field just loved being psychologists.  It is difficult to give up that identity completely, especially for those who have been leaders in the field and have devoted countless hours.  Time devoted to the profession may be inversely related to one's number of hobbies.  Almost everyone, including those no longer working as psychologists, very much wants to continue being productive, in the sense that work and doing things to promote better communities bring meaning and vitality to life.  APA State Association guru Mike Sullivan: "I have a very different take on retiring, meaning having productive goals to accomplish.  For me it's meant a whole new horizon of productivity in direct community service (volunteering)!"  Many, like Ruth and Linda Garcia-Shelton, feel blessed to finally find themselves reconnecting with family and friends, having previously felt somewhat guilty about perhaps placing their budding careers a bit higher than their families.  Many women of their era struggled with work-family balance, although at that time society did not quite frame the underlying pressures so delicately and distinctly.

            An evolving, although still almost unspoken theme, is the undercurrent of existential urgency – realization of the mortality of ourselves and those we love.  Reflecting upon the impact of mortality is complicated, partly because the underlying values, beliefs, and meanings are typically not discussed in our culture.  In fact, we actively avoid focusing upon them.  But they are there.  All of our lives we've been busy achieving and meeting responsibilities and expectations to -- do well in school, raise children, earn a living, be socially and culturally engaged – and then, we finally retire.  We haven't been trained for this.  And what makes it so urgent and scary for some, is that we also have the awareness that life is moving along very rapidly and that this period is the last time ever to live in a way that is personally important and meaningful.  In Them Old Cotton Fields Back Home.  Aloha,

 

Ruth Ullmann Paige, former APA Board of Directors; & Pat DeLeon, former APA President

California Psychological Association – May, 2012