EVOLVING PROFESSIONS – INTERESTING TIMES:

The 30^th Annual APA State Leadership Conference (SLC):  "Countdown to Health Care Reform," as always, was a truly outstanding event.  From my public policy/political perspective, I was particularly pleased with the extent to which those fortunate to attend the conference learned firsthand the intricacies of working with the media at both the local and national level.  Former Hawaii Psychological Association (HPA) President June Ching, for example, described her impressive efforts over the years to be "helpful" to our local print, radio, and television colleagues, while always being mindful of her unique expertise.  Arthur Evans, Jr., Commissioner of the Department of Behavioral Health and Intellectual disAbility Services for the City of Philadelphia, and Robin Henderson of the Central Oregon Health Council described their visionary efforts to "bend the cost curve," while ensuring that beneficiaries received gold-standard care; i.e., demonstrating that psychology's involvement would bring "added value" to the overall quality of life of their neighbors.  David Ballard's exemplary Psychologically Healthy Workplace Awards Ceremony once again highlighted the broad impact of psychology in improving daily lives throughout America.

The presentation on the APA/ASPPB/APIT joint Telepsychology Taskforce demonstrated our profession's responsiveness to the unprecedented challenges occurring within the nation's health care environment.  "The Task Force for the Development of Telepsychology Guidelines has completed its work on the "Guidelines for the Practice of Telepsychology."  The APA Board of Directors will be asked at their June 2013 meeting to recommend that the APA Council of Representatives at its meeting in August 2013 adopt as APA policy these Guidelines.  This joint effort has been funded for one additional year (2013) to allow the Task Force to continue its collaborative work to advance model regulatory language and provide guidance on risk management practices (Joan Freud)."  On a related note, ASPPB is circulating its draft "E.Passport proposal" for public comment.  This will be a mechanism developed by ASPPB (concurrent to the Telepsychology Task Force work) to facilitate interjurisdictional practice for those providing telepsychology services.  Each of the 500-plus state psychology leaders present at SLC will undoubtedly have his/her own highlight.  SLC is a one-of-a-kind leadership and advocacy training event, which in my judgment is only surpassed by our annual convention (this year being held in Honolulu) in its importance to our professional community.

            A former APA Congressional Science Fellow and now Executive Director of the Practice Directorate, Katherine Nordal in her Keynote Address passionately laid out for the audience the importance of being personally involved and actively engaged in the public policy/political process over the long haul.  "At this time last year, the future of the Affordable Care Act (ACA) seemed uncertain.  Since then, we've had a Supreme Court decision that upheld the ACA and the November reelection of President Barack Obama.  The Affordable Care Act has survived, and implementation of the largest expansion of the health care safety net will proceed.  The clock is ticking toward full implementation of the law and January 1, 2014 is coming quickly.  But January 1^st is really just a mile maker in this marathon we call health care reform.  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us.  The details of ACA implementation vary from state to state, and so do the key players.

            "All of you are painfully aware of the difficult health care environment in which we find ourselves these days:  * Ever increasing demands for cost containment, declining levels of reimbursement and limits on service delivery.  * Greater regulatory requirements.  And, * Increasing competition in the psychotherapy marketplace, particularly due to growing numbers of masters-trained mental health providers.  Fee-for-service is being replaced by alternative reimbursement mechanisms and marketplace and regulatory developments are encouraging more collaborative and integrated practice models.  I see professional psychology facing challenges on three levels:  First, there are challenges on the federal level where for starters, there are plenty of unfamiliar faces on Capitol Hill – a total of 94 new House and Senate members in the 113^th Congress.  There are challenges for the states.  A principle example is expansion of Medicaid.  Millions of consumers are expected to move into the Medicaid system as the ACA is fully implemented.  Medicaid programs in 16 states do not recognize private sector psychologists as providers.  For those that do, many place conditions and restrictions on psychologists' participation.  For example, requiring physician referral for psychological services.  As of 2010, only 25 state Medicaid programs utilized health and behavior codes.  In addition to challenges at the federal and state levels, there are challenges for individual practitioners, regardless of practice setting.  One of the major ongoing challenges facing many practitioners is the need to adapt to new and emerging systems of care.  Looking to the future, viable practice options will vary from one psychologist to another.

            "Let's focus on what's happening to address the challenges – beginning with what psychology brings to the table.  One of the first steps in positioning for reform is for practitioners to recognize that they bring numerous professional skills and strengths to integrated care settings, including:  * Conducting thorough psychological assessments.  * Understanding environmental factors such as family and community systems.  * Designing, monitoring and evaluating interventions.  * Promoting patient responsibility, resilience and recovery.  * Applying behavioral principles to modify health-risk behaviors and attending to interpersonal barriers to behavior change.  And,  * Understanding group dynamics and facilitating teamwork.  These are factors that create 'value-add' for psychologists on health care teams and in integrated, interdisciplinary systems of care.  And that's what many of our practitioners increasingly will need to promote: the value and quality they can contribute to emerging models of care.  We are a highly educated and talented discipline, and we need to identify and create opportunities to make others aware of the skills and strengths we can contribute to health care.  I believe that if we are not valued as a health profession, it will detract from our value in other practice arenas as well.  So regardless of how we feel about the current state of our health care system, psychology must take its seat at the table and contribute to the solutions needed to fix our ailing system.  Psychology will be valued to the extent that we bring our knowledge to bear on the grand challenges of our society.  And believe you me, health care is a grand challenge.

            "I can sum up in two words what we encourage state leaders to focus on as the countdown to health care reform proceeds: Advocacy and Education.  On the advocacy front, we must step up to the plate and insist that psychologists and the psychological and behavioral services we deliver be included in emerging models of care and payment mechanisms.  No one else is fighting the battles for psychology… and don't expect them to.  We need to look at our advocacy broadly as taking advantage of any opportunity to help others understand and appreciate the value of psychology and psychological services.  It's not enough to have a good message.  We also need good messengers.  Education involves both public education and outreach, along with psychologist education and training needed to prepare the profession for the new practice models that will evolve with health care reform.  The skill sets needed for a psychology practice that predominately involves psychotherapy are not necessarily sufficient for practice in integrated care settings.  Yes, the clock is ticking towardJanuary 1, 2014.  But remember, we're not running a sprint.  Health care reform is a marathon – we're in it for the long haul.  New models of care and changes in health care financing won't take shape overnight.  We can't afford to be left out of health care again (i.e., Medicare) and then have to spend decades playing catch-up.  We can't hope to finish the marathon called health care reform if we're not at the starting line.  Fortunately, many psychology leaders have embraced our call to action."

            Advances Within Professional Nursing:  This Spring I had the opportunity to attend two national/international nursing conferences addressing how their profession is responding to our ever-changing health care environment.  The American Association of Colleges of Nursing (AACN) 2013 Spring Annual Meeting was entitled "Guiding Change: Technology in Nursing Higher Education."  Not surprisingly, there was a focus on exploring challenges inherent in the increasingly technology-dependent environment of nursing higher education, as well as the utility and effectiveness of simulation in nursing education and research-based suggestions for the future.  The importance of public policy/political advocacy remained a consistent theme.  The Hawai'i State Center for Nursing held its annual Pacific Institute of Nursing conference, "Partnership with Parity: The New Paradigm."  Two of their speakers described particularly interesting developments for non-physician clinical practice, within the policy context of the 2010 Institute of Medicine (IOM) report "The Future of Nursing: Leading Change, Advancing Health."  The IOM noted that with more than three million members, the nursing profession is the largest segment of the nation's health care workforce.  And recommended that * Nurses should practice to the fullest extent of their education and training.  * Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.  * Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.  And, * Effective workforce planning and policy making require better data collection and information infrastructure.

            The first recommendation of the IOM was to "Remove scope-of-practice barriers.  Advanced practice registered nurses should be able to practice to the full extent of their education and training."  Perhaps most intriguing was the call for the Federal Trade Commission and the Antitrust Division of the Department of Justice to review existing and proposed state regulations concerning advanced practice registered nurses (APRNs) to identify those that have anticompetitive effects without contributing to the health and safety of the public.  States with unduly restrictive regulations should be urged to amend them to allow APRNs to provide care to patients in all circumstances in which they are qualified to do so.

Attorney Barbara Safreit reported that the National Governors Association (NGA) had recently released a policy document specifically addressing this issue, "The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care."  Highlights include: research suggests that Nurse Practitioners (NP) can perform many primary care services as well as physicians do and achieve equal or higher patient satisfaction rates among their patients (including time spent with patients, prescribing accuracy, and the provision of preventive education).  State laws and regulations governing NPs revealed wide variation among the states with respect to rules governing scope of practice, including the extent to which states allow NPs to prescribe drugs, to practice independently of physician oversight and to bill insurers and Medicaid under their own provider identifier.  "To better meet the nation's current and growing need for primary care providers, states may want to consider easing their current scope of practice restrictions, as well as their reimbursement policies, as a way of encouraging and incentivizing greater NP involvement in the provision of primary care….  None of the studies in NGA's literature review raise concerns about the quality of care offered by NPs."

            Cathy Rick, Chief Nursing Services Officer for the Department of Veterans Affairs (VA), described the extraordinary progressive changes in the newest VHA Nursing Handbook, which, in essence, will now provide VA advanced practice nurses with the authority for independent practice, regardless of individual state licensure limitations, unless an individual VA facility limits their scope within that facility.  This visionary document has been "cleared" by the relevant legal authorities who will be affirmatively assisting hesitant states in appreciating the federal government's supremacy powers within federal facilities.  The handbook notes that research and evidence-based practice have demonstrated the significant and synergistic relationships between delivery of nursing care, patient and resident outcomes, and staff satisfaction as well as process effectiveness and efficiency.  It recognizes that nursing care is complex and that paradigms have shifted (and will continue to shift).  VHA nursing care delivery will be agile, innovative, and supportive of the Veteran as the driver of their individual healthcare.  The basic tenets of VHA nursing are aligned with the ANA Standards of Practice and achieved through evidence-based practice, defined elements of practice, and professional development.  Two key underlying components are that the patient owns and drives their care based on the information available and nursing interventions are based on the best available evidence and accepted standards of practice.  Specifically the Nursing Handbook states:

"Clinical nursing practice varies widely among the States.  To ensure safe and appropriate health care to the nation's Veterans, VA has standardized the elements of practice, within VA, for clinical nursing practice other than the prescribing of controlled substances, without regard to individual State Practice Acts.  This ensures a consistent standard of nursing care throughout VA's national health care system….  Under the Federal Controlled Substances Act… a health care practitioner may prescribe controlled substances only if the practitioner's State license authorizes such prescribing.  Accordingly, APRNs, including NPs, may prescribe controlled substances within VA only if they are authorized to do so by their State of licensure or registration and comply with the limitations and restrictions on that prescribing authority.  Where VA establishes elements of nursing practice that are more expansive or otherwise inconsistent with State practice standards, VA's practice standards control.  VA nurses must follow the VA nursing practice standards established in VA rules, regulations, and policies."  Without question this is a most impressive development for our nursing colleagues.  The readership should recall that the AACN announced that in October, 2004 their member schools voted to endorse moving the current level of preparation necessary for advanced nursing practice from the master's degree to the doctorate-level (i.e., the Doctor of Nursing Practice (DNP)) by the year 2015.  Psychology could learn a lot from our nursing colleagues – we are living in "changing times."

Exciting Opportunities To Contribute:  One of the most rewarding aspects of being in a university environment is the constant exposure to new ideas and challenges.  Steve Brewer recently presented a colloquium on his fascinating research at the Uniformed Services University of the Health Sciences (USUHS).  "There is very little research examining the effects of combat deployment on the driving abilities of post-deployment service members.  However, there is evidence that service members have an increased risk of being involved in a vehicular accident within the first six months of returning from a combat deployment.  Specifically, within the first six months post-deployment there was a 13% increase that all service members (regardless of age/rank) would be in a vehicular accident.  Junior enlisted (E1-E4) had a 22% increase and 18-21 year olds had a 25% increase.  Also, the number of deployments increased the likelihood of being at-fault in an accident.  One deployment meant a 12% increase; two deployments meant a 27% increase; and three or more deployments meant a 36% increase in the likelihood of being at-fault in a vehicular accident.  There is also research that describes the effects of PTSD and TBI on cognitive abilities, many of which are required for the safe operation of a motorized vehicle.  In order to study the effects of combat deployment on driving abilities, we at the USUHS Ettenhofer Laboratory for Neurocognitive Research ran a pilot study in cooperation with the University of Virginia.  We used a virtual reality driving simulator (VRDS) that was designed with multiple testing scenarios.  The participants' driving abilities were measured through motor tests and cognitive tests.  The findings and feedback from the participants of this pilot study will be used to improve the operational scenarios.  These improved scenarios will eventually be used to examine the effects of deployment and other variables to establish the safe and unsafe driving characteristics of participants.  Scenarios will also be utilized for rehabilitative purposes to assist with improving unsafe driving abilities into safe ones.  Such a process could be included in post-deployment training to decrease the incidence of vehicular accidents."

           Interesting Life Journeys:  Having retired from the U.S. Senate staff after 38+ years, I have become quite interested in learning what colleagues that I have worked closely with over the decades are now doing post-psychology or in expanded roles.  Long time VA psychologist visionary Rod Baker has "retired" authoring, co-authoring, and editing three books on the history of psychology in the VA and has just published his fourth book,More Stories from VA Psychology.  This latest publication, like a previous one, features career stories written by retired and current psychology leaders whose careers span 61 of the 66 years of VA psychology history that was established in 1946.  The career stories add an entertaining first person perspective that expands the reader's understanding of the formal history of VA psychology.  Moreover, I recently learned that Rod has a broader writing activity that includes five published articles on the history of the Old West.  And, I just finished reading his very enjoyable historical fiction novel, The Rune Master Saga, set in 9^thcentury Norway.  Highly recommended – his clinical and developmental perspectives are definitely present.  The sequel should be equally intriguing.  See his Author page onAmazon.com to learn how Rod became interested in writing fiction.

            Kay Daub, Professor of Nursing at the University of Hawaii at Hilo, recently became actively involved in hospice care programs on the Big Island of Hawaii.  "Several months ago, I had the opportunity to read a bit about End of Life care and what it means to patients who are dying.  I had always been very interested in death and dying, but somehow as way leads on to way, I began my nursing career in telemetry and ICU.  Though many cases involved end of life care, my focus had been cure no matter what.  So many ethical dilemmas surround the end of life, as I suppose so many ethical dilemmas surround the beginning of life.  How does one wrap their head around the concept of comfort care, and let go of the notion of cure no matter how painful, cold, futile, or lonely?  I have now taken on this interest and have pursued caring for patients at the end of life; this is in addition to my current busy academic career that removes me from the 'bedside.'  What a gift this has been.  It is a challenge to go beyond the comfort zone of avoiding communication about a difficult subject.  The elephant in the room, what is on my patient's mind; how do I talk about death, active death?  I have started meeting the patient and family where they are.  I have gotten to hear lovely and sometimes not so lovely stories of memories over a life span.  I have even heard a patient talking to someone who died before him.  My focus is on comfort rather than cure.  My nursing has become more holistic, much more patient and family centered.  There is a lesson to be had.  Death is our greatest teacher.  It does teach us how to live.  Death can come at any time in one's life, how wonderful to end with great comfort and reflection."

            Reflecting upon the exponential growth and expanding influence of professional psychology over the past four-plus decades, trailblazer Gene Shapiro recently commented: "We need another 'dirty dozen' to fight for the role of tomorrow's providers."  As Katherine noted: "No one else is fighting the battles for psychology… and don't expect them to."  Aloha, 

Pat DeLeon, former APA President – Division 29 – May, 2013

INSPIRATIONAL VISION

    It is difficult to believe that four decades ago, I embarked upon what would become a most fascinating journey, on the very first day of the infamous Watergate hearings.  I retired from the U.S. Senate staff with wonderful memories and a deep feeling of accomplishment.  Our nation's Capital is an unforgettable place; rich in history and tradition, and for those who decide to become engaged in the public policy/political process, providing a once in a lifetime opportunity to "make a real difference" in the lives of our nation's citizens.  It is simply an awesome experience that I would recommend to every colleague; an opportunity to truly "give psychology away" in the finest sense.  When I arrived in Washington, DC, professional psychology was, in retrospect, in its infancy – especially in becoming involved in the public policy/political arena.  Practice legends Ted Blau, Nick Cummings, Max Siegal, Logan Wright, and Ray Fowler had not yet begun thinking about running for APA President.  What today we might consider specialized professional divisions (e.g., Divisions 38, 41, 42, 55, etc.) simply did not exist.  In the mid-1970s, we were collectively just beginning to appreciate our potential role as generic health care providers, beyond being "merely" mental health specialists in small private practices and community mental health centers.

In the early 1970s, the profession was fortunate to have committed visionaries at both the state and national level.  In New Jersey, Gene Shapiro, Bob Weitz, Marv Metsky, and Stan Moldawsky were paving the way for psychology's ultimate recognition as a licensed independent profession.  Those seeking to advance our professional agenda had little expectation that APA, which was historically heavily influenced by academic psychology, would be the appropriate vehicle for guiding professional psychology's (r)evolution.  Consequently, much of the creative energy over the next several decades would be strategically expended outside of APA as California's Nick Cummings and the late Rogers Wright, along with their "dirty dozen" colleagues, pressed for (dare we say "lobbied for") psychology's statutory recognition.  Future APA President Jack Wiggins (envisioning and naming the National Register), Gene, and Carl Zimet worked with the APA Board of Directors and the American Board of Professional Psychology to establish this vibrant entity, chaired by Carl, outside of APA's governance.  The professional school movement and specialized post-doctoral educational initiatives (e.g., rehabilitation psychology and psychology and the law) would come.  Reflecting, I expect that it is probably impossible for today's early career psychologists to truly appreciate yesterday's seemingly turbulent and yet vibrant environment.  So many really do owe so much to so few.

In the midst of what must be considered a period of extraordinarily exciting professional growth, our esteemed colleague Alfred M. Wellner strived to operationalize what he, a gifted visionary, could readily see needed to be accomplished.  He was clearly an individual who was ahead of his time.  He appreciated that if the profession of psychology were ever to fulfill its clinical potential, it would have to position itself for those who established federal (and state) health policy standards in a logical and transparent manner.  He understood that psychology would have to address the vexing questions: "Who are we?" and "How can we assure the public (and those who ultimately pay for our services) that we are who we say we are?"  At the time, Gene and Jack were focusing upon independent recognition under the Department of Defense CHAMPUS program, where these fundamental questions had to be answered for non-psychologist administrators.   Al soon came to experience that as a discipline, psychologists are wonderfully talented in developing rationales for why something cannot be done or exploring ad infinitum why what has been proposed must be modified.  In spite of these seemingly insurmountable challenges Al persisted and even invited me to participate in reviewing resumes for potential inclusion in his envisioned National Register of Health Care Providers in Psychology.  Several states had not yet passed licensing laws so the Register served as the resource for insurance carriers and others to identify qualified psychologists eligible for reimbursement.  Should those with PhD's be differentiated from those with EdD's?  Was a doctorate in clinical substantially different than one in counseling or educational psychology?  What about licensed masters level psychologists?  There were no simple answers; yet Al pressed on – proclaiming decisions had to be made and always in an open and judicious manner.  The Register was serving a critical need of the time providing an objective listing of those who should be deemed "psychologists" for the purpose of receiving reimbursement for their clinical services.  And, its Psychologists' Legal Consultation Plan brought to life the crucial interface of psychology and the law for many practitioners.  Alfred M. Wellner was a visionary who was decades ahead of his time.  Mahalo.

With the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA), our nation has finally taken the position that all Americans will have access to timely healthcare, particularly patient-centered, gold standard (i.e., data driven) primary care.  Putting this in perspective, this has been a policy agenda for nearly every President since Franklin D. Roosevelt, regardless of political affiliation.  By 2014, almost all of the provisions of ACA will have been implemented and the healthcare environment for psychology's practitioners and training institutions will have undergone unprecedented change.  The extraordinary advances occurring today within the computer and communications fields call out for some form of national licensure and national scope of practice for each of the health professions.  There is increasing evidence that the quality of telehealth services are comparable to, and often significantly more cost-effective, than traditional face-to-face provider relationships based upon geographical availability, especially with the younger technology-savvy generation.  Under the leadership of Al's successor, Judy Hall, the Register has been proactively positioning itself to address this professional and societal need, working closely with the leadership of the various state licensing boards and now being recognized, or in the process of being recognized, in 46 jurisdictions in the U.S. and Canada as a vehicle for licensure mobility.  Similarly, the Register's leadership has been highly cognizant of the unique and pressing needs of our early career psychologists for obtaining quality and relevant continuing education experiences.

The Register was established at a time when psychology was just beginning to seek federal statutory and regulatory recognition.  Over the years, we successfully obtained inclusion under CHAMPUS (now TRICARE), the Federal Employees' Health Benefit Program, the Federal Workers Compensation Act, the Federal Criminal Code, various provisions of Medicare; and such training initiatives as the Indian Education Act Fellowship program, the National Health Service Corps Scholarship Program, and the Individual Federal Insured Loan Program.  Recognition was obtained under various provisions of the Social Security Disability Benefits Act, not to mention eligibility for the U.S. Public Health Service Regular Corps which is the sole requirement for being appointed U.S. Public Health Service Surgeon General.  This was also the era when Nick and his colleagues participated in the Colorado Medicare study Senate Finance Committee hearings, exploring to what extent psychological services were "safe, effective, and appropriate" pursuant to the U.S. Office of Technology Assessment finding that only 10 to 20 percent of all medical procedures had been shown by controlled tests to be beneficial.  Today there are of course many new legislative challenges; for example, obtaining inclusion under the Medicare Graduate Medical Education (GME) program, Medicaid (which is the foundation for the ACA's beneficiary expansion efforts), and express recognition under the Accountable Care Organization and Medical Home provisions of ACA.

At this year's 2013 outstanding APA State Leadership conference, Practice Directorate ED Katherine Nordal reflected upon the radically changing healthcare environment: "At this time last year, the future of the Affordable Care Act (ACA) seemed uncertain.  The ACA has survived, and implementation of the largest expansion of the health care safety net will proceed.  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us.  The details of ACA implementation vary from state to state, and so do the key players.  I see professional psychology facing challenges on three levels: First, there are challenges on the federal level.  Beyond the federal level, there are challenges for the states.  A principle example is expansion of Medicaid as ACA is fully implemented.  And, there are challenges for individual practitioners regardless of practice setting.  Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  I believe that if we are not valued as a health profession, it will detract from our value in other practice arenas as well. So regardless of how we feel about the current state of our health care system, psychology must take its seat at the table and contribute to the solutions needed to fix our ailing system.

"No one else is fighting the battles for psychology… and don't expect them to.  Health care reform is a marathon – we're in it for the long haul.  New models of care and changes in health care financing won't take shape overnight.   We can't afford to be left out of health care again [i.e., Medicare] and then have to spend decades playing catch-up.  We can't hope to finish the marathon called health care reform if we're not at the starting line.  Fortunately, many psychology leaders have embraced our call to action."  We need another "dirty dozen" to fight for the role of tomorrow's providers.  Aloha,

Pat DeLeon, former APA President – National Register – April, 2013

 

BEING RESPONSIVE TO SOCIETAL CHANGE

 Former APA President Ron Fox recently addressed our health policy class at the Uniformed Services University of the Health Sciences (USUHS).  Responding to a question regarding the future of professional psychology, given the apparent ever increasing interest in master's level practitioners, the former Dean was quite optimistic.  He proffered that the "tools" psychology is teaching its future generations will be very valuable.  The challenge will be developing effective venues to utilize these skills beyond boutique practices where, for example, those specializing in serving children will undoubtedly always be able to find concerned "loved ones" willing to pay for quality care.  Ron emphasized the importance in today's health care environment of psychology's practitioners being able to work collaboratively within medical systems, which the President's recently enacted Patient Protection and Affordable Care Act (ACA) would undoubtedly consider providing "integrated" patient-centered care.

From a health policy perspective, thereis considerable interest in utilizing the skills of alternative providers.  In the Department of Defense, for example, Behavioral Health Technicians (BHTs) have had impressive success in providing treatment for patients with behavioral health problems such as substance abuse, sexual assault and domestic violence, social issues, and posttraumatic stress disorder (PTSD).  These practitioners collect the required data from clients and are responsible for unit training on various behavioral health topics.  Under the supervision of a licensed provider (including mental health nurses), the enlisted BHTs conduct initial interviews, perform assessments, provide follow-up care, administer psychological tests, assess patient response to rehabilitation or treatment, co-facilitate group therapy sessions, and perform Combat and Operational Stress Control (COSC) functions.  Perhaps most surprising for USUHS students was the realization of how much independent work the BHTs perform while deployed.  Due to the lack of licensed mental health providers, they work alone for weeks or months at a deployed site where they conduct the initial assessment, create a treatment plan, conduct individual or group therapy, and even make medication recommendations.  They work under the auspice of the behavioral health provider assigned to that camp or region through a precept method.  The Army and Navy currently employ approximately 1200 BHTs between them.

            Earlier this year the U.S. Senate conducted a hearing "Assessing the State of America's Mental Health System."  SAMHSA Administrator Pamela Hyde noted that behavioral health is essential to an individual's overall health and that the ACA will provide one of the largest expansions of mental health and substance abuse coverage in a generation by extending health coverage to over 30 million Americans, including an estimated 6-10 million with mental illness.  She pointed out that Medicaid is the largest payer of mental health services, with the ACA extending Medicaid coverage to as many as 17 million additional individuals and their families.  And, she expressed her willingness to take a leadership role in funding "Mental Health First Aid" training for teachers.  Project AWARE proposes $15 million for training teachers and other adults who interact with youth to detect and respond to "mental illness," including how to encourage adolescents and families experiencing these problems to seek treatment.

Another witness expressed considerable enthusiasm for this initiative, describing it as evidence-based practice that represents early intervention and early detection that – if implemented broadly enough -- could permit America's community mental health providers to help millions in distress.  The 12 hour training was described as somewhat similar to first aid classes taught by the Red Cross for physical health conditions.  The importance of having a diverse array of training audiences is the key to the program's public health approach.  In Colorado, instructors have conducted training with the State Sheriff's Association and the Colorado Department of Corrections, with the goal of training all of the State's corrections and parole officers.  A number of the Governor's Cabinet and Department Heads have received the training and plans are underway to train all rabbis in the Denver Metropolitan area, as well as various school district and higher education personnel.  The unfortunate Aurora shooting has been a critical catalyst.  We would rhetorically ask: Are our State Psychological Associations involved in this potentially exciting "grass roots" movement?  Aloha,

 

Pat DeLeon, former APA President – Division31 – March, 2013

SLOW DOWN, YOU MOVE TOO FAST

 With the enactment of President Obama's Patient Protection and Affordable Care Act (ACA), our nation's health care environment has truly entered uncharted waters.  Unprecedented change is inevitable.  Yet, from a health policy perspective, a discernible foundation has been evolving over the past decade.  Increasing access to patient-centered primary care; an emphasis upon prevention and wellness; interdisciplinary collaboration across the health professions; integrating physical and mental health; and data-driven accountability (i.e., "gold standard" care) is what is being demanded.  The extraordinary advances occurring within the communications and technology fields provide exciting opportunities (e.g., telehealth, virtual realities, and personalized health apps).  Health care, like education, is fundamentally locally based.  As Katherine Nordal has made abundantly clear during her State Leadership Conferences (SLC), psychology must get personally involved at the state and local level if we expect our clinical expertise to be appropriately recognized.  As she has graphically emphasized: "If we're not at the table, it's because we're on the menu."  The Institute of Medicine: "Health care in America has experienced an explosion in knowledge, innovation, and capacity to manage previously fatal conditions.  Yet, paradoxically, it falls short on such fundamentals as quality, outcomes, cost, and equity.  Each action that could improve quality – developing knowledge, translating new information into medical evidence, applying the new evidence to patient care – is marred by significant shortcomings and inefficiencies that result in missed opportunities, waste, and harm to patients."  Psychology must not be so naïve as to assume that our potential clinical contributions will be appreciated by those shaping our nation's health policies.  The States today have an extraordinary opportunity to shape their own health care destiny.

            Oregon – "She Flies With Her Own Wings":  In 2011 the State of Oregon projected a $2 billion deficit in its Medicaid budget.  The Governor (a former emergency room physician) negotiated an agreement with the Obama Administration to address the deficit if the program would grow at a rate that is two percent slower than the rest of the country, and thereby ultimately generate an $11 billion savings over the next decade.  Oregon would pursue the Holy Grail in healthcare policy -- slower cost growth.  A major provision of ACA allows the states to significantly expand their Medicaid program to cover everyone below 133 percent of the federal poverty line.  In Oregon, Medicaid is expected to enroll 400,000 new patients by 2022, nearly doubling its current numbers.  "In terms of cost-control experiments, this likes of this are something we have never seen in health care."

            Robin Henderson, a regular attendee at SLC, is executive director of the Central Oregon Health Council and works within the St. Charles Health System.  "Many places around the country are waiting for health reform, integration, and other changes to happen to them.  They wait for 'the answer' that will bend the cost curve, and look outside for guidance, ideas, leadership, and motivation.  Central Oregon isn't that place.  Long considered Oregon's playground, we have been on the bleeding edge of health reform efforts in Oregon for years.  Our recent efforts have centered on the creation of 'Coordinated Care Organizations,' heralded by the Centers for Medicare and Medicaid Services as the Medicaid corollary to the Accountable Care Organizations (ACOs) in the ACA.  Before the federal legislation was even crafted, health leaders in this scenic part of the country knew things had to change.  They knew their health system – comprised of St. Charles Health System, three community mental health centers, three public health agencies, Mosaic Medical Center (the region's largest federally qualified health center (FQHC) serving all three counties); the Central Oregon Independent Practice Association representing more than 600 independent practitioners; and even PacificSource Health Plans, the Medicaid payer serving the region – had the potential to lead the way.

            "In early 2009, community members gathered together and decided to take on three areas of escalating healthcare costs – over utilization of the region's emergency departments, increases in high risk pregnancies that resulted in increased births in the region's neonatal intensive care unit (NICU), and a lack of resources and care coordination for children and youth with special healthcare needs.  These three areas shared common threads – the lack of care coordination, especially in relation to the increased need for services to combat the social disparities of health that drive up healthcare costs and reduce patient engagement; and the lack of any fiscal or agency collaboration between physical and mental health needs.  Patients would come to the region's emergency departments with complex needs, but there was no mechanism to coordinate with community mental health agencies for their care.  Babies born in the neonatal intensive care unit with known indicators for future developmental problems had no coordinated resource for early identification until problems were highly noticeable.  Children with complex physical and behavioral disorders could only receive comprehensive diagnostic evaluations after enduring a nearly year long wait list for the one clinic in Oregon – more than 180 miles away from the region.  This was unacceptable to health leaders in the region and needed to change.

            "The envisioned projects were called the Health Integration Projects, and for the next two years, the region's health leaders brought them to fruition without added funding, grants, or increased payments.  The results have been highlighted in the national media and are now being studied by the academic community thanks to the efforts of Ben Miller at the University of Colorado School of Medicine, who has shared his experiences with SLC attendees.  They formed the basis for what is now known as the 'Central Oregon Health Council' – a non-profit public/private partnership of health and community leaders dedicated to improving the health of the region, with the goal of fulfilling the Triple Aim – Better Health, Better Care, and Better Cost for their community.  Under the direction of myself as Executive Director, this collaborative serves as the governance entity for the region's only Coordinated Care Organization.

            "This year's goals are focused on continuing efforts to double the number of regional primary care homes with Behavioral Health Consultants and start a pre- and post-doctoral internship/residency program for training the next cadre of psychologists to serve this community and others, expanding nursing care coordination in pediatric settings, and expanding the Title V population currently served by the region's Program for the Evaluation of Development and Learning – a monthly multi-disciplinary clinic led by neuropsychologist Sondra Marshall that is the hub for children and youth with special healthcare needs and the region's NICU follow-up clinic.  Efforts to integrate public health and primary care have focused on expansion of Maternal/Child Health initiatives placing WIC screening and other nursing care coordination services directly in regional obstetrics practices to identify high risk prenatal mothers and wrap-around services as early as possible.  We also focus on expanding the successful integrated School Based Health Centers in high-risk neighborhoods to serve families that otherwise would not seek healthcare services.  One of the biggest pushes is the expansion of multi-disciplinary healthcare teams targeting the region's highest-cost, most complex patients and wrapping services around them to improve their health outcomes and engagement in their own care – and reducing costs by doing so.  These are just a few of our goals – for a complete picture, visit our website at www.cohealthcouncil.org.

            "It is noteworthy to emphasize that the region does all of this work without grants, foundation support, increased state spending, or assistance of any kind.  We committed our own resources to improve the lives of our friends and neighbors, and reconnect the mind and body once and for all because we know we are blessed to live in one of the most beautiful places on Earth.  Considering the primary economic driver of this region is tourism, come for a visit and see what we do.  Just don't forget your skis or your golf clubs."

            Division President in 1990 – A Colleague With Vision:  "A Brief Biography – I started my professional life by joining a primary care practice and purchasing a part of a medical office building on the grounds of a small rural hospital in Wyoming in the late 1970s.  I have worked closely with physicians and other medical professionals throughout my career.  I began consulting with my medical colleagues on the appropriate medication for the treatment of psychiatric disorders in the early 1980s.  Because I have a fully integrated practice and that practice needed expert providers we began hiring Nurse Practitioners (APNs) in the early 1990s in a primary care role.  These APNs had full Rx authority but would frequently ask my opinion regarding the best choice for psychiatric medications for their patients.  In the mid-1990s I cosponsored a motion in the Council of Representatives to create Division 55.  The purpose of this new division was to promote psychologists' direct involvement with Rx authority.  Having worked with APNs in my practice and with psychologist colleagues nationally to promote Rx authority for our profession – I was committed to securing Rx authority for myself.

            "Unfortunately, the Wyoming Psychological Association has had no strong center of gravity for the advancement of Rx authority and has, in fact, had a number of members in leadership positions who have worked to defeat colleagues' efforts in this regard.  During my APA advocacy work for Rural Health I worked with a number of leaders in the nursing community on national boards and committees including Dr. Colleen Conway Welch, the Dean of the College of Nursing at Vanderbilt University.  Over time my nursing colleagues convinced me to enter a program of training in nursing with the goal of becoming an advanced practice nurse with prescriptive authority.  Although there is not a direct route in academia for psychologists to add advanced nurse training, the more I studied the possibility, the more I liked it.

            "With the guidance of my nursing mentors in 1998 I completed an ASN degree and passed the NCLEX (the national RN examination).  I completed the academic course work for this degree 'on line' and the clinical training at my local hospital where I have been a part of the medical staff since 1978.  You may remember some of my missives at that time filed as the 'True life adventures of a Boy Nurse.'  A term my clinical instructors gave me after making up a hospital identification badge that said: 'Dr. Enright – student nurse.'  I learned a lot from the nurses on PCU, ICCU, and in surgery.  I had a good deal of fun changing roles, soaking up all the expertise I could from these talented professionals.

            "In 2000 I completed a MS in Nursing at the University of Wyoming and was licensed as an APRN with full prescriptive authority.  The State of Wyoming has one of the best licensing laws for APRNs in the country.  I have a fully independent license with no oversight by other health care professionals.  My prescriptive authority is the same as an MD.  There is no limitation on my formulary.  I have the authority from the DEA to prescribe the full schedule of controlled substances.  This means I can prescribe Schedule II Stimulants to my ADHD patients, Narcotics for pain patients, or whatever is appropriate.  My authority is limited in the same way a physician's authority is limited.  I am required to show that I am qualified to prescribe the medications I chose to use in my practice.  Just as a primary care doctor does not prescribe cancer drugs without special training, I only prescribe medications that I am trained to administer – which are, of course, primarily psychotropic drugs.  This makes a lot more sense to me than having a limited formulary – with Schedule II drugs under the review of another profession (language in at least one of the current state psychologist Rxing laws).

            "I have been licensed as an APRN and prescribing for 12 years.  I have never once regretted my decision to complete my nurse training.  My conviction is reinforced by the fact that psychologists in the State of Wyoming still do not have Rx authority.  In the last 12 years I have not had to call a doctor one time to ask if he/she might write an Rx for my patient.  I have instead had a number of physicians refer patients to me for medication management.

            "I have what I consider to be an ideal work setting.  On a daily basis I prescribe medications for my patients.  I have physician colleagues in my office to consult with regarding the potential adverse side effects on the combination of psychotropic and other medications.  You would likely not be surprised by the number of people I see who are taking a homeopathic dose of their antidepression/anxiolytic medication or are having significant side effects to the 'cocktail' of drugs they are prescribed – this is particularly true of patients over the age of 65.  It is a pleasure to directly intervene and provide competent care to these people.

            "The APRN credential is particularly good for day-to-day practice because I can follow my patients when they travel or move to other states.  This happens quite often; especially since I live quite close to the Idaho border.  My DEA number is on file with most corporate pharmacies and it is easy to call prescriptions anywhere from Alaska to New York.  I don't know what the psychologists in the two states who have Rx authority do when their patients find themselves in another state and in need of a prescription refill.  It would seem to be at least potentially problematic.

            "As an APRN I share a nurse (RN) with one of my physician colleagues.  I am not sure if psychologists with Rx authority are allowed to extend their agency to nurses or other professionals.  The reality of this convenience is that the nurse in my office can call my Rx refills if I am in session or away.  As I mentioned, I have been on the medical staff of my local hospital since 1978.  Having credentials in both psychology and advanced practice nursing the medical staff at my local hospital consolidated my privileges.  I believe I am the only psychologist in the State of Wyoming to ever have Rx privileges granted by the medical staff.

            "Upon completion of my nurse training I was approached by my mentors regarding my willingness to join the faculty at my College of Nursing.  Unfortunately, the University of Wyoming is at some distance from my home in northwest Wyoming, so a tenure track position was not tenable for me.  I have accepted a position on the adjunct faculty of the College of Health Sciences allowing for teaching opportunities and giving me many new colleagues.

            "Upon reflection, my only regret taking this course of action to add a credential as an APRN is that I have not been able to help facilitate other colleagues taking this course of action to enrich their professional practice and, in the end, obtain Rx authority.  Obviously, a number of psychologists across the country have committed their whole careers to the training of psychologists for Rx authority.  Consequently, a good deal of financial resources has been committed to enrolling students in these programs.  No similar financial incentive is in place for psychologists extending their training to include advanced practice nursing.  The other slight regret I have is that I wish I had undertaken the training sooner!

"I do need to thank a number of people who supported me throughout this quite amazing journey.  I would not have been able to complete the process without the support and guidance of the leaders in nursing education who steered me to the proper resources and training programs, while giving me invaluable advice on how to deal with the college of nursing and the licensing board.  I also have to thank those psychology colleagues who think 'outside the box,' for without that approach I never would have even begun this process let alone come out successfully on the other side.  For all that you have done for me and all of my colleagues who have asked not 'Why?' but 'Why not?' – you have my gratitude.

            "An additional reflection – I have always thought my Advanced Nurse training was a more comprehensive education than earning a MS in psychopharmacology because of the 'hands on' requirements of the training.  It seems to me that it is important for a person who has prescriptive authority to have experience actually administering medication through multiple routes rather than assuming that you will only be prescribing medication taken by mouth in pill form.  As a nurse I have given IM injections, started IVs – you name it.  If you have prescription privileges at a hospital you need to know how to do these procedures – especially if you are expected to 'order' other support staff to do it.  I still participate in giving flu shots at our office just to keep my skills up!! – Ranger Mike [Mike Enright]."  You got to make the morning last….  Feeling groovy.  Aloha,

 

Pat DeLeon, former APA President – Division 42 – March, 2013

 

LOOKING TO THE FUTURE – PERHAPS THROUGH THE LOOKING GLASS?

Over the coming decade professional psychology will increasingly embrace its generic health psychology expertise.  As Education Directorate visionary Cynthia Belar has noted: "There is nothing new about interprofessional education, team based care, or integrated care.  What is new is the national recognition of its importance for 'Crossing the Quality Chasm' (Institute of Medicine (IOM)) and the increasing calls for such by leaders in medical education.  Psychologists in health settings have often provided team based care, but training for such has usually begun at the internship or postdoctoral levels.  With the focus on interprofessional competencies there are increased demands for interprofessional education in the earliest stages of training, where students can learn with and from each other and before stereotypes get rigidified.  Early involvement in interprofessional education provides a challenge for doctoral programs housed in colleges of arts and sciences or universities without other health professions students, but one not impossible to meet.  In fact the Graduate Psychology Education (GPE) program of HRSA, of which APA was the architect, has since its inception required the training of psychologists with at least two other health professions for receipt of grant funds.  We have said before how federally qualified health centers (FQHCs) and departments of internal medicine, pediatrics, and family practice can provide invaluable experiences in training for team-based primary care.  Programs that want to prepare health service providers should run, not walk, to these settings and work to establish collaborative opportunities for training."  President Obama's landmark Patient Protection and Affordable Care Act (ACA), with its distinct emphasis upon increasing access to patient-centeredprimary health care, provides a number of incentives for interdisciplinary care and interdisciplinary training.  We would suggest that this (re)volution provides the public sector with an unprecedented opportunity to demonstrate critical clinical leadership while developing truly innovative partnerships with psychology's (and professional nursing's) training institutions, in order to effectively deliver gold standard care for its beneficiaries.

            The IOM recently issued another futuristic report "Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation." Two-thirds of adults and almost one-third of children in our nation today are overweight or obese.  This epidemic of excess weight is associated with major causes of chronic disease, disability, and death.  Its annual cost is estimated at $190.2 billion.  After reviewing hundreds of prior strategies for their promise in accelerating obesity prevention, the IOM mapped out how the most promising interacted with, reinforced, or slowed each other's progress.  This "systems approach" resulted in several specific recommendations including: * Make physical activity an integral and routine part of life.  * Create food and beverage environments that ensure that healthy food and beverage options are the routine, easy choice.  * Transform messages about physical activity and nutrition.  * Expand the roles of health care providers, insurers, and employers.  And, * Make schools a national focal point.  The IOM stressed that because obesity is such a complex and stubborn problem, a bold, sustained, and comprehensive approach is needed.  Action must occur at all levels – individual, family, community, and the broader society – with ongoing assessment of progress being key as efforts move forward.  Obesity risks are often disproportionate among minority, low-income, less educated, and rural populations, due to inequitable distribution of health promotion resources and community risk factors that contribute to disparities in obesity prevalence.  We would suggest that those individuals and their families who primarily rely upon the services of the public sector would be particularly at risk and that the psychosocial and behavioral skills of advanced practice nurses and psychologists could be extraordinarily cost-effective.  University of Hawaii President MRC Greenwood served as vice chair of the IOM committee.

Those in attendance at the APA Orlando Opening Ceremonies could clearly appreciate that addressing obesity was an extremely high priority for President Suzanne Bennett Johnson.  Suzanne bestowed well deserved Lifetime Recognition awards on Kelly Brownell and Rena Wing for their decades of pioneering, standard-setting work.  And yet, we are also aware of significant emotional "push back" she has received from a vocal subset of the membership.  Perhaps this contingent, which does not believe that obesity should be of serious concern to psychology, feels that it is a "medical" problem and that we only deal with "mental health" issues.  Or, perhaps they feel that talking about obesity "stigmatizes" individuals and therefore by addressing psychology's potential contribution, one is being discriminatory.  A smaller subset apparently even believes that "obesity is a myth," notwithstanding considerable scientific and clinical evidence to the contrary.  Thankfully, our next generation continues to expand their horizons.  Lia Billington, who is a prescribing psychologist in New Mexico, is currently conducting a fellowship with the Society of Teachers of Family Medicine.  As part of this experience, she is working on a "scholarly project" to be presented at their national meeting this summer.  Her hypothesis is that there are a number of prescribing/medical psychologists who are significantly contributing to Medical Education (formally or informally) and is attempting to track them down [lia.billington@gmail.com].

            Impressive Learning Opportunities in the Public Sector:  "After the War – The Uniformed Services University of the Health Sciences (USUHS) Medical and Clinical Psychology Department provided a recent seminar from the perspective of a Wounded Warrior's family member.  Stacy Fidler is the mother of Marine Lance Corporal Mark Fidler, who was severely wounded in Afghanistan on the 3^rd of October, 2011, while on foot patrol, after being in country less than two weeks.  While the initial blast took off one leg below the knee and the other leg above the knee, the extensive and complicated injuries to his entire body required that the surgeons amputate from the pelvis down.  Considered a miracle by many in the medical community, Mark was not expected to survive.  Stacy's unflagging support and advocacy are, no doubt, an integral part of his survival and her continued dedication to her son ensures that he receives the best care available.

            "Stacy is not a professional speaker, but she has a way of relating her story to an audience.  She sat on a chair in the middle of the stage and easily, but passionately, told the story of how her life has changed in the last year and a half.  She discussed the initial shock and confusion she felt upon hearing the news that her son was seriously wounded in a blast.  She recalled hastily packing a bag to travel to Walter Reed and the excruciatingly slow hours until she could see her son.  She discussed the many painful surgeries that he has undergone, and the effects on him and those around him.  Stacy shared how her son feels phantom pain in his missing legs every day, but how he fears the pain going away because then he won't feel his legs at all.  Stacy discussed the need for healthcare providers to build rapport with the Wounded Warriors, and to never forget that they are still people, and not just a name on a round.

            "Stacy also shared amusing stories about how Mark was in such pain that he could not see President Obama when he came to visit the Walter Reed hospital.  This 'refusal' led to Mark being investigated and out on a watch list.  Stacy discussed how her son had learned to adapt to his situation with his internal fortitude.  For instance, he has surfed by standing on his hands.  He also claims that push-ups are much easier now.  It has been Mark's sense of humor that helps him through the toughest times.  For instance, he likes to occasionally bark at people just to see what their reactions will be.  Stacy was honest about the difficulties they have faced with coordinating care and finding resources.  She discussed how the family and caretaker community help one another, both emotionally and also with information on programs, drug interaction, providers, and medical procedures.  Stacy related the great need to never forget that a Wounded Warrior is not their injury.  They have an injury, but they are still the person they were before.  Mental health professionals working with these young men and women must keep in mind aspects that go beyond the direct injury.  For instance, she shared the story of one 19-year-old Wounded Warrior who will never be able to have sex with his wife again, and the effects on that relationship and his own self-esteem.

            "There were many more stories, each presented with candor, wit, and the bitter taste that only comes from experience.  Yet, she also related humor, and the sweet feeling of hope that comes from strength.  Stacy presented on the day that Mark was being prepped for another surgery, a skin graft for the severely burned areas of his back.  The next day Mark had the surgery and he is recovering well.  After a year and a half, Stacy and Mark's journey is still far from over, but it is obvious from whom Mark received his great strength and determination to continue.  Even as a Wounded Warrior, Mark continues to exemplify the greatest characteristics of the Marine Corps and the military in general.  And so does his mother, Stacy.  To you both I say, 'Semper Fi' [Steven Brewer]."  We would remind the readership that this is at a time when the media reports that more troops were lost to suicide in 2012 than in combat.  "Knowing is not enough; we must apply.  Willing is not enough; we must do" (IOM/Goethe).

            The 113^th Congress:  On January 24, 2013 Pamela Hyde, Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), testified before the U.S. Senate that SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.  SAMHSA envisions a Nation that acts on the knowledge that:  * Behavioral health is essential for health.  * Prevention works.  * Treatment is effective.  And, * People recover from mental and substance disorders.  In order to fulfill this mission, SAMHSA has identified eight Strategic Initiatives to focus the Agency's work on improving lives and capitalizing on emerging opportunities.  SAMHSA's top Strategic Initiatives are: Prevention; Trauma and Justice; Health Reform; Military Families; Recovery Supports; Health Information Technology; Data, Outcomes and Quality; and Public Awareness and Support.

            Acutely aware of the Newtown tragedy and citing the work of psychologist John Monahan, the Administrator noted that behavioral health research and practice over the last 20 years reveal that most people who are violent do not have a mental disorder and that most people with a mental disorder are not violent.  In fact, those with mental illness are more likely to be the victims of violent attacks than the general population.  Demographical variables such as age, gender, and socioeconomic status are more reliable predictors of violence than mental illness.  She further testified that almost half of all Americans will experience symptoms of a mental health condition at some point in their lives.  Yet today, less than one in five children and adolescents with diagnosable mental health problems receive the treatment they need.  And, only 38% of adults with diagnosable mental health problems – and only 11% of those with diagnosable substance use disorders – receive needed treatment.

            Integration -- Given that behavioral health is essential to an individual's overall health, SAMHSA administers the Primary and Behavioral Health Care Integration (PBHCI) program.  The purpose of this program is to improve the physical health status of people with serious mental illnesses (SMI) by supporting communities to coordinate and integrate primary care services into publicly funded community mental health and other community-based behavioral health settings.  It is focused on increasing the health status of individuals based on physical or behavioral health need, encouraging structural changes in existing systems to accomplish its goals.  To date, the program has awarded 94 grants and 55% of awardees are partnering with at least one Federally Qualified Health Center (FQHC).  [Recall Cynthia Belar's vision].  This integration has resulted in significant physical and behavioral health gains.

            In concluding, the Administrator reaffirmed that President Obama's ACA advances the field of behavioral health by expanding access to behavioral health care; growing the country's behavioral health workforce; reducing behavioral health disparities; and implementing the science of behavioral health promotion.  The most recent data indicates that the national expenditure on mental health care was $113 billion and for substance abuse $22 billion in 2005.  With Medicaid already being the largest payer of mental health services, the ACA will extend Medicaid coverage to as many as 17 million hardworking Americans.  SAMHSA's number one strategic initiative is Prevention of Substance Abuse and Mental Illness, including fulfilling the public health promotion component of ACA.  Aloha,

Pat DeLeon, former APA President – Division 18 – February, 2013

TIMELY EVOLUTION

     With the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA), APA established its Center for Psychology and Health, with CEO Norman Anderson at the helm.  The Center's mission is to aggressively expand psychology's presence within the evolving health care delivery models being adopted across the nation.  Former Practice Directorate Deputy Executive Director Randy Phelps heads up the Center's Office for Healthcare Financing with the pressing challenge of ensuring that emerging and current healthcare financing policies treat psychology's practitioners equitably and fairly.  He will direct APA's participation in the American Medical Association (AMA) Relative Value Update (RUC) and Current Procedural Terminology (CPT) processes, and will coordinate advocacy with the APA Practice Organization and APA involving the commercial carrier market and the Centers for Medicare and Medicaid Services (CMS).  A decade ago, APA had the foresight to establish the Health and Behavior CPT codes.  These codes provide an immediately available and critical vehicle for reimbursement ofhealthcare psychology services (beyond mental health services) within fee-for-service integrated care mechanisms in support of team-based care, which is a hallmark of the ACA.  There can be no question that physical health and mental health are intimately intertwined.  However, perhaps psychology's biggest challenge within the new healthcare environment is that the profession is being defined by marketplace and national health policymakers as primarily (if not exclusively) as a mental health profession, rather than a more generic healthcare profession.  For example, as former APA President Suzanne Bennett Johnson passionately emphasized during her Orlando Opening Ceremony, even though psychology has created a number of very effective treatment strategies for addressing the nation's epidemic of obesity -- with two-thirds of adults and almost one-third of children being overweight or obese -- our practitioners cannot be reimbursed in primary care for these services which must be provided by physicians or nurse practitioners.

            Randy's challenge is very real on two accounts.  The Institute of Medicine (IOM) has observed that health care in America has experienced an explosion in knowledge, innovation, and capacity to manage previously fatal consequences.  Yet, paradoxically, it falls short on such fundamentals as quality, outcomes, cost and equity.  Each action that could improve quality – developing knowledge, translating new information into medical evidence, applying new evidence to patient care – is marred by significant shortcomings and inefficiencies that result in missed opportunities, waste, and harm to patients.  Americans would be better served by a more nimble health care system that is consistently reliable and that constantly, systematically, and seamlessly improves.  In short, the country needs health care that learns by avoiding past mistakes and adopting newfound successes.  Thus whether psychology's critical expertise will ultimately be embraced is an "open question."  Another major barrier is having our members appreciate that unprecedented change is occurring.  APA has been successful in having psychologists deemed eligible to bill under three types of CPT codes, mental health (including therapy and diagnosis), testing (including neuropsychology), and health and behavior.  The 2011 Medicare data indicate that nationwide our practitioners have submitted less than 400,000 bills under the health and behavior code; in sharp contrast, we have submitted several million under "mental health."  Simply stated, psychology is not billing (nor acting) as if we are a healthcareprofession.  This must change.  Aloha,

 

Pat DeLeon, former APA President -- West Virginia Psychological Association – February, 2013

 

THE LAND OF VISIONARIES

  Making A Difference:  One of the most fulfilling aspects of working within Nursing at the Uniformed Services University of the Health Sciences (USUHS) and the University of Hawaii (with Law and Pharmacy) is the opportunity to pursue interdisciplinary collaboration, which is one of the hallmarks of President Obama's landmark Patient Protection and Affordable Care Act (ACA).  One of the very last events of my APA Presidential term was to travel to the State of Washington in December, 2000 to present a well-deserved Presidential Citation to your colleague Colleen Hacker for her outstanding work with the U.S. Women's Olympic Soccer Team, which in my judgment, revolutionized the expectations of our nation's female youth for what they could accomplish in sports, science, and education.  They made a lasting impression on my daughter Kate.  That evening, I reflected upon the many national accomplishments of WSPA's leaders; for example, Ruth Paige whom I have had the pleasure of serving with on the APA Board of Directors, Barry Anton, and Andy Benjamin.  I recalled Al Paige inviting me to Ocean Shores in May, 1981 to talk about the importance of your maintaining the doctoral level standard, notwithstanding internal "political pressures."  Former APA Congressional Science Fellow Margy Heldring and Elizabeth Robinson were catalysts for a number of important APA policy issues, including attracting more women into APA's governance.

            Recently I had the opportunity to address the leadership of several national pharmacy organizations and learned, once again, that their members from your state have been on the cutting edge of pharmacy's maturation.  Today the Doctor of Pharmacy (PharmD) degree is the educational standard and their practitioners are providing comprehensive, patient-centered primary care (comparable to what health psychologists envision), including such preventive services as relaxation techniques, blood pressure evaluations, and anti-smoking educational efforts.  Our College of Pharmacy in Hilo conducts well attended community health fairs and is training Hawaii's psychologists in psychopharmacology.  The profession of pharmacy has obtained "collaborative practice" medication authority in almost all states and throughout the federal services (i.e., VA, DoD, USPHS, and Bureau of Prisons), often including the ability to initiate, modify, and terminate drug protocols.  While pharmacists have been involved with vaccines dating back to the mid-1800s and the distribution of smallpox vaccine, approximately two decades ago pharmacists began routinely immunizing patients in their communities as a standard practice activity.  The Washington State Pharmacists Association initiated the first ongoing formalized training of pharmacists in vaccine management in 1994, leading to the American Pharmacists Association's (APhA) nationally recognized training program for their members, in conjunction with the CDC.  Today (in contrast to psychology's orientation) organized pharmacy has embraced the utilization of pharmacy technicians, especially with the advent of the impressive advances occurring within the communications and technology fields.  Psychology should learn from pharmacy's experiences, including working closely with the pharmaceutical industry to sponsor innovative service delivery models.  Within the nursing profession, which also has been steadily expanding its scope of clinical practice over the past several decades, their national leaders have often been from your state.  And, various Washington State educational institutions have long maintained an impressive presence throughout Rural America; including on Indian reservations, the Pacific Basin, and the State of Alaska.  Providing patient-centered, cost-effective, and demonstrably accountable care has been paramount throughout these efforts.  I would love to hear of WSPA's efforts to work collaboratively with your state's federally qualified community health centers (FQHCs).

            Novel Models:  Former APA President Alan Kazdin recently addressed the need for our nation to develop novel models for delivering quality mental health services.  There can no longer be any question that there are significant economic and personal burdens of untreated "mental illness" throughout the nation and the world.  Mental health and physical health are inextricably intertwined.  Within the U.S. approximately 50% of our population meets the criteria for at least one psychiatric disorder during their lifetime.  Many of the barriers for delivering care for physical health issues to large swaths of individuals in need, particularly in developing countries, are recognized to be similar to the barriers of providing mental health care.  Alan points out that within the mental health professions the current model of delivering care is expanding; many involve the use of technology and online-versions of treatment drawing upon the Internet and other social media.  Similar to pharmacy's recognition, our former President has seriously proposed exploring "task shifting" which is a method of redistributing the tasks of delivering services to a broad range of individuals with less training and fewer academic qualifications than traditional health care workers possess in order to scale up the scope of providing services.  The underlying concept is not new having emerged from global health initiatives, particularly in developing countries where the majority of task-shifting applications have focused upon physical health where shortages of human resources and the burden of illness are acute.  This approach has recently been expanded to mental health concerns because of its ability to be scaled up to provide services to individuals who otherwise do not have access to care, as well as its adaptability to diverse countries, cultures, and local conditions.  Standardized treatments, decentralized delivery models, and simplified treatment protocols are systematically evolving.  Perhaps "lessons learned" from the business community's experience with "disruptive technology and disruptive innovations" will become the key.  To appreciate the true potential of this approach, psychology's training models of the future must become interdisciplinary in nature and we would suggest, moving beyond those of the traditional health professions.

            An Interesting Example of Alan's Vision -- Behavioral Health Technicians:  "Recently those of us at USUHS were fortunate to have five enlisted behavioral health technicians (BHTs) speak with the students, faculty, and staff of the Medical and Clinical Psychology Department.  The group consisted of Army and Navy personnel, with various assignment and deployment experiences.  The main speaker for the group was Army Sergeant First Class (SFC) Jonathan Colon, the Senior Enlisted Leader for the Directorate of Behavioral Health and the senior 68X (Army Behavioral Health Technician) for the Walter Reed National Military Medical Center of Bethesda.

            "SFC Colon discussed the primary duties of the BHT within the Army, Navy, and Air Force.  For example, the Army BHT assists in providing treatment for patients with behavioral health problems such as substance abuse, sexual assault and domestic violence, social issues, and posttraumatic stress disorder (PTSD).  They collect the required data from clients and are responsible for unit training on various behavioral health topics.  Under the supervision of a licensed provider (including psychological nurse), the enlisted BHT can conduct initial interviews, perform assessments, provide follow-up care, administer psychological tests, assess patient response to rehabilitation or treatment, co-facilitate group therapy sessions, and perform Combat and Operational Stress Control (COSC) functions.

            "The Navy and Air Force BHTs perform very similar functions, but with some distinct differences.  For instance, Navy BHTs are initially trained as corpsmen, which means they also have extensive medical training and can assist with emergency patient care if necessary.  The Navy is responsible for overseeing the needs of the Marine Corps, as that group is designated under the Department of the Navy.  The Air Force BHT job duties include on-call consultation to the Command and clinic management, though the Air Force BHT has a smaller role in conducting therapy sessions.

            "Perhaps the most shocking bit of information for the audience was the discovery of how much independent work the BHTs perform while deployed.  Due to the lack of licensed mental healthcare providers, these BHTs are left to work alone for weeks or months at a deployed site.  They will conduct the initial assessment, create a treatment plan, conduct individual or group therapy, and even make medication recommendations.  They work under the auspice of the behavioral health provider assigned to that camp or region through a precept method.  The BHT will conduct the work and create the recommendations, then contact the provider by phone for approval or changes, and then implement the finalized plan.

            "Another key piece of BHT duty is to act as the liaison between the troops and the commanders, and between the licensed provider and the troops.  All licensed providers are military officers, and all BHTs are enlisted.  The difference can sometimes be a gulf that is difficult to traverse, and the BHTs are the bridge that connects both sides.  Many times, troops will not want to see a licensed provider, but they have an issue they want to discuss.  An enlisted BHT, who is in the ranks working, eating, and bunking with these troops, is more likely to find out about the issue and offer assistance.  Their presence also reinforces the strength and trust between the troops and the Command structure, as well as helping to eliminate the stigma of being treated in behavioral health.  Obviously, the skills and experiences of these BHTs cannot be overemphasized, nor should they be underestimated.  They are skills that need to be utilized by the licensed providers of all the military branches, lest we lose them [Steven Brewer]."  Interesting times as always.  Aloha,

Pat DeLeon, former APA President – WSPA – January, 2013