THE EVOLUTION TOWARDS INTEGRATED CARE

A Gradually Maturing Foundation:  When the Final Report of the APA Ad-Hoc Task Force on Psychopharmacology, chaired by Michael Smyer, was submitted to the Council of Representatives in November, 1992 it anticipated that: "Practitioners with combined training in psychopharmacology and psychosocial treatments can reasonably be viewed as a new form of health care professional, expected to bring to health care delivery the best of both psychological and pharmacological knowledge.  The contributions of this new form of psychopharmacological intervention have the potential to improve dramatically patient care and make important new advances in treatment."  Interestingly, Anita Brown, who was one of the staff liaisons, eventually joined the U.S. Army in order to become one of the first 10 military prescribing psychologists.

            Training/Policy:  The Task Force developed its recommendations within a framework of three levels of training and practice in psychopharmacology: * Basic Psychopharmacology Education; * Collaborative Practice; and * Prescription Privileges (RxP).  Collaborative Practice (Level 2) training requires a doctoral degree and reflects the knowledge base necessary to participate collaboratively with other health care professionals in managing medications prescribed for mental disorders and integrating these medications with psychosocial treatment.  Training at this level includes more in-depth knowledge of psychoactive medications and drugs of abuse, as well as knowledge of psychodiagnosis, physical assessment, pathophysiology, therapeutics, emergency treatments, substance abuse treatments, developmental psychopharmacology, and psychopharmacology research.  Training for collaborative practice competence includes coursework, practica, and internship experiences.  From our policy frame of reference, this would provide the necessary training for a psychologist to "functionally prescribe" in conjunction with an appropriately licensed health care provider, such as a primary care provider, Advanced Practice Nurse, or psychiatrist, which would be similar to the role that clinical pharmacists are increasingly adopting today.

            Administrative/Implementation:  Bob McGrath, Director of the M.S. Program in Clinical Psychopharmacology and Certificate Program in Integrated Primary Care at Fairleigh Dickinson University, provided a listing of the 16 state psychology licensing boards which have formally addressed this evolution, focusing upon "the best interest of the client/patient."  California, for example, notes -- "There are many psychological conditions which manifest themselves in physical symptoms.  There are physical problems which have psychological symptoms as well.  The best interests of the patient demand that psychologists work closely with primary care physicians and psychiatrists who are prescribing medications to the patient of the psychologist.  While a psychologist's responsibility may include involvement in limited aspects of a patient's medications, the patient's physician is the only person who may lawfully prescribe and dispense the medication for the patient [August, 1998]."  District of Columbia – "A psychologist may offer a medication recommendation to the prescribing physician about a patient he or she has evaluated when such recommendation is within the boundaries of his or her competence based on his or her education, training, supervised experience, or appropriate professional experience.  It is then incumbent on the physician, based upon all of the evidence before him or her, which may include the recommendations of the psychologist, to decide what, if any, medication or medical treatment to prescribe [May, 1998]."  Florida  – "A Florida licensed psychologist may make recommendations for medications to physicians, including psychiatrists, as well as to other health care professionals, who are granted the authority to prescribe medications [July, 1998]."  Prior to the enactment of their RxP law in May, 2004, Louisiana – "It is within the scope of practice of psychology to gain competence in the field of psychopharmacology.  Psychologists who gain competence in psychopharmacology may provide consultations to professionals regarding psychotropic medications [July, 1999]."  The other states which Bob referenced are: Maine, Maryland, Massachusetts, Missouri, New Hampshire, New Jersey, New York, Ohio, Oklahoma, Tennessee, Texas, and Vermont.  We would be interested in learning of similar developments in other states and public/semi-public systems such as Federally Qualified Community Health Centers and state mental health programs.  This can be surprisingly controversial for some of our colleagues as I learned in addressing the Pennsylvania Psychological Association.  However, in case there is any question as to whether in-depth knowledge of medications is valued by our nation's health care system, the U.S. Department of Labor reports that among workers employed in health care occupations (not including doctors and dentists, many of whom are self-employed), the nation's 266,410 pharmacists had the highest average wages -- $104,260 – in May 2008.  And, with over 2.5 million people employed as registered nurses, that occupation is the largest among all health care occupations.  Registered nurses' wages are typically the highest of occupations with employment numbered in the millions (including occupations not related to health care).

            Visionary Leadership Within The VA:  "Since it began offering paid postdoctoral fellowship positions in 1994 (with eight positions across the nation), VA's Office of Academic Affiliations has continued to emphasize the importance of postdoctoral education by continuing to increase the number of available positions.  By the 2013-14 academic year, the number of postdoctoral fellowship positions had been increased to 348 located at 62 different VA facilities in the U.S. and Puerto Rico.  In addition to the general clinical psychology fellowships, many of these positions now are in specialty areas such as neuropsychology and rehabilitation psychology, while others include emphasis areas that incorporate Geropsychology, HCV & HIV Treatment, Health Psychology with an emphasis on Primary Care-Mental Health Integration, PTSD & Trauma Treatment, Psychosocial Rehabilitation and Recovery, and Women Veteran's Needs.  The number of positions should be even larger for the 2014-15 year" [Bob Zeiss, VA Office of Academic Affiliations, retired].

            The senior nursing leadership within the VA recently proposed a national scope of practice such that individual state nursing practice acts would not limit their ability to provide quality care.  As might have been expected, there was "push back" from medicine alleging a "public health hazard," specifically focusing upon whether nurse anesthetists (CRNAs) should be supervised by anesthesiologists (various state statutes differ on this requirement).  Ken Pope reports that more than 60 physician groups have expressed "strong concerns" that this would effectively eliminate physician-led team-based care within the VHA.  Excerpts from Secretary Shinseki's response to interested Members of Congress: "VHA is proposing the authorization of full practice by CRNAs across the Department of Veterans Affairs (VA) health care system.  This policy change will enable all VA CRNAs, not just those for whom the states currently allow, to practice to the full scope of their academic preparation and training.  The policy will increase access to care and ensure continuation of the highest quality of care for our Nation's Veterans, and help meet the growing demands for health care services nationwide while standardizing the scope of practice for CRNAs across VA's health care system.

"CRNAs safely administer more than 34 million anesthetics each year to patients in the United States… using all anesthetic techniques and practicing in every possible setting.  Over time, CRNAs have compiled a strong record of safety.  That safety record is unchanged whether the anesthesia is provided by a CRNA working independently or by a CRNA working under the supervision of a physician.  The available evidence does not substantiate that independent CRNA practice presents a threat to health and safety or in any way lowers the quality of anesthesia care….  Taking into account differences in patient and procedure complexity, the study revealed that patient outcomes did not differ between the states that did not require physician supervision and states that did….  Both studies confirmed that there were no measureable differences in quality of care or patient outcomes when anesthesia services were provided by CRNAs, Anesthesiologists, or CRNAs supervised by physicians.  Current VHA policy recommends that CRNAs and Anesthesiologists work together in a care team model but does not require physician supervision of CRNAs.  The proposed policy supports this team-based model of care that will fully utilize the knowledge, skills, and abilities of CRNAs.  As a member of the anesthesia team, CRNAs will be able to lead anesthesia teams, consult with their physician colleagues, and will receive the same professional practice review, evaluation, and monitoring as all other anesthesia providers….  The overarching goal of VHA is to provide safe, effective and timely health care.  The Undersecretary for Health is aware there are differing views with regard to physician supervision of CRNAs.  To that end, VHA will engage in a rulemaking process which will afford all interested parties the opportunity to comment on the proposed policy change."

            The Institute of Medicine (IOM):  The National Academy of Sciences (NAS) recently celebrated its 150^th anniversary, having been chartered by President Abraham Lincoln in 1863 to "investigate, examine, experiment, and report upon any subject of science."  In 1970 the IOM was established by the NAS to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public.  APA's CEO Norman Anderson was recently elected to this distinguished body.  One of the hallmarks of President Obama's landmark Patient Protection and Affordable Care Act (ACA) is an increasing emphasis on provider accountability and data-based decision making.  Another is fostering interdisciplinary collaboration within integrated systems of care.  Not surprisingly, members of the IOM, in their other capacities, have been instrumental in drafting and implementing the ACA.

This Winter the IOM requested nominations for a forthcoming Consensus Study on "Psychological Testing including Symptom Validity Testing (SVT)."  The committee will consist of 12 members with the three underlying objectives: * Perform a comprehensive review of psychological testing, including SVT (with emphasis on the MMPI-2, TOMM, Malingering Probability Scale, Structured Interview of reported Symptoms, Validity Indicator Profile, Structured Inventory of Malingered Symptomatology, the Rey's 15-Item-Test (FIT), and Portland Digit Recognition Test.  * Determine the relevance of psychological testing, including the SVT, to disability determinations in claims involving physical or mental disorders; and, * Provide guidance to help adjudicators interpret the results of psychological testing, including SVT.  The study is being sponsored by the Social Security Administration with the goal of addressing and improving the agency's policies and processes related to disability claims.  Experts in fields such as neuropsychology, psychiatry, psychology, cognitive rehabilitation, health care cost/benefit analysis, and health service systems are being sought.  The committee will be exploring multiple questions under six subgroups:  * Use of Psychological Testing, including SVT; * Testing Norms; * Qualifications for Administration of Psychological Testing, including SVT; * Administration of SVT Testing, including SVT; * Reporting Results; and, * Use of Psychological Testing, including SVT, in the Disability Evaluation process.

            Our Colleagues in Nursing and Pharmacy have long appreciated the importance of the IOM's deliberations to the quality of health care provided in our nation and to their professions' future.  At the Uniformed Services University of the Health Sciences (DoD) I enjoy teaching a small health policy class for nursing and psychology graduate students.  "Since the launch of the IOM in 1970, nurses have been members of the IOM with an even greater number having served on IOM boards, committees, forums, and roundtables.  Since 1973, when the IOM began serving as the National Program Office for the Robert Wood Johnson Foundation (RWJ) Health Policy Fellows initiative, nurses have been part of this interdisciplinary program to participate in health policy formulation at the highest levels of government.

"Since 1992 the IOM has hosted the Distinguished Nurse Scholar-in-Residence program.  Supported by the American Academy of Nursing, the American Nurses Foundation, and the American Nurses Association, this residential program has been supporting nurse leaders in playing a more prominent role in health policy development at the national level through a 1-year program of orientation (scholars join the RWJ Health Policy Fellows' orientation in the Fall) and study at the IOM.  The scholar produces a report as a result of working on a current IOM initiative related to his/her area of expertise.  This year's Distinguished Nurse Scholar-in-Residence for 2013-14 is Beatrice Kalisch, Director of Innovation and Evaluation and Titus Professor of Nursing at the University of Michigan.  She brings extensive experience in quality of care and patient safety.  She will also be working on the upcoming IOM study of diagnostic errors.  The 2012-13 Distinguished Nurse Scholar-in-Residence, Marla Salmon – an IOM member and the immediate past Dean of the University of Washington School of Nursing – will continue her role as resident scholar.  Her work is focusing on three areas of policy and scholarship:  * Global nursing workforce capacity building; * Women's development aimed at enhanced educational and economic wellbeing; and, * Social impact investment and microfinance as mechanisms for reducing barriers to women's education and subsequent sustained economic engagement" [Marie Michnich, former RWJ Fellow who served with Senator Bob Dole for three years].  The 2003 Scholar was Angelia McBride, a fellow Purdue University psychology graduate; the 2006 Scholar was Ada Sue Hinshaw, Dean of the Daniel K. Inouye USUHS School of Nursing, where I serve as a Distinguished Professor.

A frequent discussant for my class, Lucinda Maine, Executive Vice President of the American Association of Colleges of Pharmacy (AACP), shared her profession's appreciation for the long term importance of public policy involvement and the IOM.  "IOM member J. Lyle Bootman, Dean of the University of Arizona College of Pharmacy and 2012-13 President of the AACP, challenged his members to 'Get to tables of influence' to insure that pharmacists' roles in improving health and health care could be maximized.  He did not overlook the power of the IOM tables in implementing his own recommendation.  With resources from AACP and other organizations, a fellowship was endowed in the IOM Anniversary Fellowship Program.  Every other year in perpetuity a pharmacist from academia, practice or both will be selected to serve as the Pharmacy Fellow at IOM.  Over two years they attend IOM meetings, work to support study committees, forums and other IOM groups.  Dr. Sam Johnson, affiliated with the University of Colorado in Denver and a leader in pharmacogenomics at Kaiser's Rocky Mountain Health System, assumed the position of inaugural fellow in October 2012 and will complete his experience in October 2014.  He describes his experience as nothing short of 'life changing.'  It is clear that he has made an important imprint on the work of the IOM as well."

A Sea Change In Orientation:  The conference agreement for the Fiscal Year 2014 Consolidated Omnibus Appropriations bill, which President Obama has now signed into public law, contains an intriguing directive for the Substance Abuse and Mental Health Services Administration.  "The agreement provides for a new five percent set-aside for the Mental Health Block Grant.  The set-aside is for evidence-based programs that address the needs of individuals with early serious mental illness, including psychotic disorders, as proposed in Senate Report 113-71.  It is expected that in implementing this set-aside, SAMHSA will collaborate with NIMH to develop guidance to States so that funds are used for programs showing strong evidence of effectiveness.  It is expected that SAMHSA and NIMH brief the House and Senate Appropriations Committees on implementation status of this set-aside no later than 90 days after enactment of this act."

Those fortunate to attend the annual Practice Directorate State Leadership Conferences (SLC), which in my judgment are one of the highlights of the APA year, have recently been exposed to the vision of Art Evans, Commissioner of the Department of Behavioral Health and Intellectual disability Services for the City of Philadelphia.  Art has been singularly focused on the transformation of the city's large behavioral health system.  This involves hundreds of millions of dollars, hundreds of employees, tens of thousands of service recipients and ensuring a safety net for a city of 1.5 million people.  The transformation of the behavioral healthcare system is focused on recovery and resilience outcomes and has required working at multiple levels and domains simultaneously.  For example, the department has invested heavily in empirically supported treatments and has formed partnerships with clinical researchers such as Aaron Beck, M.D. and Edna Foa, Ph.D. to do large-scale implementations of evidence based practices.  Simultaneously, Art and his colleagues have used financial incentives to improve provider performance, developing performance metrics for 90% of their service system.  In addition to improving clinical service delivery, much of their focus has been on non-clinical strategies that they believe are essential to helping people achieve the best possible outcomes.  Philadelphia has one of the most robust peer programs in the nation, training and deploying hundreds of people in recovery from mental health and addiction problems throughout their system from acute inpatient settings to assertive community treatment teams.  Community work also includes working with members of diverse faith backgrounds who can support recovering people within their congregations and working with indigenous community leaders from immigrant groups to develop alternative pathways into treatment, as well as culturally responsive support services.  Art firmly believes that the next frontier for behavioral health is the adoption of a public health framework and strategies to address the psychological health of people.

            Enjoyable/Intriguing Journeys:  Since retiring from the U.S. staff after 38+ years with Senator Inouye, I have become increasingly intrigued by the experiences of colleagues who have "retired" from their previous employments.  "If your Oregon tour schedule allows time I would be pleased to share coffee or a meal.  I live in The Dalles, which if you check your map, is in the Columbia River Gorge.  We are about 85 miles from Portland going East on I-84.  It is probably the most scenic Interstate route in the nation and includes Multnomah Falls, Angel Falls, Bonneville Dam, etc., etc., etc.  It is an easy, wonderful drive.  We spend about eight months in The Dalles and four months in Yuma.  We travel frequently.  In retirement I travel, hunt, fish, volunteer on Veterans Issues, 4-wheel the desert southwest, and write.  I am rewriting a book entitled '20^th Birthday' which is a diary of my time in combat in Vietnam and its aftermath in my life.  The first edition can be found on Amazon and Kindle.  It is a good journey and lots of life continues after retirement when we are no longer defined by what we do but who we are" [Pat Stone, former APA Congressional Fellow].  Over the years we have also come to appreciate how personal the public policy world can be.  Judith Glassgold, who is director of the APA Congressional Fellowship program and a former APA Congressional Fellow herself, reports that this year's Fellows Irina Feygina will serve with Senator Bennet focusing on environment, energy, and disaster relief issues while Joshua Wolff will be in the Policy Health Office of the Senate HELP Committee, working with Jenelle Krishnamoorthy, a former Congressional Fellow.  Aloha,

Pat DeLeon, former APA President – Division 29 – February, 2014

 

CREATIVE MINDS -- FASCINATING JOURNEYS

When many of us think of the contributions of Minnesota psychology, the MMPI immediately comes to mind, as it well should -- dating back to 1943.  The personal journey of MMPI expert, and now Professor Emeritus, James Butcher exploring Watercolors as a late-life adventure, and the extraordinarily impressive APA governance service of his University of Minnesota colleagues Bruce Overmier and Jo-Ida Hansen, seem equally significant however.  As editor of Psychological Services, I had the pleasure of working closely with Shelia Brandt on behalf of the profession's public service members.  Having worked on Capitol Hill for nearly four decades, I was very pleased to learn of her growing interest in becoming involved in the public policy process.  This year she is serving as a Humphrey School of Public Affairs Fellow.  Those fortunate to attend the annual Practice Directorate State Leadership Conferences (SLC), which in my judgment are one of the highlights of the APA year, have recently been exposed to the vision and dedication of another explorer Art Evans, Commissioner of the Department of Behavioral Health and Intellectual disability Services for the City of Philadelphia.

            Arthur C. Evans, Jr. is a psychologist and frontline policymaker who oversees a $1 billion behavioral healthcare system in Philadelphia.  Growing up in Florida in the 1970's, the unlikely journey that brought the son of a schoolteacher and an Air Force electronics technician to his current position was somewhat circuitous.  After graduating as a music major at a local community college, he happened upon his psychology teacher who asked him what he planned to do next.  He admitted he didn't know but, while he enjoyed the field a great deal, he did not want to major in psychology, because he thought it would take him too long to complete school through to a doctorate.  That brief conversation altered the course of his life as his teacher encouraged him to pursue his real interest and identified a couple of colleges that he could attend, including Florida Atlantic University (FAU) where he would matriculate with a bachelors and master's degree in experimental psychology.  At FAU he received rigorous training in research, including a year of full time work experience through a co-op at the United States Army Aeromedical Research Laboratory.  He credits this strong scientific foundation to a core belief; that the answers to many of the complex problems that society faces may lie in psychological research.  But, he has observed, the dots between the researchers and those trying to resolve the problems often remain unconnected.

            Earning his doctorate in clinical/counseling psychology at the University of Maryland at College Park, this turned out to be an ideal training program for the career for which he was ultimately preparing.  With his upbringing in 1970s Florida, he was acutely aware of the challenges facing the African-American community and felt compelled to put himself in a position where he could help the community.  He reasoned that because there were very few African-American psychologists – he had only met one at the time – it would be important for him to have the broadest possible training in order to be able to serve in as many roles as possible.  While some of his colleagues endeavored to specialize, he sought a wide skillset that would allow him to work with people experiencing a range of conditions.  But he was fascinated by the training that related to community psychology.  Both the underlying philosophy and values, as well as the techniques, such as ecological assessments, were very much aligned with his view that psychology should be both intra-psychically focused, as well as focused on the social factors that affected psychological health.  During his second year at Maryland, he had the opportunity to do an internship at what would later be called the APA Office of Legislative Affairs.  Learning the critical role that policy played in addressing mental health issues through this APA experience, it planted the desire to do work at the policy level that would come to fruition many years later.

            Yale University School of Medicine, where Art completed his pre-doctoral internship, was one of the only programs in the nation where one could receive both clinical and community psychology training.  It was an ideal launch pad for the career that he has pursued.  His internship allowed him to consolidate his training in experimental, clinical and community psychology and, given the complexity of the work involved, his diverse training was very useful.  After finishing up at Yale, he decided to remain in New Haven and take a position as the clinical director of a new medical detoxification center that was being developed.  He also joined the clinical faculty at Yale and started a private practice and consulting business with several partners.  This combination of clinical, administrative, research, and teaching activities was a great fit and set the stage for rest of his career to date.  Learning to manage multiple and diverse activities simultaneously was both rewarding and necessary for the types of positions that he has undertaken.  All have required a broad range of skills.  For example, developing a new medical detoxification center requires administrative skills, clinical knowledge, political acumen, the ability to conceptualize how a program fits into an existing system of care, and the ability to use research to drive program design to name a few.  Drawing from the various pools of his training and experiences has become a way of life when it comes to his work.

            After several years in New Haven, Art was invited to delve into policy work at the Connecticut Department of Mental Health and Addiction Services at the State Capital in Hartford, initially as the agency's first Director of Managed Care and then later as the Deputy Commissioner for the agency – a political appointment.  In both of these positions he was tasked with creating programming and developing new approaches to service delivery.  Shortly after being appointed Deputy, Commissioner Thomas Kirk (also a psychologist) made the policy decision to adopt "recovery" as the overarching framework for organizing the Connecticut Behavioral Healthcare System, becoming the first behavioral health system in the nation to do so.  Working with several psychologists and others in the field, including a large number of people in recovery from mental health and addiction problems, they undertook the task of figuring out conceptually and practically what this would mean and began employing the strategies necessary to make this major paradigm shift.  This work continues today both in Connecticut and Philadelphia, where Art currently serves as Commissioner of the Philadelphia Behavioral Health System as he has since 2004.

            In Philadelphia, Art has been singularly focused on the transformation of the city's large behavioral health system.  This involves hundreds of millions of dollars, hundreds of employees, tens of thousands of service recipients and ensuring a safety net for a city of 1.5 million people.  The transformation of the behavioral healthcare system is focused on recovery and resilience outcomes and has required working at multiple levels and domains simultaneously.  For example, the department has invested heavily in empirically supported treatments and has formed partnerships with clinical researchers such as Aaron Beck, M.D. and Edna Foa, Ph.D. to do large-scale implementations of evidence based practices.  Simultaneously, Art and his colleagues have used financial incentives to improve provider performance, developing performance metrics for 90% of their service system.  In addition to improving clinical service delivery, much of their focus has been on non-clinical strategies that they believe are essential to helping people achieve the best possible outcomes.  For example, Philadelphia has one of the most robust peer programs in the nation, training and deploying hundreds of people in recovery from mental health and addiction problems throughout their system from acute inpatient settings to assertive community treatment teams.  Community work also includes working with members of diverse faith backgrounds who can support recovering people within their congregations and working with indigenous community leaders from immigrant groups to develop alternative pathways into treatment, as well as culturally responsive support services.

            Art Evans believes that the next frontier for behavioral health is the adoption of a public health framework and strategies to address the psychological health of people.  This has many implications for psychology including the development and incorporation of population-based interventions, focusing on population health, addressing psychological wellness – as opposed to an often singular focus on treating pathology – and greater emphasis on prevention and early intervention.  At SLCs Art has called on Psychology to play a major leadership role in moving the field in this direction.  It will require though, connecting the dots from many areas of psychology.  If psychology does begin connecting the dots to address the complex challenges facing communities and the nation's healthcare system, the field will thrive over the next several decades.

            Vision And Personal Involvement Is Not Limited To Any Profession:   One of the hallmarks of the Uniformed Services University of the Health Sciences (USUHS) (DoD), where I currently enjoy teaching a health policy class, is interdisciplinary collaboration at the educational, clinical, and research level.  Lucinda Maine, Executive Vice President of the American Association of Colleges of Pharmacy (AACP), shared her profession's appreciation for the long term importance of public policy involvement.  "Institute of Medicine (IOM) member J. Lyle Bootman, Dean of the University of Arizona College of Pharmacy and 2012-2013 President of the AACP, challenged his members to 'Get to tables of influence' to insure that pharmacists' roles in improving health and health care could be maximized.  He did not overlook the power of the IOM tables in implementing his own recommendation.  With resources from AACP and other organizations, a fellowship was endowed in the IOM Anniversary Fellowship Program.  Every other year in perpetuity a pharmacist from academia, practice or both will be selected to serve as the Pharmacy Fellow at IOM.  Over two years they attend IOM meetings, work to support study committees, forums and other IOM groups.  Dr. Sam Johnson, affiliated with the University of Colorado in Denver and a leader in pharmacogenomics at Kaiser's Rocky Mountain Health System, assumed the position of inaugural fellow in October 2012 and will complete his experience in October 2014.  He describes his experience as nothing short of 'life changing.'  It is clear that he has made an important imprint on the work of the IOM as well."  The importance of "escaping from one's professional silo" and appreciating the past was underscored by USUHS colleague Mike Feuerstein: "Especially in psychology, sorry to say.  Someone's innovation is another's past effort.  Maybe that is how progress occurs in life and why it takes so long.  Can be frustrating but you don't get to see it until you are 'older'."  Aloha,

Pat DeLeon, former APA President – Minnesota Psychological Association – January, 2014

 

 

OUR NEXT GENERATION – THEIR TIME HAS COME

  From a health policy perspective, our nation is undergoing a radical transformation from what might once have been considered, not that long ago, a "momma-pop" individual-oriented health care delivery model to becoming a systematically data-driven and provider accountable health caresystem that will ultimately be client-centered with an emphasis upon prevention, wellness, and holistic care.  This fundamental change reflects the essence of President Obama's Patient Protection and Affordable Care Act (ACA).  There are several driving factors which made the enactment of his far reaching legislation timely and politically feasible.  Health care costs have continued to rise at an unacceptable rate.  Today health care in the United States is more expensive than in any other developed nation costing $2.7 trillion in 2011, or 17.9% of the national gross domestic product.  Numerous studies have confirmed that there is much variation in health care spending, use, and quality within geographical areas; and further, that according to the Institute of Medicine (IOM) regions that deliver more services do not appear to achieve better health outcomes than those that deliver less.  In fact, underuse, misuse, and overuse of various services often put patients in danger.

Equally important has been the unprecedented advances occurring within the communications and computer technology fields.  Not that long ago, on April 27, 2004, then-President George W. Bush noted: "The way I like to kind of try to describe health care is, on the research side, we're the best….  (W)hen you think about the provider's side, we're kind of still in the buggy era….  It's like IT, information technology, hasn't shown up in health care yet….  If properly used, it is an industry-changer for the good.  It enables there to be a better cost structure and better quality care delivered, in this case in the health field.  And, yet the health care industry hasn't touched it, except for certain areas ….  By introducing information technology, health care will be better, the cost will go down, the quality will go up."  Today, it is becoming increasingly possible to systematically compare provider outcomes across diagnoses, patient populations, systems of care, and the longevity of patient lives.  Those seeking to provide and pay for Quality Care are actively exploring the critical psychosocial-economic-cultural gradient of care which APA CEO Norman Anderson has been proposing for over a decade.

Within the political/health policy context, as former Mississippi resident (and now Practice Directorate Executive Director) Katherine Nordal has emphasized at State Leadership Conferences (SLC), change is here.  "The clock is ticking towards full implementation of the law [ACA] and January 1, 2014 is coming quickly.  But January 1^st is really just a mile marker in this marathon we call health care reform.  Many of our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  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.  For two years in a row at SLC our theme has been health care reform, and we've focused on the critical need for psychology to get engaged.  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."

Those of our colleagues who have gravitated to specialized fields such as forensic practice, organizational coaching, and providing integrated health services will do very well over the next decade.  As former APA President Ron Fox has emphasized to the psychology-nursing Health Policy class I teach at the Uniformed Services University of the Health Sciences, although we may think that what we have learned during our extensive training is self-evident – it is not, and he assures the graduate students that they will be well respected as they advance in their chosen careers.  Katherine also emphasizes that the individual States are now in the driver's seat under the ACA and that local political/policy involvement is absolutely critical for the profession.  The underlying statute and implementing regulations for two of the major ACA provisions, the Patient-Centered Medical Home and the Accountable Care Organization, do not expressly mention "psychology."  At last spring's SLC Katherine highlighted your association's impressive efforts to demonstrate psychology's "value-add" under Medicaid and within interdisciplinary primary care settings, both of which are central to the ACA.  Reflecting upon organized psychology's highly emotional objections to President Clinton's Managed Care initiatives, Blowin' in The Wind readily comes to mind.  "How many times must a man look up before he can see the sky?"  We would suggest that "The answer my friend is…." -- Within the 2010 IOM report "On the Future of Nursing: Leading Change, Advancing Health."  Aloha,

Pat DeLeon, former APA President – Mississippi Psychological Association – January, 2014

 

LOOKING OUTWARDS AND HOPEFULLY FORWARD

One of the most important and rewarding responsibilities of public service psychology is to continually look to the future to explore how to best address the most pressing needs of the nation.  The National Academy of Sciences -- which recently celebrated its 150^th anniversary, having been chartered by President Abraham Lincoln in 1863 to "investigate, examine, experiment, and report upon any subject of science" -- provides an exciting vision; for those educated within the health sciences, in particular the deliberations of its Institute of Medicine (IOM).  As the nation steadily implements the provisions of President Obama's landmark Patient Protection and Affordable Care Act (ACA), one must expect increasing dialogue among health policy experts (including those "paying the bills") at the local and national level in order to most effectively address the inherent challenges in such a fundamental change.

            On April 27, 2004 then-President George W. Bush noted: "The way I like to kind of try to describe health care is, on the research side, we're the best.  We're coming up with more innovative ways to save lives and to treat patients.  Except when you think about the provider's side, we're kind of still in the buggy era….  It's like IT, information technology, hasn't shown up in health care yet….  We're here to talk about how to make sure the Government helps the health care industry become modern in order to enhance the quality of service, in order to reduce the cost of medicine; in order to make sure the patient, the consumer, is the center of the health care decision-making process.  And we've made great progress.  There's a role for the Federal Government….  (T)he Federal Government can lead because we're spending a lot of money in health care.  We're a large consumer on behalf of the American people.  Think about it: Medicare, Medicaid, veterans' benefits, Federal employee health insurance plans… and therefore it provides a good opportunity for the Federal Government to be on the leading edge of proper reform and change….  And there's the ways to make sure that the Federal Government's role is helpful in expanding information technology….  If properly used, it is an industry-changer for the good.  It enables there to be a better cost structure and better quality care delivered, in this case in the health field.  And, yet the health care industry hasn't touched it, except for certain areas.  And one area that has is the Veterans Administration….  By introducing information technology, health care will be better, the cost will go down, the quality will go up…."

            Institute of Medicine (IOM):  A critical issue which the IOM recently addressed is Variation in Health Care Spending, where research has long shown that Medicare spending varies greatly in different regions of the country, even when expenditures are adjusted for variation in the costs of doing business; meaning that certain regions have much higher volume and/or intensity of services than others.  Having been involved in the public policy/political arena for nearly four decades, one appreciates that those involved in providing clinical services quite reasonably seek to maximize their reimbursement levels.  For years, the particular rationale of a geographically based value index seemed to make intuitive sense.  Nevertheless, the IOM ultimately recommended that Congress not adopt this for Medicare payments as the majority of health care decisions are made at the provider or health care organization level, not by geographical units.

            Health care in the United States is more expensive than in other developed countries, costing $2.7 trillion in 2011, or 17.9 percent of the national gross domestic product.  Increasing costs strain budgets at all levels of government and essentially threatens the solvency of Medicare which is the nation's largest health insurer.  At the same time, despite advances in biomedical science, medicine, and public health, health care quality remains inconsistent.  In fact, underuse, misuse, and overuse of various services often put patients in danger.  Many of the current efforts to improve this situation focus upon Medicare, which mainly pays practitioners on a fee-for-service basis and hospitals on a diagnoses-related group basis (which is essentially a fee for a group of services related to a particular diagnosis).  As indicated, Medicare spending varies greatly in different regions of the country and those regions that deliver more services do not appear to achieve better health outcomes than those that deliver less.

The ACA calls for renewed examination of the role of geography in how Medicare reimburses hospitals, physicians, and other providers.  The IOM concluded that regional differences are real and persist over time.  However, there is much variation within geographic areas, no matter how broadly or narrowly defined.  Accordingly, the IOM recommended that Congress notadopt a geographically based value index for Medicare payments because the majority of health care decisions are made at the provider or health care organization level, not by geographic units.  Adjusting payments geographically based on any aggregate or composite measure of spending or quality would unfairly reward low-value providers in high-value regions and punish high-value providers in low-value regions.  To promote high-value services from all providers, Medicare should continue to test payment reforms that offer incentives to providers to share clinical data, coordinate patient care, and assume some financial risk for the care of their patients.  Sound like the underlying themes of President Clinton's Managed Care initiative?

            In a series of studies spanning three decades – and the subject of a U.S. Senate Appropriations Committee hearing in November, 1984 -- experts at the Dartmouth Institute for Health Policy have demonstrated significant variation in Medicare spending and quality across geographic regions.  In addition, the IOM commissioned extensive research examining populations with specific diseases or clinical conditions.  This analysis confirmed that the regional differences in both spending and use of services are large.  For example, hospital referral regions whose spending was at the 90^th percentile spent 42 percent more per Medicare beneficiary each month than regions at the 10^th percentile, without adjustments for any differences between regions.  An overall explanation for the variations remains elusive.  Variation in patient preferences, provider discretion, and other differences in health status and market factors that are not captured in the data could be responsible for the unexplained variation.  Differences in the use of post-acute care (PAC) and acute care services stood out as key drivers of variations in Medicare spending.  If there were no variation in PAC spending, variation in total Medicare spending would fall by 73 percent.  If there was no variation in both acute care and PAC spending, total Medicare spending variation would drop by 89 percent.  In the commercial insurance market, regional differences in price markups, rather than the utilization of health care services, are the prime influence on geographical variation in spending.

Focusing upon the ACA, the IOM recommended that in order to improve value, CMS (which administers Medicare) should continue to test payment reforms such as value-based purchasing, Patient-Centered Medical Homes, bundled payments, and Accountable Care Organizations.  [Note, psychology is not expressly mentioned in either the underlying statute or implementing regulations for Patient-Centered Medical Homes or Accountable Care Organizations.]  These reforms are directed at decision-making entities and provide incentives for health care providers to integrate care delivery, coordinate care with other providers, and share data on service use and health outcomes in real time.  CMS should also pilot programs that allow beneficiaries to share in the savings for higher-value care.  Finally, CMS should make Medicare and Medicaid data more accessible for research purposes, as well as collaborate with private insurers so that new payment models can be evaluated across payers.  Medicare covers more than 47 million Americans, including 39 million people age 65 and older and 8 million people with disabilities.

            NIMH:  In January, 2013 Thomas Insel, Director of the National Institute of Mental Health (NIH) testified: "The burden of mental illness is enormous.  In the United States, an estimated 11.4 million American adults (approximately 4.4 percent of all adults) suffer from a serious mental illness (SMI) each year, including conditions such as schizophrenia, bipolar disorder, and major depression.  According to a 2004 World Health Organization report, neuropsychiatric disorders are the leading cause of disability in the United States and Canada, accounting for 28 percent of all years of life lost to disability and premature mortality.  The personal, social and economic costs associated with these disorders are tremendous.  Suicide is the 10^th leading cause of death in the United States, accounting for the loss of more than 38,000 American lives each year, more than double the number of lives lost to homicide.  A cautious estimate places the direct and indirect financial costs associated with mental illness in the United States at well over $300 billion annually, and it ranks as the third most costly medical condition in terms of overall health care expenditure, behind only heart conditions and traumatic injury.  Even more concerning, the burden of illness for mental disorders is projected to sharply increase, not decrease, over the next 20 years.

"NIMH-supported research has found that Americans with SMI die eight years earlier than the general population.  People with SMI experience chronic medical conditions and the risk factors that contribute to them more frequently and at earlier ages….  (T)he vast majority (80.1 percent) of people having any mental disorder eventually make contact with a health care professional to receive treatment, although delays to seeking care average more than a decade….  NIMH aims to support research on earlier diagnosis and quicker delivery of appropriate treatment, be it behavioral or pharmacological….  Research has taught us to detect diseases early and intervene quickly to preempt later stages of illness."  Later on that year, Alan Kraut, Executive Director of the Association for Psychological Science (APS), as well as several APA senior staff, attended a high level meeting at NIMH in which considerable interest was expressed in working with the IOM to explore establishing appropriate matrixes for determining the quality of mental health services being provided.  Interestingly, as Alan pointed out, this was the subject of U.S. Senate Finance Committee hearing in August, 1978 entitled "Proposals to Expand Coverage of Mental Health under Medicare-Medicaid."  Substantive change takes time, notwithstanding its importance.

            Taking the Next Step:  The newest clinical psychopharmacology training program for RxP is located at the University of Hawaii at Hilo, College of Pharmacy, from which active duty psychologist M. Todd Bell graduated.  "Just over a year ago, I completed the Masters of Science in Clinical Psychopharmacology program.  When I began this two year program, I had no idea how rigorous or comprehensive the training would be, but looking back now, I realize it was, without exception, the most strenuous (and mentally exhausting) professional training in which I have participated.  It has deepened my understanding of my patients by having a greater appreciation for their biological functioning, which has led to a more 'balanced' biopsychosocial perspective.  Obviously, the training significantly increased my knowledge of psychotropic medications, but it also provided enough broad focus in general pharmacology to afford me a degree of competence and comfort in discussing medication as well as to feel confident in incorporating pharmacological treatment strategies into a patient's comprehensive plan of care.  What was not so obvious to me at the time I participated in the program was that I would go on to feel a greater sense of companionship with other healthcare professionals as we share cases and collaborate more frequently.  This new sense of familiarity is contrasted with the 'silo' effect of more traditional mental health services which I had been accustomed to and is mostly isolated from the rest of a patient's healthcare.

            "As for practice following credentialing, I have discovered increased kinship and camaraderie with other healthcare providers.  I enjoy sharing cases with other professionals and have been excited at the prospect of having additional tools to incorporate into my practice.  I have found that I have not altered my usual scope of practice much in that I still provide assessment and psychotherapy for patients rather than seeing patients 'only' for medication.  In particular, I have found the collaboration with Nurse Practitioners and the consultation with fellow Psychologists to be very rewarding.  I am completely satisfied with the quality of training and feel that it really did prepare me for prescribing medication in a safe and effective manner."

"Speaking as an official 'Old Person,' one who was required to start collecting Social Security benefits eight years ago, I believe that organizational memory is very important, and I am ever fascinated by the history of things – especially since, as time passes, I meet more and more people with no personal knowledge of things that I and my same-age peers have lived through.  The disconnect is amazing [Gerald Leventhal]."  "What's Past is Prologue."  Aloha,

Pat DeLeon, former APA President – Division 18 – January, 2014

 

CRITICAL INVESTMENTS IN OUR NEXT GENERATION

The Institute of Medicine (IOM):  The Board of Children, Youth, and Families of the IOM will establish a Forum on Promoting Children's Cognitive, Affective, and Behavioral Health (C-CAB Health Forum).  This Forum will engage in dialogue and discussion to connect the prevention, treatment, and implementation sciences with settings where children are seen and cared for, including primary health care, schools, preschools and child care, social service and child welfare, juvenile justice, family court, military, and community based organizations, and to create systems that are effective and affordable in addressing children's needs.  A major goal of the Forum is to highlight and address gaps in the science of implementing programs and practices in the service of informing research, policy, and practice.  One necessary component of addressing implementation science is knowledge utilization of the end user or decision maker, which can be at the local, state, or federal level.  The Forum will address gaps in the science of implementation by convening a multi-sectorial group of representatives from academia, federal agencies, professional organizations, and philanthropy in an ongoing way, over three years.  This group of Forum members will decide on two workshop topics per year and work with the Academies staff to design the agendas and invite speakers and guests to participate.  Workshops can be designed to engage the users of research from state and local agencies as well as intermediaries who translate research for legislators and service providers.  Psychologist Kimber Bogard is the staff director for the IOM Board.  Those colleagues familiar with the philosophy behind President Obama's Patient Protection and Affordable Care Act (ACA) will quickly recognize how this IOM initiative nicely parallels the legislation.

            Earlier in the year, the Board issued an insightful report Confronting Commercial Sexual Exploration and Sex Trafficking of Minors in the United States, with psychologist Sharon Lambert serving as a committee member.  Every day in our nation children and adolescents are victims of commercial sexual exploitation and sex trafficking.  The report concluded that efforts to prevent, identify, and respond to this national tragedy are largely under supported, inefficient, uncoordinated, and unevaluated.  They require better collaborative approaches that build upon the capabilities of people and entities from a range of sectors.  In addition, such efforts will need to both confront demand and the individuals who commit and benefit from these crimes.  Supported by the Department of Justice, the report focused primarily on trafficking for purposes of prostitution, exploiting a minor through prostitution and survival sex – which is the exchange of sex or sexual acts for money or something of value.  The Committee based its deliberations on three fundamental principles: * These crimes should be understood as acts of abuse and violence against children and adolescents; *  Minors who are commercially sexually exploited or trafficked for sexual purposes should not be considered criminals; and, *  Identification of victims and survivors as well as any interventions should do no further harm to these unfortunate victims. 

            Numerous factors contribute to the general societal lack of understanding and awareness.  These crimes may be simply overlooked, as they often occur at the margins of society and behind closed doors.  Victims may not come forward.  And, those who routinely interact with victims and survivors may lack awareness or tools to properly identify and assist victims.  Accordingly, there is no reliable estimate of the incidence or prevalence of these crimes and many victims go without help.

The Committee proffered three fundamental recommendations and urged that those are involved and who genuinely care seek to leverage existing resources towards these objectives.  1.) Increasing Awareness – Many professionals and individuals who interact with youth -- such as teachers, health care providers, child welfare professionals, and law enforcement officials – are unaware that these crimes occur and often are ill-equipped in knowledge about how to respond to victims, survivors, and those at risk.  Developing, implementing, and evaluating relevant training activities on how to identify and assist these young victims is necessary.  Public awareness campaigns are needed, with a special focus on increasing awareness among children and adolescents to help them avoid becoming victims.  2.) Strengthening Laws, Improving Understanding, and Prevention -- Minors who are the victims can still be arrested, detained, and given permanent records as offenders.  Instead, they should be redirected from criminal or juvenile justice systems to child welfare systems or other appropriate agencies.  Sadly, individuals guilty of taking advantage of these children have largely escaped accountability.  There is an extremely limited evidence base related to these crimes, particularly related to areas of prevention and intervention, with much variability in quality.  Accordingly, the Committee called for implementing a national research agenda in order to:  * Advance knowledge and understanding of commercial sexual exploitation and sex trafficking of minors in the United States.  * Develop effective, youth-centered, multi-sector interventions designed to prevent minors from becoming victims and to assist victims.  And, * Form strategies and methodologies for evaluating the effectiveness of prevention and intervention laws, policies, and programs.   3.) Collaboration and an Information Sharing Platform is essential – No one sector, discipline, or area of practice can fully understand or respond effectively to the complex problems surrounding commercial sexual exploitation and sex trafficking of minors.  Therefore cooperation is essential.

IOM -- A nation that is unaware of these problems or disengaged from solutions unwittingly contributes to the ongoing abuse of minors.  If acted upon in a coordinated and comprehensive manner, those involved can strengthen the nation's emerging efforts to prevent, identify, and respond to commercial sexual exploitation and sex trafficking of minors.  Myth – Help is readily available for victims and survivors.  Fact – There are far too few services to meet the current needs.  The services that do exist are unevenly distributed geographically, lack adequate resources, and vary in their ability to provide specialized care.

Efforts at the State Level:  "In the Spring of 2012, in response to a request from the Governor's wife, the Anchorage-based Cook Inlet Tribal Council (CITC) President & CEO Gloria O'Neill dedicated staff time to work with service providers from various fields to develop recommendations for state action to address sex trafficking in Alaska.  As a former Congressional staffer and policy analyst for CITC, I was tasked to guide the group.  Federal and local law enforcement and state juvenile justice officials provided technical assistance.  Sex trafficking is an overwhelmingly complex issue that requires multi-sector awareness and response.  According to the literature, vulnerability, often caused by trauma, particularly child abuse and neglect, is a significant risk factor.  Alaska has very high rates of trauma in the general population.  Six trafficking cases have been prosecuted in Alaska; however, concrete action towards prevention, victims' services, and demand reduction have been stymied by the paucity of data and research.  Our group found there was sufficient national and international research and examples of action from other states to guide the development of a basic framework for action in Alaska.  The legislature, which had just strengthened the trafficking statutes and created a temporary task force on the topic, was ripe for input.  Our final product included a background report, a plan of action, and recommended statutory changes.  More than half of our group's recommendations were included in the State Task Force's report to the legislature, and some, such as a comprehensive approach to demand, and new funding for prevention and services were left out.  However, our work effectively framed the issue for policy makers and service providers in Alaska.  Recognizing our work and its impact, FBI staff has nominated CITC for the FBI Director's Community Leadership Award [Lisa Moreno, MSW]."

Because It Was the Right Thing To Do:  Reflections – "I don't remember much about the salary – in the mid-'70s we almost had psychologists paid on the same state schedule as physicians.  I believe the Director of the Department of Health did not really know the difference between psychologists and psychiatrists.  I also recall that his daughter was a psychologist.  At one point he ordered the state hospital to close one of the wards for patients for security.  The hospital did not want to do that.  I later called him to personally say 'thank you' since we were having trouble with the patients sent from the prisons and courts.  Apparently he was very grateful for the support and when the position came open as head of Mental Health he thought of me.  It went fairly well for almost two years when the hospital called me and told me not to renew the contract for one of the psychiatrists.  He was foreign trained and was messing up the medication orders.  So much so that another psychiatrist had to follow him to correct his orders.  I did not recommend the renewal.  A few days later the Director called me in and told me we had to renew the contract.  I told him the problem and explained we couldn't afford to do it.  I found out later that his family had given $20,000 to the Governor's election.  In any case, I told the Director again that the records were clear and my answer was 'no' and that just in case someone tried to change the records, I had taken a copy home with me.  I then walked out of the office and said to myself, 'I think I just resigned.'  I was right and the next week he appointed a psychiatrist to the position.  I was tempted, but never did ask my successor what he did about it.  I assume he renewed the contract.  Jobs like that are too closely related to politics for me.  I went back to my old job until '95 [Joe Blaylock, first psychologist to be appointed as the head of the Mental Health Division of the State of Hawaii]."  Aloha,

 

Pat DeLeon, former APA President – Hawaii Psychological Association – December, 2013

 

TRULY UNCHARTERED WATERS

As the nation's health care leaders anticipate the expanding implementation of President Obama's Patient Protection and Affordable Care Act (ACA), there have been increasing concerns raised at both the state and federal level regarding the availability of qualified health professionals to address the complex behavioral, mental health, and substance-use treatment demands that are expected.  Building upon the current Medicaid system, the ACA will provide for the largest expansion of mental health and substance-use coverage in a generation, with 32.1 million Americans gaining access to these services, while another 30.4 million currently with some coverage will gain federal parity protection.  Under the law, insurance offered in the new marketplace must cover a core set of "essential health benefits," which includes mental health and substance-use disorder services.  As we now move towards integrated systems of care (Accountable Care Organizations (ACOs) and Medical Homes, for example) a critical question surfaces: Does there exist today sufficient numbers of psychologists, doctors of nursing practice (DNPs), and other traditional mental health providers trained to fill this niche, or will other disciplines (such as clinical pharmacists, occupational therapists, or newly evolving behavioral health care providers) expand exponentially into this unchartered arena?  And, are our training programs even aware of the changing behavioral health care environment?

Creative Models:  Since early 2000, visionary and former APA President Nick Cummings has called for the development of an entirely new training model of Behavioral Care Providers, who would work side-by-side with the patient's designated primary care provider.  Today such a program is actively underway at Arizona State University/Mayo Rochester School of Medicine, granting the Doctor of Behavioral Health (DBH) degree and focusing upon the emerging field of integrated behavioral health.  The classes are all online, with individual supervision also online.  There is two-way internet capacity.  The program makes arrangements for field placements in each locale for each student.  They have had absolutely no difficulty in placing students, and over half the placements hired the students, upon their receiving their degree, to create or expand an integrated program in their system.  The Nicholas A. Cummings Doctor of Behavioral Health program has slightly over 300 students, with 19 full-time faculty and 37 part-time faculty.  It is online all over the U.S. with several students being abroad in England, France, Germany, Malaysia, and Dubai.  The students come together in Phoenix twice a year; each time for a week.  Five of the graduates are now CEOs of large health care systems.  Nick's title is appropriately "Founding Sponsor," reporting directly to the University President.  It is perhaps unique in combining evidence-based interventions for integrated behavioral health, behavioral entrepreneurship, and management and accountability for clinical and cost outcomes.  Nick recently received word from China that they now have an affiliation with Jinan University, the largest university in China, which is affiliated with 10 smaller universities in the region.  They will become one of the largest, if not the largest, in the category of U.S. universities applied clinical/management education and training programs in China.

At this year's Illinois Psychological Association (IPA) annual convention, under the Presidency of Beth Rom-Rymer, Keith Baird described his vision for Behavioral Care Providers.  "A consortium of behavioral care providers is forming in Illinois, Behavioral Care Management (BCM), aiming to become a large-scale organizer of behavioral care which will negotiate contracts with ACOs and others.  Our developing network will have psychiatrists, psychologists, social workers, licensed clinical professional counselors, marriage and family therapists, and addiction specialists working collaboratively to deliver a new healthcare product to the marketplace.  We aim to lower health care costs by providing ease of scheduling with our behavioral care providers.  We will offer prevention and wellness services to the 'lives' that we cover, as well as promote access to our ever growing internet library resources.  This is geared to reduce the occurrence of various healthcare problems.  In addition, 40 BCM providers are completing their certification in integrated behavioral care through the University of Massachusetts.  We will offer behavioral care solutions to patients with chronic medical conditions that have a behavioral component, such as type II diabetes, high cholesterol, high blood pressure, obesity, and other stress-related health issues.  We are also working hard to deliver competitive reimbursement rates to our providers for the traditional services of psychotherapy, psychological testing, consultation, and pharmacotherapy."

Interdisciplinary Training:  Although the ACA envisions interdisciplinary, integrative, and collaborative training and service delivery initiatives, at the operational level this is much more difficult to accomplish than one might imagine.  Breaking down historical educational silos takes time and high level administrative commitment.  Educational institutions may have "different tuition rates" for courses taught, for example, in law vs. psychology; and, different disciplines may be on different quarter or semester schedules even within the same health sciences center.  Overcoming such institutional barriers and resistance is definitely a challenge.  However, we can assure you that it is well worth the effort.  Since retiring from the U.S. Senate staff, I have had the pleasure of serving on the faculty of the Uniformed Services University of the Health Sciences (USUHS) of the Department of Defense (DoD) and fostering interdisciplinary training has become a high personal priority.  For ultimately, it will be in the best interest of the next generation of health care providers and their patients (i.e., "educated consumers").

A Personal View:  "I recently had the privilege to participate in a military deployment psychology course.  During this course, the majority of the students were psychologists.  This group dynamic was ideal to be able to communicate and get to know the unique psychologist role along with educating on my role, the psychiatric nurse practitioner.  As a student and professional it is vital to learn the different perspectives our colleagues have on the part psychiatric nurse practitioners play in the mental health arena.  Partaking in this course gave me insight on the need for educating our colleagues on what our scope of practice encompasses.  It also enabled me to put a different lens on and learn about the roles of the whole mental health team including psychiatrists, psychologists, and social workers.

"There were several topics discussed including the deployment experience, cultural considerations in the deployed environment, sexual assault, ethics, traumatic brain injury, provider sustainment, and more.  Each topic was of equal significance and essential to the military mental healthcare field.  A belief that exists embraces psychologists and social workers doing the therapy while the psychiatrists and nurse practitioners prescribe medication.  A part of this course was designed to teach a therapeutic modality, including cognitive behavioral therapy for insomnia and either cognitive processing therapy or prolonged exposure therapy.  This section validated that although nurse practitioners are able to prescribe medications, we are also able to do therapy.  More importantly, we learned how to do these therapies in the deployed environment.

"Another captivating topic discussed during this course was technology in the mental healthcare field.  Technology is constantly evolving and has become integrated in patient care.  As providers, we must stay up to date with technology to deliver the most comprehensive care to our patients.  We learned about virtual worlds to treat disorders such as posttraumatic stress disorder, and mobile apps to guide patients with relaxation techniques and deep breathing exercises.  The lines of which provider was able to deliver the best technological care between different mental health professionals were erased, and together we were taught a treatment option in providing the greatest care for our patients.

"I am looking forward to graduating and working with my mental health colleagues from every path of the academic world.  Being able to participate in a course designed for our fellow psychologists is an imperative step in working as a team.  This team will help provide the best care for those who defend this nation and their families.  We must be able to utilize every specialty and communicate efficiently within our field to deliver healthcare at its finest [Bethany Casper; Capt. USAF]."

            The IOM:  The Institute of Medicine (IOM) was established in 1970 to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public.  Acting under the Congressional charter granted to the National Academy of Sciences in 1863, it serves as an advisor to the federal government and upon its own initiative, identifies critical issues of medical care, research, and education.  This year psychology was extremely well served by the election of APA CEO Norman Anderson to this distinguished body.  This fall, the IOM Board on Children, Youth, and Families convened top experts from multiple disciplines to analyze the best available evidence on critical issues facing children, youth, and families today.  Considered perspectives were elicited from the biological, behavioral, health, and social sciences fields focusing upon the entire lifecycle of our nation's families.  Psychologists Gary Evans, Ann Masten, Pamela Morris, and former Sesame Street CEO David Britt serve on the board.  Kimber Bogard, also a psychologist, serves as staff director.

            Having worked on Capitol Hill for nearly four decades, one of the most intriguing presentations personally was that by the Director of the Washington State Institute for Public Policy, the nonpartisan research arm of the Washington State legislature.  At the request of the legislature, the institute provides detailed cost-benefit analyses on a wide range of public policy areas.  This would include, for example, legislative proposals to reduce crime, improve educational outcomes, reduce child abuse and neglect, improve mental health, and reduce substance abuse.  Express dollar consequences (costs and benefits) were assigned to various proposed preventive efforts, such as encouraging nurse practitioner home visits, over the lifetime of the program and its beneficiaries.  It reminded me of the Office of Technology Assessment (OTA) which from 1972 to 1995 provided a similar non-partisan perspective for the U.S. Congress.  The overarching theme for that segment of the meeting during which the institute director presented focused upon family based preventive interventions which reflected the critical role that the family unit can play as a key mediator for child health outcomes.  The overall panel:  * Examined science that highlights the effect of the family on child health outcomes;  * Assessed how family-based interventions could be brought to scale to sustain positive child health outcomes;  * Considered the implications of benefit-cost analysis of these interventions for public policy;  and, * Explored how the board could advance family focused science and evidence based policy to promote children's' health, safety, and well-being.  One of the underlying questions discussed was: How to "scale-up" those initiatives that were demonstrated to be effective in order to impact the largest possible beneficiary population?  An indication of the national impact the board's deliberations can have was the considerable publicity generated by the release of its subsequent recommendations addressing sports-related concussions in youth, from elementary school through young adulthood, including military personnel and their dependents.

            An Earlier IOM Report:  The critical contribution of interprofessional collaboration to quality care has been known for decades.  In 2004, the IOM released its report entitled Improving Medical Educationfor which psychologists Eugene Emory and Neil Schneiderman served as committee members.  "There are a number of compelling reasons for all physicians to possess knowledge and skill in the behavioral and social sciences.  Perhaps most important is that roughly half of the causes of mortality in the United States are linked to social and behavioral factors [citing HHS reports from 1993 and earlier].  In addition, our nation's population is aging and becoming more culturally diverse.  Both of these trends highlight the need for enhanced physician capabilities in the behavioral and social sciences."  The committee found that there was very little literature on either barriers to the inclusion of the behavioral and social sciences in medical school curricula or strategies that might be employed to overcome such barriers.  However, it was definitely felt that the importance of an institutional commitment to behavioral and social science instruction cannot be overemphasized.  That without a firm belief on the part of the medical school faculty and administration, that this knowledge and skill is an important part of a physician's education and training, their recommendations would be ineffective in producing change.

            The committee further noted that the then current structure of American medical education was adopted in the early 1900s and had not varied greatly since that time.  The basic sciences – anatomy, physiology, biochemistry, and microbiology – were introduced as a scientific foundation on which clinical practice knowledge and skills were built.  In addition, the introduction of clinical science in the context of a university constituted a significant shift from a community practice-based, apprenticeship model of preparation for careers in medicine to one in which clinical medicine was taught by full-time faculty in a university-owned or university-affiliated teaching hospital.  Over the years, however, shifts have occurred within the basic structure of medical education, including those related to learning techniques.  Today, one hears more and more, for example, about the movement from passive learning through lectures to more active learning utilizing problem-based curriculum and most recently, the increasing utilization of technologically oriented simulation models.

            Exciting Journeys:  "GOLEM HAUNTS HARVARD – There's nothing like a high school or college reunion to focus attention on the reality of aging.  I recently attended the 40^th reunion of the Harvard and Radcliffe Class of 1973.  Name badges were critical to identifying classmates whose 20 year old faces had morphed into those of older adults in the foothills of traditionally defined 'old age.'  Unease about the march of time was evident in aging-related joking by classmates about memory and diminished loss of physical vigor.  A class discussion about research on aging was well-attended and provoked informal discussions about what each of us might do to make our later years personally, financially, and socially meaningful.  As a geropsychologist with 35 years in the field of aging, I shared my own personal and professional perspectives on aging with my classmates that emphasized the resilience of most older adults in contending with late life challenges.

"Skepticism from my classmates about what was seen as an overly rosy view of getting older was not unexpected.  Social expectancy research well demonstrates that most individuals acquire negative expectations about the aged and aging throughout their lifetimes.  Negative expectations about old age can be self-fulfilling prophecies.  As a psychology undergraduate, I remember reading Robert Rosenthal's Pygmalion in the Classroom in which he documented that simply by telling teachers that they should expect good performance from a class of students, those students, in fact, subsequently evidenced good performance.  The 'golem effect' is that low expectations lead to low performance.  It would be sad if my classmates – who are among the best and brightest of their generation – lived their later years under the shadow of golem and deprived themselves of the satisfactions that the later years can bring" [Greg Hinrichsen, APA Congressional Science Fellow (2007-2008) served with U.S. Senator Ron Wyden].  Rod Hammond, former Director of the Division of Violence Prevention, Centers for Disease Control and Prevention (CDC), was recently elected to the Berkeley Lake, Georgia, City Council – "I am failing the retirement thing! (Smile)."  Aloha,

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

 

THE FUTURE DEPENDS UPON WHERE ONE STANDS

  The enthusiasm for the future which was so palpable among the Early Career attendees at our recent Honolulu convention was similarly evident within that subset of the approximately 325 participants this Fall at the Illinois Psychological Association (IPA) annual convention, "Advocating for Psychology and Our Community: The Time is Now."  There can be little question that the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA) will bring unprecedented change to our nation's health care environment.  The law envisions educated consumers (i.e., patients) taking responsibility for their own health care, including capitalizing upon the advances occurring almost daily within the communications and technology fields.  We will gradually transform from a fundamentally illness-oriented approach to one which places a priority upon prevention, wellness, and data-based care that emphasizes holistic, interdisciplinary, and integrated services.  Educational institutions will have to carefully consider whether they are really exposing their students to healthcare information and experiences (e.g., nutrition, exercise, resilience, etc.) or are they merely reinforcing an illness-oriented status quo that is comfortable.

Building upon the current Medicaid system, the ACA will provide for the largest expansion of mental health and substance-use coverage in a generation, with 32.1 million Americans gaining access to these services, while another 30.4 million currently with some coverage will gain federal parity protection.  Under the law, insurance offered in the new marketplace must cover a core set of "essential health benefits," which includes mental health and substance-use disorder services.  Within this overarching federal framework, the implementation process now moves to the individual state level.  Historically, unfortunately, organized psychology has been less than enthusiastic about serving the Medicaid and Medicare beneficiary populations.  Change is always unsettling and takes time, often far longer than one might initially expect, especially fundamental change.  Today's practitioners will undoubtedly experience significant "pain" as the projected changes are steadily implemented.  The next generation, however, will thrive – as long as the field of psychology remains relevant and continues to attract "the best and brightest."  The ACA provides significant challenges and for those with vision, exciting opportunities.  Especially, we would suggest, for those with an underlying commitment for serving society.

IPA's Call to Action:  "Why am I such a strong proponent of advocacy for ourselves, as psychologists?  Because if we don't advocate for ourselves, who will?  We advocate for ourselves because we identify ourselves in the world as psychologists.  We as individuals feel more empowered when we stand up, publicly, and declare that psychologists can make a difference in the world: with our patients, in the business and corporate world, in community agencies, in the criminal justice and civil litigation system, in government, in medicine.  How do we advocate for ourselves?  We develop a statement of purpose and a rationale.  We talk to friends and colleagues and we sign up a core group of interested people, who will hopefully become a group of highly enthusiastic, fervently committed, deeply engaged, inner circle people!  We figure out a plan for implementation.  Why should we advocate for others?  Because we are not solitary figures in our world.  We depend on others and others depend on us.  Because we are compassionate in the face of suffering.  We advocate for others because, as we strengthen others, we strengthen ourselves.  Today, we help others.  Tomorrow, others help us.  Insularity is suffocating.  Personal gain only is short-sighted and limiting.  We live in an interdependent world where there is knowledge and richness in diversity and pallor in sameness.  Why must we advocate, now, for our community and our profession?  There is no time to lose.  Our national healthcare system is at a critical juncture.  Hundreds of thousands of new patients will join the state Medicaid rolls as of January 1^st.  Approximately 250,000 of them will be diagnosed with a mental illness.  Our mental health system is not equipped to care for these new patients.  We, as psychologists, can make a difference and it is up to us to be at the forefront of change in the ways in which mental health care is delivered in our state.  Obtaining prescriptive authority is a critical step.  Either we rise to meet the challenge of our society's healthcare crisis or we run the risk of getting swept away by the incoming tide of change.  There is no other time but now [IPA President Beth Rom-Rymer]."

The Illinois Psychological Association prescriptive authority legislation (RxP), after considerable open and public debate, passed their Senate by a vote of 37-10-4.  Their chief Senate Sponsor is Don Harmon, the President Pro-Tem of the Senate.  With their lobbyists, IPA's leadership made the critical strategic decision to spend the next 12 months educating psychologists and legislators around the state on RxP issues, rather than immediately press for a House vote.  Theirs is a two year legislative session.  As always, "we live in interesting times."

            The Educator's Voice:  "We don't hear nearly as much about RxP in APA as we once did.  I think the combination of a long lull in getting bills passed, combined with continuing criticism of RxP by what turns out to be a pretty tiny group, has taken some of the wind out of the sails.  Sometimes these days when we're talking about planning for the future of the profession, RxP feels to me a little bit like your crazy Uncle Alfred.  Everybody knows it's still around and going strong, but you're not supposed to mention it in polite company.  It's too bad, because instead we should be celebrating the accomplishments of our prescribing psychologists.  We have several who have been decorated by the military.  We have brethren who have joined the Indian Health Service (IHS) for the opportunity to work in truly disadvantaged communities.  We have prescribers in Federally Qualified Community Health Centers and in Cancer Care Centers, and who have been deployed to help in major disasters.  We should be proud of our 20+ year record as a prescribing profession, not making believe it's not there [Bob McGrath, Director of the Fairleigh Dickinson University Clinical Psychopharmacology and Integrated Primary Care programs]."

A Voice from The Past:  "Volunteering is a wonderful vehicle for professional and community service.  In retirement, the opportunities abound.  Volunteering has afforded me many opportunities to find satisfaction and fulfillment in giving back to others.  My experience volunteering in the community during my 'retirement' has given me a wonderfully fulfilling life outside of psychology.  In Columbia, South Carolina, I deliver Meals on Wheels, exercise special needs dogs at Howlmore Animal Sanctuary, and teach line dancing.  I have also coordinated group service opportunities through my church to persons who are homeless.  I was recently honored to be the first 'runner up' for a national volunteer award given by the Meals on Wheels Association of America.  I endorse Marian Wright Edelman's belief that 'Service is the rent we pay for living.'  It has made retirement 'golden' for me, and many others [Mike Sullivan, former NYSPA President and APA State Advocacy guru for 13 years]."  Aloha,

 

Pat DeLeon, former APA President – NYSPA – November, 2013