PERSERVERANCE AND SPIRIT HAVE DONE WONDERS IN ALL AGES

The Importance of "The Bigger Picture":  Over lunch in the Uniformed Services University of the Health Sciences (USUHS) cafeteria, Kevin McGuinness recently discussed with several nursing doctoral students the importance of appreciating the "bigger picture" for those wishing to become actively involved in health policy.  A former military Service Member and now an officer in the USPHS (and a national leader in the federal RxP movement), Kevin's personal goal is to see mental health addressed with the same urgency as physical health within the federal system and for psychology to be understood as a primary weapon in the armamentarium of public health, capitalizing upon its cost-effectiveness when integrated within primary health.  Kevin consistently emphasized the necessity of taking a broad holistic view of "health care," including the context in which one works.  Looking around the room, it became evident that the historical emotionally charged battles over the possible "purple suit" identity of uniformed Defense health care providers really represented concerns of the past.  Here were nurses and other health care disciplines, selected from each of the Services, learning and socializing together.  That afternoon he would address our health policy class, attended by nursing and psychology students – reminding us that integrated, interprofessional training is one of the hallmarks of President Obama's Patient Protection and Affordable Care Act (ACA).

Moving Away From Isolated Silos:  During its deliberations on the Fiscal Year 2014 Appropriations bill for the Department of Defense (DoD), the Senate Appropriations Committee addressed the importance of DoD working collaboratively with the Department of Veterans Affairs (VA) on behalf of their beneficiaries.  "While the DoD and VA may have different missions, they are bound together in a mutual mission to support those who have served in the defense of the country.  Over the past several years, collaboration between the Departments has significantly increased and the number of joint projects and services has expanded.  The Committee applauds these efforts and believes that future information sharing between DoD and VA must strengthen in order to ensure a seamless transition from active duty and timely access to VA benefits.  Nowhere is this more evident than in the transmission of service treatment records from DoD to VA.  These records are essential in the VA's process of making accurate and timely determinations of benefits to which a veteran may be entitled….  In October 2010, DoD and VA established a first-of-its-kind partnership with the opening of the Captain James A. Lovell Federal Health Care Center [FHCC].  This is a fully integrated Federal healthcare facility that serves Active Duty military, their family members, military retirees, and veterans.  The Committee continues to support the pilot program at FHCC and believes it will produce valuable lessons that can be used to expand future collaboration between DoD and VA hospitals as well as produce substantial savings to the taxpayer by combining the two healthcare systems where practical."

            Earlier this year, VA announced its partnership with Kaiser Permanente to pool resources and ideas to solve some of the largest and most complex challenges in VA health care.  The Secretary: "VA is always on the lookout for opportunities for partnerships with the private sector and other federal agencies to enhance care for Veterans.  We are proud to partner with Kaiser Permanente for the health and wellbeing of our Nation's Veterans."  It is expected that this joint effort will enable more effective research and sharing of best practices, focusing initially on four areas: Telehealth and virtual care; Genomics; Care of Veterans who are members of Kaiser Permanente; and Advanced analytics to use large data sets and population management with appropriate patient privacy protections.  The two systems expect to develop recommendations for how to design care using advanced analytics and technologies, as well as research.  This is building upon a 2010 agreement in which the two organizations launched a pilot program to exchange medical data using the Nationwide Health Information Network.  That project allowed clinicians from both organizations to obtain a more comprehensive view of a patient's health record using electronic health record information, including information about health issues, medications and allergies; while ensuring privacy and confidentiality.  An expressed goal is to increase ease of access and quality of services.  With over 8 million enrollees, VA operates the largest integrated health care delivery system in the nation.  We would be interested in learning whether VA is negotiating similar agreements with Federally Qualified Community Health Centers, which are the true "safety net" for many Americans, particularly in rural America where a number of veterans reside.

            The Importance of Investing in Prevention:  Several of the lessons which Kevin shared are: * Change takes time, often far longer than one would initially expect.  And, * Those establishing policy often focus upon the immediate crisis, rather than investing in prevention in order to avoid future crises.  A graphic example: Today, the nationwide epidemic of obesity is a high priority for the Obama White House.  However, in 2007 the RAND Corporation proclaimed: "America appears to be in the midst of an obesity epidemic.  Should we care?"  Obesity in the U.S. had been increasing steadily over the past two decades – with severe obesity increasing the fastest.  Obesity translates into higher health care costs (more than smoking or drinking) and contributes to disability at all ages.  It was apparent that traditional clinical approaches, in particular bariatric surgery, could not slow the trend.  Medicare and Medicaid savings stemming from increasingly good health among the elderly could be swamped by the cost consequences of disability among the young.  More than one in five U.S. adults were then classified as obese based on self-reported weight, and almost one in three based on objectively measured weight.  Compared with their normal-weight counterparts, the obese spend 36% more on health care services and 77% more on medications; the comparable numbers for current smokers are 21% and 28% respectively, and less for problem drinkers.  Severely obese people are more than twice as likely to be in fair or poor health and have about twice as many chronic medical conditions.  For men, severe obesity is associated with a 300% increased probability of having limitations on basic activities of daily living; for women, the effects are even larger.

Another RAND study that year found: "When it comes to getting the right care at the right time, children in this country fare even worse than adults."  They are not receiving recommended preventive care and screening services, such as regular weight and measurement checks to ensure they are growing properly and not at risk for obesity.  Foreshadowing another one of Kevin's policy messages: * Neighborhoods exert a powerful effect on residents' physical activity and thus neighborhood design should be considered a public health issue.  Girls pose a particular concern because their physical activity is known to decrease as they progress through adolescence.  "Obesity is the most serious public health problem confronting America today."  Testifying before the Senate Appropriations Committee in 2012, U.S. Army Major General Jimmie Keenan noted: "In America, we in DoD spend an average of 100 minutes each year with our health care team.  The other 525.500 minutes of the year our patients are not with us – the same amount of time our environment influences the behaviors that determine our health occur."  The psychosocial-cultural-economic gradient of health care is absolutely critical.  Public service psychology and advanced practice nursing must embrace their professional responsibility of addressing broad public policy/public health issues in order to be effective in the long run, including focusing upon and advancing wellness, patient responsibility, and environmental risk factors.

            The National Institute on Minority Health and Health Disparities (NIMHD) (NIH):  The Fiscal Year 2014 budget request for NIMHD was $283.3 million.  Its fundamental mission is to lead scientific research to improve minority health and eliminate health disparities.  Cognizant of the potential of science and the multiple factors and related issues that underlie health disparities, NIMHD's approach to achieving this mission is embodied in building a broad-based coalition of partners across multiple disciplines and sectors.  Although the U.S. has seen recent improvements in the overall quality of care, stark disparities in health quality and access to care persist in many communities, as well as pervasive differences in health between groups around the country.  Increasing evidence-based research findings continue to underscore the complex interplay of factors such as race, ethnicity, social, economic, geographic, environmental, genetic, and behavioral influences across the life-course that contribute to the early onset of disease, the aggressive progression of a disease, and to premature death.  In particular, Translational Science and Recruiting and Retaining Diverse Scientific Talent and Creativity are foundational aspects of the Institute's efforts to eliminate health disparities.

The approach of the NIMHD health disparities programs is to examine the causes of health disparities; integrate science, practice, and policy approaches to address health disparities; provide a platform for academic institutions to conduct research and support the training of a diverse workforce; offer a vehicle to build community research capacity, study national and global patterns of health disparities; and advance the translation and dissemination of research results.  The elimination of health disparities requires a transdisciplinary evidence-based approach, which incorporates efforts to promote translational science to ensure that the benefits of scientific discoveries reach those most affected by health disparities.

            A series of community health reports resulting from NIMHD-funded research reveal that social, economic and environmental conditions of low-income and non-white neighborhoods in some U.S. counties can project who is sick, healthy, and will live longer.  The results of these reports have policy and practice implications as it relates to the systems and structures that contribute to health disparities.  In another study utilizing quantitative and qualitative methods to study racial/ethnic disparities in early life risk factors for childhood obesity, researchers will study several factors.  Including, for example, the extent to which maternal experiences of two chronic stressors, racism and interpersonal violence - before and during pregnancy – are of significance.  It is felt that there is a unique and compelling need to promote diversity in the biomedical, behavioral, clinical and social sciences research workforce.  Thus, enhancing workforce diversity is a priority.  We would suggest that many of those who receive care from the Division's membership could benefit from NIMHD's vision.

            He Never Drank Water.  He Always Drank Wine:  It has been fascinating to hear from colleagues of different disciplines describing their post-retirement experiences.  Some wistful; some exhilarating.  "I still feel that I have something to share and pass on.  The desire to teach and educate this upcoming generation of health care professionals is strong.  I am applying for another opening at…."  "I decided to end my job search.  I am getting older, and there is age discrimination.  I accept it.  So I am cobbling together consultancies and subsidizing the payers.  I am frugal; so far I am making it.  Not to worry, I am doing fine!  It is what it is."  Two other colleagues with extraordinary professional backgrounds described trying unsuccessfully to join the Peace Corps, even though both were in excellent physical and mental health.

And at the same time, "I am retired from all things psychological thus not doing reviews anymore.  Priscilla and I are enjoying retired life in central Virginia, especially the increased family time.  Lunch in C'ville yesterday with an old friend.  Lang Lang concert last night in C'ville (incredible performance!!).  Breakfast at our house this morning with our daughter and son-in-law who live here.  They brought the homemade muffins, we fixed the rest.  UVa women's basketball game this afternoon with friends (we have season tickets).  Strategic planning committee meeting for me tomorrow for our neighborhood association (750 homes), and couples bridge on Tuesday night at our country club.  Staying busy.  It's a good life [Ludy Benjamin]."  Times are changing as today's generation of senior colleagues steadily departs from their prior, in retrospect predictable professional lives.  Former Division 18 President Jacqueline Wall recently sensed what is perhaps a fundamental shift in perspective: "Just so you know, I have received 20 nominations for President-elect.  Most people say that they are too busy to assume the responsibility.  It makes me wonder if the nature of our work has changed so much that people are beginning to protect their time to the point of decreasing involvement in anything that isn't obligated by an employer or for which compensation is given.  I mentioned the other day that when I started, the standard organizational practice was 50% patient contact time.  I'm hearing now that my colleagues are in direct patient care 80-90% of the day; leaving little time for things like writing reports, making phone calls, answering e-mails, etc.  Gives one pause and makes me think we'd best rethink how we do things."  If I'd bet on ol' Stewball, I'd be a free man today.  Aloha,

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

 

ADDRESSING SOCIETY’S NEEDS

Former APA Practice Directorate State Association Guru Mike Sullivan truly appreciated the importance of our state associations providing creative leadership in bringing psychology's expertise to focus upon society's most pressing needs.  As educated professionals, this is our societal responsibility.  "Heads Up Kentucky" was an enjoyable, highly visual effort to promote healthy lifestyles on the local level.  It effectively asked if residents knew that: "Stress is linked to the six leading causes of death: heart disease, cancer, lung ailments, accidents, cirrhosis of the liver, and suicide."  The Hawaii Psychological Association recently highlighted Gaby Toloza's collaborative efforts with the Hawai'i Autism Foundation and local YMCA to provide family centered support that focused upon the concept of Self-Care for the Caregivers of children on the autism spectrum.  For eight Saturdays, these families participated in two hour workshops with their children, including siblings.  A number of HPA members donated their time and expertise.  The second hour was targeted towards engaging the participants in physical exercise.  The goal being to behaviorally embed the need and benefits of physical exercise for parents with special needs children.  It was a very successful event with the parents gaining a greater awareness of their own need for self-care.

            As a nation, we are entering a new era of transformative health care reform.  The unprecedented advances occurring within the communications and technology fields, as well as the priorities of the Obama Administration reflected in the Patient Protection and Affordable Care Act (ACA), indicate a future of patient-centered care with a priority on prevention, wellness, and data-driven clinical decisions.  The advances occurring within telehealth (i.e., Telepsychology) will eliminate historical geographical and hopefully cultural barriers.  The VA and DoD have been leading the way.  In FY 2013 more than 600,000 Veterans received care utilizing telehealth – more than 1.7 million episodes of care.  Former Division 31 and Georgia Psychological Association President Linda Campbell and ASPPB CEO Steve DeMers have been proactively guiding psychology through these unchartered waters.  We suggest that this would be an excellent topic for our state associations to focus upon.  What are the laws, regulations, ethical issues, and supervision possibilities? -- while providing "hands-on" demonstrations, perhaps utilizing federal or state technology.  This could be in conjunction with other professions – another key element of the ACA.  And, of course, developing legislative agendas to provide critical reimbursement support.  There is a particular need for these services at Federally Qualified Community Health Centers, which are society's "safety net."

From our public policy perspective, nursing has historically been particularly responsive to addressing society's needs, especially throughout rural America.  Accordingly, we were pleased to participate in two conference calls during the past year in which the Administration requested their help in educating society about the benefits of ACA – Vice President Biden hosted the first; Secretary Sebelius the second.  Will psychology earn similar respect?  Aloha,

Pat DeLeon, former APA President – Division 31 – March, 2014

 

AN INTRIGUING GLOBAL PERSPECTIVE

APA Past President Don Bersoff recently took the wintery Amtrak Acela from Philadelphia in order to address my health policy class at the Uniformed Services University of the Health Sciences (USUHS), continuing his personal commitment to those who "place themselves in harm's way."  Our next generation of military psychologists and advanced practice nurses learned of his ROTC and Children Defense Fund experiences, as well as his service as an Air Force psychologist during the Vietnam War.  Reflecting upon his international travels during his Presidential year, Don described how the training models for psychology in the United States and around the world are of different lengths, and that this has led to collaborative efforts to tease out commonalities and essential competencies.  APA is very well respected internationally – as one quickly appreciates during our annual convention Opening Ceremonies.

            Earlier this year, the Institute of Medicine (IOM) released its report "U.S. Health in International Perspective: Shorter Lives, Poorer Health."  Our nation is among the wealthiest nations in the world, but it is far from the healthiest.  Although Americans' life expectancy and health have improved over the past century, these gains have lagged behind those in other high-income countries.  This health disadvantage prevails even though we spend far more per person on health care than any other nation.  The IOM panel which developed this report was struck by the gravity of its findings in reviewing data from 16 "peer" countries – other high-income democracies in Western Europe, Canada, Australia, and Japan.  For many years, Americans have been dying at younger ages than people in almost all other high-income countries.  This disadvantage has been getting worse for three decades, especially among women.  Not only are our lives shorter, but Americans also have a longstanding pattern of poorer health that is strikingly consistent and pervasive over the life course – at birth, during childhood and adolescence, for young and middle-aged adults, and for older adults.  This includes faring worse for injuries and homicides, obesity and diabetes, and disability.  Many of these conditions have a particularly profound effect on young people, reducing the odds that Americans will live to age 50.  For those who reach age 50, these conditions contribute to poorer health and greater illness later in life.

            The U.S. health disadvantage cannot be fully explained by the health disparities that exist among people who are uninsured or poor.  Several studies are now suggesting that even advantaged Americans – those who are white, insured, college-educated, or upper income – are in worse health than similar individuals in other countries.  No single factor can fully explain the U.S. health disadvantage.  For example, although individual behaviors are clearly important, they do not explain why Americans who do not smoke or are not overweight also appear to have higher rates of disease than similar groups in peer countries.  Without action to reverse current trends, the health of Americans will probably continue to fall behind that of people in other high-income countries.  Americans are dying and suffering from illnesses and injury at rates that are demonstrably unnecessary.  From a public policy and public health perspective, as a nation we can and must learn from other countries.  Over the years that I served on the U.S. Senate staff, I came to appreciate that two agencies in particular within the Department of Health and Human Services (HHS) have a significant international presence: The John E. Fogarty International Center (FIC) at the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC).  The Health Resources and Services Administration (HRSA) plays a smaller, but still significant role.

            The Fogarty International Center:  The Fiscal Year 2014 budget request of $72.864 million for the Fogarty Center provides an intriguing glimpse of potential opportunities for early career colleagues, as well as the ongoing HHS efforts to develop a comprehensive strategic approach for world-wide health care.  Director's Overview: From leading the call for an AIDS-free generation to developing vaccines and therapeutics for diseases that affect populations worldwide, the United States is a global leader in health research and scientific advances that improve the lives of Americans and people across the globe.  These discoveries are often made by U.S. and foreign scientists working in close collaborations that enable the best and brightest minds to tackle complex health challenges together.  The FIC therefore supports innovative training and research programs for U.S. and low- and middle-income country (LMIC) scientists that strengthen the research capabilities and catalyze the international scientific partnerships that lead to research discovery and improved health.  By investing in current and future leaders in global health research and strengthening the long-term capacity of research institutions to provide robust and sustainable platforms for cutting-edge science, FIC advances the goals and extends the leadership of the NIH and the U.S. government in science and research, while playing a vital role in building the capacity needed to successfully tackle critical health challenges.

*  Recruiting and Retaining Diverse Scientific Talent and Creativity.  FIC programs have supported long-term research training for over 4,500 scientists worldwide, in collaboration with over 230 U.S. and LMIC research institutions.  These investments provide unique training opportunities for early-career global health researchers, and aid in the retention of this diverse scientific talent in the research enterprise.  The Framework Programs for Global Health Innovation brings together teams of postdoctoral trainees from many disciplines to produce fresh insights into global health problems, and innovations for implementation in low-resource settings.  For example, a medical, engineering, and architecture team from Boston, South Africa, and Peru is receiving the training needed to design and validate effective, affordable prototypes for air disinfection that can help prevent airborne infections, such as tuberculosis and influenza, from spreading in low-resource settings.  The Medical Education Partnership Initiative, co-administered by HRSA, is transforming medical education and research training for medical students in 12 African countries utilizing e-Learning and resource-sharing to train the next generation of scientific leaders to solve their country's most pressing health problems – from HIV/AIDS to maternal and child health, and to non-communicable conditions, such as mental health and cardiovascular disease.

*  Translational Science FIC programs support researchers who are generating critical scientific evidence and applying this research to specific interventions, policies, and programs.  Infectious disease outbreaks from human and animal hosts post significant potential health and economic threats in the U.S. and other countries.  The Research and Policy in Infectious Disease Dynamics program – cofunded by the Department of Homeland Security – brings together senior infectious disease modelers and postdoctoral fellows to conduct the research and develop infectious disease modeling approaches that can help the U.S. and other policymakers plan for and respond to potential infectious disease threats.  These models have explored, for example, how the Avian Influenza can develop into outbreaks from an initial case and how these outbreaks can be controlled effectively.

*  Today's Basic Science for Tomorrow's Breakthroughs initiative supports catalytic basic biomedical and behavioral research that can lead to tomorrow's breakthroughs.  The FIC Brain Disorders program supports cutting-edge research in LMICs on nervous system development, function, and impairment throughout life – research that could lead to new diagnostic, prevention, and treatment strategies.  In India, grantees are exploring why Alzheimer's affects Indian populations less than populations in developed countries.  In Uganda, research is creating a base of knowledge on dementia in those with long-term HIV infection.

Future Challenges -- the need for sustainability poses a significant challenge for investments in global health research and research training.  FIC investments continue to evolve with increasing research capabilities in LMICs in order to build on successes and support the training of individual scientists and strengthen research institutions.  In addition, FIC will increase support for institutional networks and hubs for data collection and sharing.  When such sharing platforms are built around a core of trained individuals and strengthened institutions, they can effectively harness the different strengths of these institutions, and promote enhanced efficiencies and more robust, collaborative science.  FIC envisions that its U.S.-LMIC GEOHealth hubs will become global leaders in the collection, management, synthesis, and interpretation of data on environmental and occupational health, serving the larger multi-national regions in which they reside, as well as supporting research of great relevance to both these LMIC regions and the U.S.  In sub-Saharan Africa, universities supported are emerging as regional training centers and upgrading the technology to enable distance learning and resource-sharing among institutions.  This model is revolutionizing African medical education and research training by enabling partner institutions across Africa to pool their areas of expertise, sharing teaching tools, and ensure that all students receive the highest-quality instruction from the continent's best qualified faculty and researchers.  These efforts will ensure that the U.S. will continue to compete and lead in science.  The behavioral sciences have much to contribute to the underlying FIC mission.  The key question is whether psychology and nursing faculty appreciate their potential contributions and are they appropriately engaged?

Change Always Takes Time:  In March, 2005 then-HHS Secretary Michael Leavitt testified before the Senate Appropriations Committee:  "Influenza.  Since the H5N1 strain of Avian Influenza first appeared in 1997, public health officials have grown increasingly concerned about the possibility that a pandemic strain will emerge that could cause an additional 90,000 to 300,000+ deaths in the United States.  Avian Influenza has reappeared in Southeast Asia again this year, indicating that the virus has become endemic.  The FY 2006 budget continues to expand HHS's efforts to be prepared in the event this or another deadly influenza strain changes in a way that makes it easily communicable from person to person.  Since FY 2001, HHS has increased its direct expenditure related to influenza vaccine from $42 million to $439 million in FY 2006, in addition to insurance reimbursement payments through Medicare….  Increasing the use of annual influenza vaccinations will both reduce annual morbidity/mortality, and make the Nation better prepared in the event of a pandemic.  CDC estimates that 185 million people should receive annual immunizations – but fewer than half of that number have ever been immunized in a given year."  The vision of FIC's leadership continues to be most timely.  Secretary Leavitt also noted: "This year, for the first time ever, States spent more on Medicaid than they spent on education."

            Reflections For The Future:  ACA-- Coral Andrews served as the first Executive Director of the Hawaii Health Connector, the State of Hawaii's online health-insurance exchange that was established by the Hawaii legislature to implement President Obama's Patient Protection and Affordable Care Act (ACA).  A former Navy nurse, she reports her two years building the Connector has been among the most challenging and rewarding chapters of her health-care career – even providing the opportunity to speak directly with President Obama on a conference call.  She is currently a Regent for the American College of Health Care Executives (ACHE).  "Healthcare executive competencies in the era of healthcare reform reflect the confluence of shared industry expertise.  In this wake of social change, psychologists and advanced practice mental health nurses are positioned as core contributors in evolving organizational dynamics and multi-stakeholder policy formulation.  To establish a competency baseline, ACHE has published a tool entitled 'ACHE Healthcare Executive Competencies Assessment Tool, 2013.'  The tool serves as a resource for executives to use in assessing their expertise in core areas of healthcare management.  The application of the assessment allows it to be applied in diverse disciplines and settings.

There is a central role that psychologists and advance practice nurses may play in assisting organizations, leaders, diverse stakeholder groups and human resources professionals in the successful application of these competencies in an operational environment.  Human resources, for example, has historically been the primary industry responsible for human capital management in organizations.  However, the lines between human capital management and psychology/nursing as applied are blurred when discussing organizational psychology principles.  Human capital management within the human resources domain can include the administrative activities of payroll and benefits administration, but it also includes applied organizational dynamics.  Similarly, psychology and nursing span many different applications: clinical, behavioral, organizational, etc.  As I reflect on the preparatory implementation of the ACA and engaging in its post-implementation, I would suggest that psychologists and advanced practice nurses can be innovative in the contributory roles that they can play in the following: organizational readiness for change, integration with other disciplines, public-private partnership business models, and beyond that the innovation of tools that organizations can leverage for assistance beyond the in-person consultative services.  Is there a role that psychology and psychiatric nursing can play in developing online software for organizations that provides resources at varying price points?  We are working with the University of Hawaii to explore a healthcare executive graduate program.  The competency tool is a 'universal' resource regardless of discipline.  I suggest our next generation should be imaginative as they contemplate clinical acumen transported into this new era of reform.  They may be on to something….  "

"As I reflect on the ACA implementation in Hawaii, there are wonderful learnings that can be carried forward as implementation continues through the 'phase in' of ACA.  The learnings are only possible if the environment allows for an opportunity to comfortably mine for insights and to openly discuss them.  When implementing new policy, there is risk.  Risk should not be viewed as a negative but as an opportunity.  Managing risk is simply a part of achieving change and creatively pursuing innovation.  Hawaii has a rich culture that provides for a solid value base which serves as a beacon for consensus.  Given the policy debate in a multi-stakeholder environment, the host culture's values serve as the framework by which consensus can be guided… a baseline to go back to when policy discussions become spirited.  Passion for policy is a good thing provided the motivation behind it always leads back to purpose.  The purpose is to achieve long term value in the health of the population.  It requires a consumer oriented design as contrasted to an organizational, top-down design.  This methodology requires adjustments by leaders and policy makers as the human tendency is to design toward one's organizational advantage.  In a multi-stakeholder environment, everyone needs to put a 'marble in the circle' to achieve success.  It minimizes dominance and leans toward sharing wins and losses in order to achieve collective success.  A risk adverse culture can constrain the openness to reflect, evaluate, and learn especially if there are strong political influencers which can occur in an election year.  To leapfrog through change, an important starting point necessitates that individuals and organizational cultures evolve to embrace success as defined in a new way.  Implementing change is not indifferent to space exploration.  We need leaders who are willing to navigate through and be alert to the cognitive and behavioral responses to change.  Often, evolving to the future state is enabled when the people and organizations involved are supported with educational insights about how to change.  It does not come naturally for all but is an important skill and capability that is required to successfully achieve the optimal implementation of the ACA for long term value.  Implementing systems is the easy part.  Bringing the people, organizations and cultures along in support of, is where organizational psychologists and clinical nurse specialists can facilitate the process."

            VA -- Heather O'Beirne Kelly, who was born at Tripler Army Medical Center and whose grandfather was stationed at Pearl Harbor on that fateful September 7, 1941 morning, recently assumed APA's lead for military and Veterans policy, including coordination of APA-wide clinical and training activities related to DoD and VA, in addition to their research portfolios, as well as that of the National Science Foundation (NSF).  She sits on the Executive Committee of the Friends of VA Medical Care and Health Research Coalition (FOVA); represents APA on the VA Office of Mental Health Services Stakeholders Group; has testified before Congress regarding funding for VA research and mental health services; and has coordinated numerous Capitol Hill briefings on topics of interest to the Veteran population, including suicide prevention, PTSD, and traumatic brain injury.  She also directs APA's Executive Branch Science Policy Fellowship Program.

            Most recently, Heather has been advancing APA's Veteran-focused priorities on Capitol Hill through hearing testimony, meetings with Congressional staff, and intensive behind-the-scenes collaboration with several key offices particularly interested in Veterans' mental health care and research.  She worked to successfully include APA's language providing for psychologists' system-wide prescribing authority within the VA, increased collaboration between VA medical centers and local enforcement crisis intervention teams, and expansion of VA lethal means reduction for suicidal Veterans which are included in draft legislation proposed by Senator Patty Murray (D-WA).

            A graduate of Smith College, Heather has worked in non-profit development for clients including the Children's Defense Fund, UNICEF, and the March of Dimes before becoming director of corporate relations for Wolf Trap Foundation for the Performing Arts.  Her clinical internship was at Children's National Medical Center in Washington, DC.  Her interest in military and Veteran issues is longstanding; her father and both grandfathers were career military officers and her mother has worked for many years in military family policy.  Aloha,

Pat DeLeon, former APA President – Division 42 – February, 2014

 

 

THE NECESSITY OF APPRECIATING THE “BIGGER PICTURE”

 Evolving Reimbursement Priorities:  With the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA), our nation's health care environment and its underlying reimbursement mechanisms are undergoing unprecedented change.  The ACA places a high priority on developing patient-centeredsystems of care which will emphasize utilizing interdisciplinary teams of providers and capitalize upon the clinical potential of the advances occurring within the communications and technology fields.  Cross-patient and cross-population comparisons in real time, will allow for the development of data-based "gold standards" of care.  Providers will be held accountable for their clinical decisions and be expected to be knowledgeable about state-of-the-art protocols, resulting from clinical effectiveness research.  Educated consumers will be urged to take responsibility for their own health care.  Prevention, wellness, healthy lifestyles, holistic care (including diet, exercise, and relaxation) will be given increasing priority.  Reimbursement strategies will gradually move from encouraging procedures to rewarding wellness.

            The Centers for Medicare and Medicaid Services (CMS) recently approved the State of Maryland's proposal to continue setting hospital prices while adding an overall cap for all hospital spending, thereby limiting hospital spending growth to 3.58% per annum for the next five years.  This will occur largely by giving each of the state's 46 hospitals a firm budget to work within.  Since the mid-1970s, Maryland has been the only state in the nation to set the prices that hospitals charge patients – and not insurance companies.  The Governor: "We need to shift away from our near exclusive focus on treating illness, and move to a balanced approach that encourages prevention and wellness.  Such a shift will reduce costs for families and small businesses and will simultaneously keep many Americans from dying of preventable causes."  If successful, Maryland state officials plan on exploring ways to extend a similar approach to other parts of the health care system, such as doctors' offices and nursing homes.  This approach should be understood within the context of the Institute of Medicine (IOM) having consistently found that health care in our nation is more expensive than in other developed countries, costing $2.7 trillion in 2011.  And, at the same time, despite advances in biomedical science, medicine, and public health, health care quality remains inconsistent with underuse, misuse, and overuse of various services often putting patients in danger.  Most significantly, regions of the country that deliver more services do not appear to achieve better health outcomes than those that deliver less.

            Individual Involvement Makes A Difference:  For over two decades, working behind the scene, Tony Puente has been in the forefront of psychology's efforts to obtain administrative parity within Medicare.  About 16% of the Gross Domestic Product of the nation is health care.  And most, if not all, is associated with a nomenclature system called the Current Procedural Terminology (CPT).  This system has been developed by the American Medical Association (AMA) under license by the CMS.  It is a numerical system of 8,000 procedures that the federal government and most private insurance companies consider scientific and clinically useful.  The CPT essentially determines what health procedures can be done, how they should be documented, and how much they should be reimbursed.  The system is comprised of over 120 advisors from the health specialties in the U.S. (e.g., psychology and family practice physicians) who advise a voting Panel of 17 members which include CMS, Blue Cross/Blue Shield, and others.  Around 1990, psychologists had access to about 3-5 codes and over time, as psychology's scope of practice and scientific breakthroughs evolved, that number has increased today to over 50.  Though the majority of the codes are in the psychiatry (mental health) section, they are also now found in other sections that reflect more medical types of problems (e.g., brain injury, diabetes, etc.).  Tony has represented APA since the AMA opened the system to non-physicians in 1992.  In 2008, he was voted on to the Panel itself and now no longer represents APA.  Instead he is responsible for addressing all health proposals and has the same voting capacity as Medicare and Blue Cross/Blue Shield.  At the Panel's next meeting they will address 110 different proposals, with APA being represented by Norman Anderson, Randy Phelps, and Neil Pliskin (Tony's replacement).

            Serving The Community:  As highly educated members of society, we have a unique obligation to provide visionary leadership and personal involvement in effectively addressing our nation's most pressing needs.  Two impressive examples of such dedication, who were highlighted by President Don Bersoff at our Honolulu convention, are Barbara Van Dahlen for "Give an Hour" and Jon Nachison for "Stand Down."  The President of the American Psychiatric Nurses Association (APNA), Patricia Cunningham, noted for her membership that in the next five years, over one million Service Members are projected to leave the military.  Accordingly, she has initiated a Presidential Task Force on Military Mental Health.  "Helping to meet the mental health needs of Service Members and Veterans is a top priority for the mental health community."  She has charged her Task Force with developing a White Paper to inform the membership and the mental health community at large on actions they believe are appropriate for an evidence-based approach to military mental health.  A former USUHS colleague of mine, Commander (Ret.) Sean Convoy, will chair the Task Force.  "I believe that there are many across APNA's ranks that want to actively support military mental health.  The problem is, they don't necessarily know how or what to do.  The APNA White Paper can provide that necessary structure."  Psychiatric-mental health nurses representing all branches of the military will be working with the Task Force.  Their deliberations will build off First Lady Michelle Obama's Joining Forces Initiative and have an evidence-based orientation.

            The IOM recently released a very thoughtful report "Educating the Student Body: Taking Physical Activity and Physical Education to School."  Like most of us, children and adolescents in our nation have grown accustomed to a sedentary lifestyle.  The predictable result has perhaps been best crystalized by the proclaimed "Epidemic of Obesity."  Extensive scientific evidence clearly demonstrates that regular physical activity promotes growth and development in youth and has multiple benefits for physical, mental, and cognitive health.  Physical activity is related to lower body fat, greater muscular strength, stronger bones, and improvements in cardio-vascular and metabolic health; as well as improvements in mental health, by reducing and preventing conditions such as anxiety and depression and enhancing self-esteem.  There is also a growing body of evidence which suggests a relationship between vigorous and moderate-intensity physical activity and the structure and functioning of the brain.  Children who are more active show greater attention, have faster cognitive processing speed, and perform better on standardized academic tests than children who are less active.  A longtime colleague to whom I had the pleasure of presenting a special APA Presidential Citation, Colleen Hacker, has worked with several women's Olympic teams over the years.  Her American Psychological Foundation (APF) William Bevan Lecture enumerated in great detail the long term health, education, and employment benefits of active participation, especially for girls, in team sports.

Due to a number of issues, including constricting budgets and the federal pressure to raise standardized test scores through increased classroom contact time, schools today are increasingly challenged to provide sufficient time, resources, and supervision for adequate physical activity.  As a result, our nation's school systems present an unprecedented opportunity for psychologists and other mental health specialists to provide pro bono consultation on how to increase the likelihood of student and faculty engagement in meaningful physical activities.  This is, after all, a "people" problem – and one too important to ignore.  Similarly, another colleague at USUHS recently inquired that since there are 9,000 rural and urban communities served by Federally Qualified Community Health Centers, which under ACA must provide mental and behavioral health services, "Are your behavioral health colleagues providing pro bono anti-violence services for the families and youth these centers serve?"  Visionaries such as Rodney Hammond (retired from CDC) have developed effective teenage-oriented anti-violence programs.  Her fundamental question remains, however.  As a profession, is psychology and nursing aggressively bringing this evidenced-based expertise to fruition, where it is so clearly needed?

            Sincere Appreciation:  As I reflect upon my rather lengthy career within APA, several individuals from New Jersey immediately stand out.  Without the guidance and mentoring of Stan Moldawsky, Marv Metsky, Bob Weitz, and Gene Shapiro, I seriously doubt that I would have been so intimately involved within our association's governance and for such a long period of time.  During my Presidential convention, Stan's band was a highlight at our Union Station "blast."  I have also had the pleasure of serving on the APA Board during Dorothy Cantor's exciting year and subsequently with her on the extremely visionary APF Board.  One of my fondest policy memories was hearing the staff director for New Jersey Senator Pete Williams say that the Chairman had directed him to include psychology in the Federal Workers' Compensation statute after listening to Gene's testimony.  Involved individuals do make a very real and lasting difference.  Aloha,

Pat DeLeon, former APA President – New Jersey Psychological Association – February, 2014

 

A NEW ERA – THE PAST IS PROLOGUE

  In April, 1974 Marc Lalonde, your Minister of National Health and Welfare, released his visionary report "A New Perspective on the Health of Canadians."  Four decades later, one can appreciate that from a health policy perspective he foresaw the potential contributions of psychology to the health and well-being of society, more clearly than most elected officials and health care professionals.  "Past improvement has been due mainly to modification of behaviour and changes in the environment and it is to these same influences that we must look particularly for further advance."  "When the full impact of environmental and lifestyle has been assessed, and the foregoing is necessarily but a partial statement of their effect, there can be no doubt that the traditional view of equating the level of health in Canada with the availability of physicians and hospitals is inadequate."  In 1979 the U.S. Surgeon General's report "Healthy People" proffered: "Prevention is an idea whose time has come.  We have the scientific knowledge to begin to formulate recommendations for improved health….  In fact, of the 10 leading causes of death in the United States, at least seven could be substantially reduced if persons at risk improved just five basic habits…."  Integration of psychology within primary care is essential.  Former APA President Nick Cummings reported that in the usual primary-care health system, physicians identify about 40% of their patients as needing some form of mental health treatment, but less than 10% actually see a mental health provider.  However, when a physician can just walk a patient a few steps down the hall to a psychologist's office, he found that 85% to 90% who needed psychotherapy, and are so walked down the hall, enter treatment.

            Times are definitely changing.  Cynthia Belar, Executive Director of the APA Education Directorate, has been alerting our educational community to the importance of the next generation being active participants within health caresystems.  Team based collaborative care (which requires interprofessional competencies), accountability (which requires skills in quality improvement and assessment of patient outcomes), a population based perspective (which requires an understanding of public health), etc. are skills which must be in the psychologist's toolbox.  President Obama's landmark Patient Protection and Affordable Care Act (ACA) encourages the development of patient-centered, integrated systems of care in which data-driven clinical decisions will become integral to "quality care."  Interdisciplinary teams will replace solo practices.  Health information technology (HIT) infrastructure allowing cross-diagnostic and cross-provider comparisons will be developed.  Cynthia's public health/population-based emphasis will be increasingly utilized in establishing programmatic priorities; as will capitalizing upon the potential in the unprecedented advances occurring within the communications and technology fields (i.e., telehealth services, virtual reality consultations, and active patient engagement).  Prevention, wellness, and family-oriented care will be the priority.  The "gold standard" of care of tomorrow will be based upon findings from competitive effectiveness research protocols.  For psychology, involvement in primary care will be an absolute necessity.

Few appreciate that it was the vision of President Lyndon Johnson during his Great Society Era -- at a time when psychologist John Gardner served as Secretary of the Department of Health, Education, and Welfare -- that the network of federally qualified community health centers (FCHCs) was established.  Today there are over 9,000 rural and urban communities across the United States receiving high quality, comprehensive care (including behavioral and mental health care) from FCHCs.  The magnitude of change was noted in 2006 by the President of the Institute of Medicine.  "Dealing equally with health care for mental, substance-use, and general health conditions requires a fundamental change in how we as a society and health care system think about and respond to these problems and illnesses.  Mental and substance-use problems and illnesses should not be viewed as separate from and unrelated to overall health and general health care.  Building on this integrated concept… the Institute of Medicine will itself seek to incorporate attention to issues in health care for mental and substance-use problems and illnesses into its program of general health studies."

Those fortunate to attend the annual Practice Directorate State Leadership Conferences – which I feel are one of highlights of APA's year – have heard Katherine Nordal passionately remind us: "January 1^st is really just a mile marker in this marathon we call health care reform [the ACA implementation date].  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us.  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.  No one else is fighting the battles for psychology… and don't expect them to.  We can't hope to finish the marathon called health care reform if we're not at the starting line."

Last year I had the pleasure of participating in the Canadian Psychological Association annual convention in Quebec City.  It was a wonderful event and brought home that you are facing challenges very similar to those of colleagues in the United States – especially having society and their elected officials appreciate how psychology can significantly impact the quality of health care, but only if citizens have timely access to our services.  Your "Mind Your Mental Health" campaign is extraordinarily timely and important for all of us.  The value of appreciating the past was recently underscored by 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.'"

Two living former APA Presidents are Canadian (born and raised there) -- Albert Bandura and Frank Farley.  Frank, whose father was born in Manitoba, teaches a History & Systems course for which Al (at age 88) joins him via speakerphone every Spring Semester.  I had the privilege of serving with Frank on the Board of Directors during his Presidency.  His vision and passion truly served both of our nations admirably.  The late Donald O. Hebb was the first Canadian elected APA President.  Aloha,

Pat DeLeon, former APA President – Manitoba Psychological Association – February, 2014

 

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