WAY UP NORTH

 Having worked with Hawaii's U.S. Senator Daniel K. Inouye for 38+ years, I have had the opportunity to visit Alaska on a number of occasions, including during my APA Presidential year in 2000.   Senator Inouye was a close personal friend of Senator Ted Stevens and over the years, I became impressed by the many similarities which existed between their two states, especially among the indigenous Native Hawaiian and Alaska Native populations.  In my judgment, the Southcentral Foundation health system, with Katherine Gottlieb as its President, is the finest health care system in the nation.  Similarly, the Cook Inlet Tribal Council, with Gloria O'Neill as its President, is a fascinating and highly effective human resources organization.  Both of these visionary institutions focus upon providing care and services to Alaska Natives and represent an unprecedented opportunity for psychology's next generation of indigenous providers – especially since their leaders respectively serve on the Board of Regents of Alaska Pacific University (APU) and the University of Alaska (UA).

            The Health Resources and Services Administration (HRSA) is one of the most important federal agencies for psychology, nursing, and the other non-physician health care providers.  It funds the all-important Federally Qualified Community Health Centers (FQHCs) network, which began under President Lyndon Johnson's Great Society Era.  And, it is the home of the Graduate Psychology Education (GPE) program, targeted to training colleagues to work with underserved populations.  The Fiscal Year 2016 GPE budget request would provide $7,916,000, noting that the demand for behavioral health services will grow as more individuals are covered under the President's Affordable Care and Patient Protection Act (ACA) and the Mental Health Parity and Addiction Equity Act.

At Alaska Pacific University, Bob Lane currently has one Native Alaska adjunct faculty member and one native student, as well as two additional American Indian students.  APU invites a number of guest speakers from the Alaska Native community and is actively seeking to make education more accessible in remote regions via blended classes and intensive weekend residencies.  The University of Alaska (UA) program has an Alaska Native Board of Elders to provide guidance to the faculty and students to ensure that the program is culturally relevant and designed to meet the needs of the Alaska Native population.  Jim Fitterling reports that before they even begin their doctoral training, all newly admitted students attend an intensive cultural retreat and sit literally, as well as figuratively, at the feet of these Elders.  UA has Native Americans as adjunct faculty, teaching courses such as Native Ways of Knowing.  The doctoral program has several graduates – including their first Alaska Native – working in the Alaska Native Health Corporations throughout the state, providing opportunities for telepsychology and telesupervision at distal sites in rural Alaska.  Interestingly, Rod Baker recently noted the Veterans Administration (VA) Office of Inspector General report found that psychology was one of their "largest staffing shortage" occupations – a finding definitely relevant to Alaska.

HRSA Administrator, Mary Wakefield: "HRSA is the primary Federal agency for improving access to health care by strengthening the health care workforce, building healthy communities and achieving health equity….  (T)he Health Center program will continue to play a critical role in the health care system by providing high quality, affordable and comprehensive primary care services in medically underserved communities even as insurance coverage expands."  The HRSA Office of Rural Health Policy was established in 1987 to serve as a focal point for rural health activities within HHS, including advising on rural policy issues, conducting and overseeing policy-relevant research on rural health issues, and administering grant programs that focus on supporting and enhancing health care delivery in rural communities.

Historically, rural communities have struggled with issues related to access to care, recruitment and retention of health care providers of all disciplines, and maintaining the economic viability of hospitals and other health care providers in isolated rural communities.  Nationwide, there are over 46 million citizens living in rural America who face ongoing challenges in accessing health care.  Rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than their urban counterparts.  The goal for the President's "Improving Rural Health Care Initiative" is to build healthier rural populations and communities through evidence-based practices.  This will include the coordination of rural health activities within HHS and across the Federal Government.  The broad and non-categorical nature of HRSA's programs allows the office to focus funding on key emerging needs.

            HRSA's pilot rural family medicine residency training initiative, in which the first year of training takes place in urban-based locations and the second and third years of residency occur in rural locations, resulted in 70% of the graduates staying in rural practice after completing their training.  The telehealth grant program is expanding the use of telecommunications technologies within rural areas that link rural health providers with specialists in urban areas, thereby increasing access and the quality of healthcare provided to rural populations.  Telehealth technology also has been found to offer important opportunities to improve the coordination of care in rural communities.  The Office of Rural Health Policy plans to expand its work with the VA addressing veterans' access to rural health providers through the support of pilot programs that use telehealth and health information technology exchange to enhance services for rural veterans.  In addition, the Office is working with the VA Office of Rural Health on the implementation of the Veteran's Choice Act which allows rural hospitals and clinics to provide services to Veterans who reside more than 40 miles from a VA facility.   The Fiscal Year 2016 budget request for the Office of Rural Health Policy is for $127,562,000.

            This winter I had to opportunity to visit American Samoa for the first time.  Without question, this U.S. territory personifies rural America with all of its unique challenges and its indigenous population.  Rural American, however, also provides unprecedented opportunities for those with vision, persistence, and compassion.  The HRSA Pediatric-Emergency Medical Services (EMS-C) program was established back in 1984, following up on my daughter's use of a then-typical hospital emergency room.  In American Samoa I had the pleasure of meeting with those in charge of their EMS-C program.  It was a wonderful experience seeing how they can respond effectively to local crises, including those caused by natural disasters.  Most intriguing was their willingness to utilize their limited resources to address their most pressing needs.  For example, transportation itself can be quite a challenge for the elderly throughout rural America and thus the EMS-C personnel conduct home visits – thereby avoiding predictable future crisis calls to the LBJ hospital emergency room.  In our judgment, the $20+ million HRSA budget request this year for this national program is truly an outstanding investment in the nation's future.  Incidentally, during one of my visits to Alaska I had a similarly rewarding experience, seeing how your EMS-C staff were creatively responding to the overwhelming need for helicopter support from rural Alaska.  Those with vision and persistence do make a real difference in the daily lives of our citizenry.  Mahalo.  Way up north, to Alaska.  Aloha, 

Pat DeLeon, former APA President – Alaska Psychological Association – February, 2015

THE AGE OF AQUARIUS

Over the years, MPA has provided outstanding vision and leadership at the national level. During my tenure on the APA Board of Directors, I had the pleasure of working closely with future APA Presidents Norine Johnson, Gerry Koocher, and Ron Levant.  MPA members have chaired a number of the major APA policy boards and committees.  Having spent my undergraduate years in your state, I might admittedly be a little biased; however, it did not surprise me that it was the Massachusetts Nurses Association that ultimately convinced their national association to support the independent practice of Advanced Nurse Practitioners.  A number of underlying features of President Obama's landmark Patient Protection and Affordable Care Act (ACA) were undoubtedly inspired by Governor Romney's Massachusetts Health Care Reform legislation.  Collectively, you have a long history of seeing the "bigger picture."  And of course, Great Barrington is the home of Alice's Restaurant – in celebration of which Arlo Guthrie has embarked on the 50^thanniversary tour.

            Times do change.  The APA Council of Representatives has reconstituted its role in order to focus primarily upon major policy issues, and we understand from Dolly Sadow that the Council will be focusing upon "translating Science into Policy" as a mega issue.  The broader underlying issue will be developing Council as a policy making and disseminating body, rather than serving as a passive reactor to initiatives perceived as not of its own making.  How will Council facilitate policy initiatives that are consistent with APA's strategic plan and which speak to society's real needs? – that is the challenge ahead.  As perhaps a first step in this radical paradigm shift, during their February meeting Council heard directly from those who have spent their professional lives being engaged in shaping national policy.  Without question, this is an exciting evolution which will take time to effectively implement.

Reflecting upon our personal interest in policy development, several of us at the Uniformed Services University of the Health Sciences (USUHS) (DoD) recently reviewed the psychology literature on teaching health policy.  Last year, under Nadine Kaslow' s leadership, Council endorsed moving towards Competency-Based education, similar to that which almost all of the other health professions have embraced and which is a cornerstone of the ACA.  Whereas the study of health policy is, for example, a required competency within professional nursing and a priority of public health and social work education, we could find very few references to this notion within psychology.  There were, of course, articles on political advocacy (which in our judgment represents only a small subset of health policy) and an increasing number of social psychology experiments – with the plea that if only used by policy makers these could make a real difference.  However, the fundamental notion of educating future members of the psychology profession about the profession of health policy which possesses its own unique history, language, and nuances seems to be, at best, an afterthought.  Accordingly, Council's new vision truly does represent a major paradigm shift.

            Another graduate from one of the Commonwealth's finest institutions of higher education (albeit not from the oldest women's college in the nation), Heather O'Beirne Kelley heads up APA's Military & Veterans Policy (MVP) team which is working to support military personnel and veterans, their families, and their communities, as well as the psychologists who conduct research with and provide direct services to these populations.  Their priorities for this year range from funding for research at the Departments of Veterans Affairs (VA) and Defense (DoD), to provision of timely, high-quality mental health care in the service member and veterans communities, and establishment of prescription authority (RxP) for appropriately trained and certified psychologists in the VA, matching that which DoD has granted for 17 years.  [Personally, we continue to wonder why MPA has not made this a priority, especially following the impressive success in Illinois last year spearheaded by Beth Rom-Rymer, who incidentally was honored by President Barry Anton at the February Council meeting.]

In terms of research funding, the President's newly released FY'16 budget proposed a nice increase for the VA's intramural research program, so APA and the larger veteran community will support that request.  However, the Administration's budget also proposed a cut to DoD basic research, which the scientific and university community will urge Congress to restore in its annual appropriations process this spring.  APA supports military personnel in seeking and receiving high-quality, effective mental and behavioral healthcare throughout their careers – from enlistment/commissioning through pre-deployment, deployment, and transition to veteran status.  MVP advocacy efforts thus are particularly focused on garnering Administration and Congressional support for issues such as mental health screening and follow-up; access to care; suicide prevention; provision of TRICARE benefits; and supporting communities and other systems (including educational, health, and legal) in understanding and working with veterans.  Your former MPA Executive Director Elena Eisman, who has also served on the APA Board of Directors, picked a fascinating time to transition to our nation's Capital.  Aloha,

Pat DeLeon, former APA President – MPA – February, 2015

 

ALICE’S 50th ANNIVERSARY TOUR

 Having A Timely and Visual Presence:  One of the most exciting aspects of being personally involved in the public policy/political process, which definitely would include participating in the APA governance, is having the opportunity to listen to, and spend unforgettable time with, visionaries who are truly dedicated to their cause.  Psychologists often do not appreciate that they are among our nation's educated elite and as such, have a special responsibility to provide proactive leadership in addressing society's most pressing needs.  I was particularly fortunate to serve as APA President just prior to Norine Johnson's term.  Norine truly appreciated how the nation would benefit from psychology's calming presence right after the horrific 9/11events and with Rhea Farberman's steady guidance, passionately addressed the concerns of our nation's children and their families by engaging the media.

In the days and weeks following, APA, with Norine as its national spokesperson, was active with the news media to help the American public understand the traumatic effect the attacks would have on some individuals.  In the first three days, APA received 166 interview requests.  In one lead interview Norine was part of an hour long CNN special segment.  By mid-October, she had done a number of national interviews and over 2,000 APA members had been interviewed on both the 9/11 and the anthrax attacks.  At her behest, the Public Communications Office created a public information brochure containing advice on how to deal with trauma, what is normal traumatic response, and how to recover.  APA teamed with the Advertising Council and the National Mental Health Association on a public service announcement encouraging parents to talk with their children about the events of 9/11.  Norine also understood the fundamental changes gradually occurring within our nation's health care environment and worked tirelessly to have the APA Council of Representatives, and ultimately the full membership, include "promoting health" in our Association's bylaws.  As President Obama's Patient Protection and Affordable Care Act (ACA) is now being steadily implemented, Norine's vision of more than a decade ago is clearly coming to fruition.

            The Administration's Budgetary Priorities:  The Administration's Fiscal Year 2016 budget request for the Substance Abuse and Mental Health Services Administration (SAMHSA) is $3.7 billion, which includes an additional $103 million funding for its top behavioral health priorities – strengthening crisis systems, addressing prescription drug and opioid abuse, expanding the behavioral health workforce, and fostering tribal behavioral health.  The Administrator: "The impact of untreated behavioral health conditions on people, communities, and healthcare costs in the United States is staggering.  For example, costs for Medicaid enrollees with common chronic conditions and co-occurring mental and substance use disorders are two to four times higher than average Medicaid enrollees….  (A)ddressing behavioral and physical health issues together can reduce costs and improve overall health."

            SAMHSA's budget emphasizes that addressing mental health and substance abuse is critical to the health of individuals and families.  Prevention, treatment, and recovery support services for behavioral health are essential components of health service systems.  Behavioral health remains one of America's most pressing needs, yet it is also one of the most undervalued and least-addressed.  The ACA, in conjunction with the Mental Health Parity and Addiction Equity Act, has the potential to create or enhance access to coverage for behavioral health services for 62 million Americans, nearly one-fifth of the nation's population.  The current behavioral healthcare infrastructure and workforce, however, will need additional capacity to absorb the influx of patients who now will have the coverage to seek treatment.  Behavioral health can, and should, be addressed as a public health issue by ensuring that the programs and policies focus on these tenets: Behavioral health is essential to health; Prevention works; Treatment works; and People Recover.

            "It has been 50 years since President Kennedy first challenged government to do more for individuals with behavioral health conditions.  In recent decades, seeking behavioral health services has become more acceptable and the science that addresses these conditions has advanced….  Many people receive this treatment within the general healthcare system allowing the specialty behavioral health system to focus on the needs of people with the most severe illnesses and/or addictions.  However, even with expanded access to treatment, more than half of people with mental illnesses and 90 percent of people with substance use disorders do not get the services they need.  The nation can do better."

Norine's vision of her profession embracing its role within the nation's evolving health care system was most prophetic.  On a recent HRSA national advisory committee conference call it was emphasized that: "Mental health disorders rank in the top five chronic illnesses in the U.S.  An estimated 25 percent of U.S. adults currently suffer from mental illness and nearly half of all U.S. adults will develop at least one mental illness in their lifetime.  In 2007, over 80 percent of individuals seen in the emergency room (ER) had mental disorders diagnosed as mood, anxiety and alcohol related disorders."  We would suggest that integrated care will become the vehicle for psychology's expansion into the more generic health care environment of the next decade.

Being At The Table:  Heather O'Beirne Kelly heads up APA's Military & Veterans Policy (MVP) team, devoted to supporting military personnel and veterans, their families, and their communities, as well as psychologists who conduct research with and provide direct services to these populations.  Her priorities for the coming year range from funding for research within the VA and DoD, the provision of high quality mental health care in the Service Member and Veterans communities, and establishment of prescription authority for appropriately trained and certified psychologists in the VA, matching that which DoD has granted for 17 years.

            Voices For The Future:  It is similarly informative to reflect upon the views proffered by those colleagues who have expressed a willingness to run for the APA Presidency, which is actually a very small and select group.  Jack Kitaeff, a lawyer and former U.S. Army psychologist, expressed his deep and abiding respect for those who have put themselves "in harm's way" and feels that the issue of veteran's mental health should be of monumental importance.  He would press for psychologists to be trained in treatment regimens targeting post-traumatic stress disorder (PTSD), including prolonged-exposure therapy, cognitive-processing therapy, and cognitive restructuring.  Amazed by how many psychologists are not members of APA, or have never considered becoming involved in the governance, he would seek to actively attract colleagues back to the Association and demonstrate to members that "they are indeed valued."  He would also focus on addressing the chronic shortage of professional psychologists dedicated to serving diverse and marginalized communities (e.g., the poor, those with HIV, diverse family structures, and the workplace), as well as underserved regions of the country.  And finally, Jack called for psychology to remain scientific and affirmatively seek to avoid allowing its advocacy efforts to be driven by ideology rather than science.  Throughout these enumerated aspirations are a number of national policy agendas which could serve the profession admirably.  "And friends they may think it's a movement.  And that's what it is…." (Ron Levant, Opening Session, 2005).  Aloha,

Pat DeLeon, Former APA President – Division 42 – February, 2015

 

INTERPROFESSIONAL COLLABORATION – THE FUTURE

For our nation's health care professionals, these are very "interesting" times.  Change is always unsettling, especially when it is difficult to predict with any sense of certainty what the future will bring.  Under the visionary leadership of APA President Nadine Kaslow, the Council of Representatives endorsed moving towards Competency-Based Education, an approach which has been adopted by nearly every other health care profession.  At the end of last year, the Accreditation Council for Pharmacy Education, Commission on Collegiate Nursing Education, Commission on Dental Accreditation, Commission on Osteopathic College Accreditation, Council on Education for Public Health, and the Liaison Committee for Medical Education formed the Health Professions Accreditors Collaborative (HPAC).  They are committed to discussing important developments in interprofessional education and exploring opportunities to engage in collaborative practice around the common goal of better preparing students to engage in interprofessional collaborative practice.  They anticipate inviting other disciplines to join their effort later this year in response to inquiries.

If one reviews the training models of the other health professions, there is considerable interest (especially within nursing and public health) in exposing their next generation of practitioners to the nuances and importance of appreciating health policy – and how, for example, over the past decade various health policy experts have increasingly urged the nation to emphasize developing systems of care, rather than continuing to rely upon individual practitioner expertise.  Unfortunately, we have observed that such training is relatively rare within psychology's training programs.  Integrated and patient-centered, data-driven holistic primary care provided by interprofessional teams is one of the cornerstones of President Obama's Patient Protection and Affordable Care Act (ACA).  And, it has clearly been a high personal priority for U.S. Army Surgeon General Patty Horoho during her tenure.

Those colleagues trained in providing mental health and/or behavioral health care face significant challenges in effectively addressing our nation's pressing needs.  On a recent HRSA national advisory committee conference call it was noted: "Mental health disorders rank in the top five chronic illnesses in the U.S.  An estimated 25 percent of U.S. adults currently suffer from mental illness and nearly half of all U.S. adults will develop at least one mental illness in their lifetime.  In 2007, over 80 percent of individuals seen in the emergency room (ER) had mental disorders diagnosed as mood, anxiety and alcohol related disorders."

At the Uniformed Services University of the Health Sciences (USUHS), nursing and psychology are pursuing ways to systematically share expertise.  A number of courses are jointly taught and/or co-attended; e.g. Stress and Trauma in the Military Context, Introduction to Physiology, and Health Policy.  Mental health students enrolled in both training programs (Doctor of Nursing Practice/Clinical and Medical Psychologist) regularly utilize the university's simulation lab where live actors "play out" various symptomology for the trainees, while monitored on closed circuit television.  Discussions are currently underway to facilitate cross-professional critiques of these experiences.  An underlying question: Why should there be different training models?

A Very Far Reaching Vision:  In January of this year, the Military Compensation and Retirement Modernization Commission, a blue ribbon panel established by Congress in 2013, submitted its 302-page Final Report to the Administration and Congress.  Even a cursory review provides a sense of the unprecedented magnitude of their recommendations.  "Our volunteer Service members are the strength of our military, and it is our continuous duty and obligation to ensure that the Services are properly resourced….  In considering the military health benefit, we focused on sustaining medical readiness by recommending a new readiness command, supporting elements, and framework for maintaining clinical skills….

            "The critical nature of joint readiness, including the essential medical readiness… make it clear that four-star leadership is needed to sustain dedicated focus on the joint readiness of the force.  Ensuring that the hard-fought progress achieved during the past decade in the delivery of combat casualty care on the battlefield, the global capability for evacuating casualties and providing critical care while in transit, and the research that has led to advances in wound care and hemorrhage control, requires strong oversight at the highest level.  The Commission thoroughly evaluated the merits of a four-star joint medical command….  (M)edicine is only one component of joint military readiness.  The essential nature of military medicine by itself warrants four-star oversight, and the Commission concludes the best course of action is to create a four-star Joint Readiness Command to manage the readiness, as well as the interoperability, efficiency, and 'jointness' of the entire military force, including medical readiness….

"Health care is a constantly changing industry.  The features of health care, including technology and the models for paying for and delivering care, rapidly evolve.  Rather than attempting to replicate a private-sector health care system within DoD, and consequently following behind, the Commission believes beneficiaries would be better served by having direct access to the innovations found in private-sector health care.  Furthermore, under commercial insurance, carriers have the tools, including the advancements in payment and delivery models… and the monetary and nonmonetary incentives… to increase value by operating more efficiently."  'Cause I'm leavin' on a jet plane.  Don't know when I'll be back again.  Aloha,

Pat DeLeon, former APA President – Division 19 – February, 2015

AS WE LIVE A LIFE OF EASE

The Accountable Care Act:  With the implementation of President Obama's Patient Protection and Affordable Care Act (ACA), our nation's health care environment is gradually undergoing fundamental change.  Change of such magnitude that we would suspect the majority of practitioners do not yet fully comprehend how it will eventually impact upon their daily professional lives.  In December, 2014 the Commonwealth Fund (CF) reported that for the first time in modern U.S. history, the uninsurance rate fell precipitously – from 20 percent to 15 percent – among adults ages 19 to 64 by the end of the first open enrollment period for the ACA health insurance marketplace.  An estimated 10 million fewer Americans were uninsured.  And based upon preliminary figures for the still-open second enrollment period, the uninsured rate seems likely to plunge even further.  In 2014, health expenditures grew more slowly than at any time since Medicare was enacted 50 years ago.  Medicare spending alone is $1,200 less per beneficiary per year than predicted just four years ago.

The CF report further noted that the Republican Party will begin 2015 with firm control over both Houses of Congress (for the first time since 2006), 31 governorships, and an advantage of more than 800 members in state legislatures around the country.  Whether divided government at the federal level will lead to an armistice over health reform, or intensified trench warfare, is anyone's guess.  Full repeal of the ACA is unlikely as long as President Obama remains in the White House.  However, more targeted attacks – perhaps through the budget reconciliation process – should be expected.  At the state level, Republican control will likely mean slower-than-expected expansion of Medicaid eligibility.  As an aside, we would note that this is in spite of the fact that during the initial U.S. Senate committee deliberations, a concerted effort was made to include Republican recommendations in order to develop bipartisan consensus – for example, carefully looking at the specifics of Governor Romney's Massachusetts Health Care Reform legislation.

More than 600 public and private accountable care organizations (ACOs) already exist, covering an estimated 20 million Americans.  The percentage of private health insurance payments that are "value-based" jumped from 11 percent to 40 percent in the past year.  ACOs and value-based payments are central components of the ACA and reflect efforts to encourage higher-quality care and lower costs through increased provider accountability for cost and quality.  Systematic efforts to reduce hospital-acquired conditions were estimated to save 50,000 lives and $12 billion since 2010.  And the practice implications not to be underestimated, five years after the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, there were $25.4 billion in incentive payments resulting in 80 percent of eligible professionals and 98% of eligible hospitals having qualified for these payments by adopting electronic health records (EHRs), potentially resulting in a transformative digital revolution within the health care system.  This technological evolution alone will significantly increase the likelihood of systematically developing across-provider and across-clinical population and diagnostic comparisons (i.e., clinical effectiveness research) with its accompanying public health orientation.  One must expect the utilization of data-based, gold standard protocols to increasingly impact clinical decision making and eventually include the all-important psychosocial-economic-cultural gradient of care.

            Interprofessional Care:  Under the visionary leadership of APA President Nadine Kaslow, the Council of Representatives endorsed moving towards Competency-Based Education and Training.  Espousing a similar training philosophy, in 2009 the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges, and the Association of Schools and Programs of Public Health formed the Interprofessional Education Collaborative (IPEC) in order to promote and encourage efforts to advance substantive interprofessional learning experiences with the goal of preparing future clinicians for the team-based care of patients.  Fundamental to the ACA is the development of integrated systems of holistic patient-centered primary care, provided by integrated interprofessional teams of providers.  Although psychology's training institutions are just beginning to appreciate the magnitude of this paradigm shift in orientation, studying health policy and developing skills to practice collegially with colleagues from other disciplines is one of the required competencies for the Doctor of Nursing Practice degree.

            The Doctor of Nursing Practice – Growing Acceptance:  The Alliance for Health Reform, which in our judgment is one of the most objective sources of non-partisan policy information for congressional staff, recently held a briefing entitled "Preparing the Nursing Workforce for a Changing Health System: The Role of Graduate Nursing Education."  The key messages were: * Nurse practitioners can help alleviate the growing demand for primary care.  Using nurse practitioners and physician assistants as part of a team can reduce the primary care shortage, improve access, and deliver more cost effective services.  * Graduate nursing education demonstrations are showing early positive results.  Cost estimates of advanced practice nursing (APN) clinical education derived from the Center for Medicare and Medicaid Services (CMS) graduate nursing education demonstration (GNE) show a favorable return on investment.  Enrollments and graduations doubled during the first two years of the demonstration.  * New models of care integrate nurses into the community.  The CMS demonstration benefits the community by integrating more nurse practitioners into community clinics.  And, * Advance practice nurses must receive post-baccalaureate training.  APNs (nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists, and certified nurse midwives) must complete baccalaureate plus master's or doctorate-level training.  The American Association of Nurse Practitioners estimates that today there are 205,000 NPs, double the 2004 number.

            A recent editorial in The New York Times rhetorically asked: "Are Midwives Safer Than Doctors?"  Citing the findings of Britain's National Institute for Health Care Excellence that it is safer for healthy women with uncomplicated pregnancies to give birth under the supervision of midwives than in a hospital maternity ward run by doctors, the Times concluded that there is "no good reason that midwives should not play a more important role in childbirth here, despite a longstanding turf war between obstetricians and midwives that has tended to keep midwives under the thumb of doctors."  Last year there were more than 3.9 million births in the U.S., only nine percent of which were attended by nurse midwives.  The professional society for obstetricians consistently raises the traditional "public health hazard" argument.  Notwithstanding, the Times concluded: "In a time of spiraling medical costs and increasing demand for health care, midwives can offer a cost-effective way of providing good maternity care.  They could also provide greater geographical reach:  Nearly half the counties in the United States have no maternity care professional, either midwife or obstetrician."  [This, of course, has historically been the essence of psychology's public policy argument for expanding its coverage.]

            Serving at the Department of Defense (DoD) Uniformed Services University of the Health Sciences (USUHS), I have become particularly interested in programs targeting military personnel, their families, and veterans.  Last fall, the Jonas Center for Nursing and Veterans Healthcare announced its Policy Scholars Program, which in conjunction with the American Academy of Nursing, will recruit 12 doctoral and post-doctoral nursing students for a two-year experience whereby they will be matched with an expert panel to learn from leading nursing experts about major health policy issues.  The underlying strategic objective is to develop leadership in the policy work that is needed to create healthy communities and to transform the nation's health care system.  "The Jonas Policy Scholars will create a pipeline of early-career nursing scholars who will contribute to shaping practice, education, and research policy relevant to nursing and the work of the Academy of Nursing; provide a mechanism for Academy expert panel leaders to mentor early-career Jonas Policy Scholars on key issues relevant to the panel's area of focus and strategies for shaping those policies; and support expert panel chairs in advancing work to inform and shape policy and improve the health of the public."

The Jonas Center for Nursing and Veterans Healthcare was established in 2006 by Barbara and Donald Jonas and is dedicated to improving healthcare by advancing nursing scholarship, leadership, and innovation.  Its two main programs are the Jonas Nurse Leaders Scholar Program, which aims to address the dire shortage of nursing faculty by preparing nurses with doctoral degrees to step into this critical role; and the Jonas Veterans Healthcare Program, which seeks to improve the health of veterans by supporting doctoral-level nursing candidates committed to advancing veterans' healthcare.  These programs currently support more than 600 doctoral scholars nationwide, with the goal of supporting 1,000 Scholars by 2016.

A Personal View:  "As a Psychiatric Mental Health Nurse Practitioner who is not only educated to provide psychotherapy and pharmacotherapy but also trained to embrace a holistic model of care, I am especially grateful to have the training and skills to provide acupuncture therapy to psychiatric patients.  In my practice, acupuncture has been an effective adjunct treatment of complex psychological and physical trauma acquired from combat.  I found that my patients benefited from the unique practitioner-patient interaction that happens during acupuncture treatment.  Patients verbalized satisfaction as they report relief from debilitating symptoms such as insomnia, pain, and anxiety.  They appreciate the relaxation component that happens outside psychotherapy when they receive acupuncture.  They become proactive in their care by requesting and calling for more acupuncture time.  Albeit some of the effects of acupuncture are short term for those who have severe psychiatric symptoms, the momentary relief they gain could be revitalizing and result in increased function even for a few days.  After an acupuncture therapy, some of my patients report: 'I haven't slept that well in a long time since deployment;"  'I was able to spend time with my child without feeling tired and fatigued;'  'I did not have an anxiety attack this week.'  These momentary gains in quality of life are significant as we care for those who have experienced trauma in combat settings [LCDR Jane Abanes]."  Prior to enrolling in the USUHS Daniel K. Inouye Graduate School of Nursing Ph.D. program, Jane was Head, Mental Health Department & Substance Abuse Rehabilitation Program, Naval Health Clinic Hawaii.

Unmet Needs; Uncharted Waters; Unprecedented Opportunities?  I recently participated in a conference call for a HRSA national advisory committee during which it was noted: "Mental health disorders rank in the top five chronic illnesses in the U.S.  An estimated 25 percent of U.S. adults currently suffer from mental illness and nearly half of all U.S. adults will develop at least one mental illness in their lifetime.  In 2007, over 80 percent of individuals seen in the emergency room (ER) had mental disorders diagnosed as mood, anxiety and alcohol related disorders."  And the band begins to play.  We all live in a yellow submarine.  Aloha,

Pat DeLeon, former APA President – Division 29 – February, 2015

 

THERE’S A MAN GOIN’ ‘ROUND TAKIN’ NAMES

  With the convening of the 114^thCongress (2015-2016), and the Republican controlling both the U.S. House of Representatives and U.S. Senate for the first time since 2006, public service colleagues should expect somewhat different legislative agendas and federal budgetary priorities to evolve.  The newly elected Senate Majority Leader has proclaimed: "It's time for a new direction.  We can have real change in Washington, and that's just what I intend to deliver."  It is too early to predict with any sense of certainty what specifically will evolve.  However, change is definitely in the air.  Accordingly, this might be a good time to reflect upon several developments that were occurring right around election time.

            Evolving Treatment Programs:  One of the foundations of President Obama's Patient Protection and Affordable Care Act (ACA) is the development of interprofessional (i.e., interdisciplinary) integrated systems of data-driven primary care which will provide a priority for preventive care and wellness, while eliminating historical barriers for receiving mental health/behavioral health services.  The ACA invested heavily in expanding the Federally Qualified Community Health Centers (FQCHC) initiative, which was established under President Lyndon Johnson's Great Society Era.  Bob McGrath, Director of Integrated Care for the Underserved of Northeastern New Jersey at Fairleigh Dickinson University and their clinical psychopharmacology program:  "Thanks to the efforts of APA to improve funding for the Graduate Psychology Education program, in July this year I unexpectedly received funding for a grant that had been recommended but not funded in 2013.  The grant was to create a clinical training site in the primary care services of a local federally qualified health center called North Hudson Community Action Center.  We got the notice a week before the grant start date, so since then has been a whirlwind of creating a program from scratch, including finding students, hiring supervisors, creating protocols, developing a training program, establishing a legal relationship between the university and the site, and developing a personal relationship with staff.  The many months of work finally paid off, and in early December we began offering behavioral health services on an as-needed basis within the women's health and internal medicine services.  The population is overwhelmingly poor and Hispanic.  Few have ever had contact with mental health services before.  In just two days, we've seen people (including several staff members) suffering with chronic pain, overwhelming life stress, suicidality and depression, family problems.  It's remarkable how great the need is, and how limited the resources are.  It's exhausting work – I don't know how the staff keeps up this pace day after day – but it feels like we're finally connecting with people in real need who can benefit from what we have to offer.  I'm excited, and I know my students are already being reshaped as clinicians by what we've created."

Bob's visionary efforts to move psychology into the future are most timely.  I recently participated in a conference call for a HRSA national advisory committee during which it was noted: "Mental health disorders rank in the top five chronic illnesses in the U.S.  An estimated 25 percent of U.S. adults currently suffer from mental illness and nearly half of all U.S. adults will develop at least one mental illness in their lifetime.  In 2007, over 80 percent of individuals seen in the emergency room (ER) had mental disorders diagnosed as mood, anxiety and alcohol related disorders."

            The Advent Of Social Media:  Congressional Management Foundation Findings (CMF):  Advocacy groups have relied heavily on constituent email communications for years, and yet a recent CMF survey of Capitol Hill communications directors, legislative directors, and legislative assistants found that three quarters of senior Hill staff report that between one and 30 comments on social media platforms like Facebook and Twitter would get their attention on an issue.  Thirty-five percent indicated that even less than 10 comments were sufficient.  Social media interactions are viewed as authentic communications and its influence was perceived as rising.  Seeing an issue "pop up" in tweets or comments in just one instance is generally not enough to get congressional attention.  Similarly, when numerous advocates tweet a prearranged message at an account all at once (i.e., "thunderclaps"), these are not viewed as authentic communications.  However, if tweets and comments on an issue appear over the course of many days on social media accounts, they are definitely noticed.  To be effective, these repeated interactions have to be viewed as having a human element expressing a genuine concern.  Because many staffers have grown up with social media, they are adept at separating out constructive comments on Facebook and Twitter from the noise.

As is the case with email, the tone and level of influence a sender has will boost the likelihood of a message being heard.  It is particularly effective when constituents interact with the specific content Hill staff have posted on the Member's Facebook.  Genuine conversations are valued.  When asked which constituent types were most influential with Congress when commenting on social media, the CMF survey found that 77% cited multiple constituents commenting within a group; 75% cited leaders of a group or organization; 69% cited a single constituent self-identifying with a group; and 58% cited a single constituent on his or her own.  While email is still the dominant form of communication, social media is expected to increase over emails and individual phone calls during the next five to 10 years.  Hill staff reported that social media is often seen as a barometer of public opinion.  APA is well ahead of the curve.  Rhea Farberman reports that APA's main website (APA.org) averages 3 million visitors per month and that 282,000 people follow APA's Facebook page.  Most impressive!

            Substantive Change Takes Time – Often Far Longer Than One Might Imagine:  In 2004, when the Republicans were in the majority, the Senate HELP Committee recommended adoption of the Act for Elder Justice [S2940], which would amend the Older Americans Act to create the Office of Elder Abuse Prevention and Services.  The accompanying Senate Report: "The proportion of the United States population age 60 years or older will drastically increase in the next 30 years as 77,000,000 baby boomers approach retirement and old age.  Each year, anywhere between 500,000 and 5,000,000 elders in the United States are abused, neglected, or exploited.  This variance reflects the unfortunate fact that there is a general lack of comprehensive data on such abuse, with 500,000 reflecting the number being reported and a significantly higher number of cases that go unreported.  Elder abuse, neglect, and exploitation have no boundaries, and cross all racial, social class, gender, and geographic lines.  Victims of elder abuse, neglect, and exploitation are not only subject to injury from maltreatment and neglect, they are also 3.1 times more likely to die at an earlier age than expected than elders who were not victims of such maltreatment….

"For over 20 years, Congress has been presented with facts and testimony calling for a coordinated Federal effort to combat elder abuse, neglect, and exploitation.  The Federal Government has been slow to respond to the needs of the victims or to undertake prevention efforts.  No Federal law has been enacted that comprehensively addresses the issues of elder abuse, neglect, and exploitation and there are limited resources available to those in the field directly dealing with these issues (Sen Rpt. #108-391)."  Enacted as a provision of the ACA on March 23, 2010, this was the first legislation authorizing specific federal funding addressing elder abuse.  Listen to the words long written down, When the man comes around.  Aloha,

Pat DeLeon, former APA President – Division 18 – February, 2015

 

THE FOUNDING FATHERS

 One of the foundations of President Obama's Patient Protection and Affordable Care Act (ACA) is the active encouragement of patient-centered, data-based interprofessional (i.e., interdisciplinary) integrated care models to be established within comprehensive systems of care, such as Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes.  In many ways, the envisioned clinical structures are very similar to President Nixon's HMOs and President Clinton's Managed Care initiatives, of which organized psychology has historically been less than supportive.  The ACA provides for a priority on preventive care and eliminating traditional barriers to receiving mental health and behavioral health care.  The all-important psychosocial-cultural-economic gradient of care is to be systematically encouraged.   We would suggest, however, that in order to successfully function (if not thrive) within this exciting evolving environment, it would be very helpful for our educators and clinicians to become intimately familiar with the training, orientation, and clinical skills of the other health care professions – not to mention developing a public health perspective.

            Under the leadership of visionary APA Past President Nadine Kaslow, the Council of Representatives voted last year to encourage psychology's training programs to affirmatively embrace Competency-Based training.  In 2007, Nadine opined: "Professional psychology is moving towards competency-based models with attention to competency-based education, training, and credentialing."   In 2009, six national schools of health professions education associations formed the Interprofessional Education Collaborative (IPEC) in order to promote and encourage efforts to advance substantive interprofessional learning experiences with the goal of preparing future clinicians for the team-based care of patients.  The IPEC collaborative partners are the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges, and the Association of Schools and Programs of Public Health.  APA cannot be one of the core groups as it is not an association of schools/programs; nevertheless, the Education Directorate has been working closely with IPEC.

            From a health policy perspective, it is significant that whereas one of the required competencies for our colleagues in nursing is Health Policy (including teaching their next generation how to become actively involved in the political process), this is not the case for psychology's training programs.  In fact, a review of psychology's literature found very few training programs offering any relevant courses or "hands-on" training experiences.  The one notable exception is APA's Congressional (and now also Executive) Fellowship program which celebrated its 40th anniversary last year, having provided this transformative experience for 119 colleagues.

            The former Speaker of the U.S. House of Representatives Tip O'Neill noted that "All politics is local."  Described slightly differently by former APA Congressional Fellow Neil Kirschner: "More often than not, research findings in the legislative arena are only valued if consistent with conclusions based upon the more salient political factors….  If I've learned anything on the Hill, it is the importance of political advocacy if you desire a change in public policy."  Having personally served on the U.S. Senate staff for 38+ years, I would suggest that the key to effective advocacy is developing quality personal relationships with one's elected officials and their staff over a prolonged period of time.  The most common professional background of elected officials has consistently been law, followed by business.  Most obtain their health care knowledge from personal or family experiences or through the popular media.  To assume they are aware of the nuances of health care or of the extent of psychology's training and thus potential contributions, would be extremely naïve.

To become an effective advocate for one's cause (including for one's profession) one must be present, possess patience and persistence, and be committed to the long haul.  It is definitely helpful to develop an appreciation for how one's legislative or administrative agenda fits into a larger societal context.  Has the time arrived for the changes you desire and are there any natural allies for what you propose?  What, for example, might be the priorities of the newly elected Republican controlled Congress?  The ACA currently places much of the responsibility for implementation of the broad underlying statute at the local and state level.  Unfortunately, as drafted, psychology is not expressly enumerated under the ACO or Medical Home provisions of the law, although the clinical services psychology could provide are clearly possible if local administrators or policy makers so desire.  Similarly, the details of the various state Medicaid programs (which form the underlying basis for the ACA's expansion of health coverage for 32 million Americans) are also determined at the state level, where once again, unfortunately, psychology has generally been silent.

When meeting with one's elected officials and/or their staff, visits to their home office, especially during a Congressional recess, can be highly productive.  Those colleagues who are fortunate to be invited to the APA Practice Directorate's exciting annual State Leadership Conferences, will receive "hands-on" training regarding psychology's national agendas, as well as experience "mock-visits" with an elected one.  However, as the former Speaker of the House noted, local is best.  To arrange such a meeting, simply call their local offices.  One does not need detailed briefing materials or a comprehensive agenda.  Their job is to make you comfortable.  If requested, APA will provide background information as well as their legislative priorities.  Professor John Linton knows the APA governance and can be an excellent advisor, as can your State Association.  Being present is the most important ingredient.

Congress is organized every two years within a committee/subcommittee structure with those elected gravitating to areas that personally interest them.  Your job is to explore how they can be most helpful to your broader agenda, based upon their committee assignments.  When I think of West Virginia psychology, I warmly reflect upon the tireless dedication of Tom Stein.  Psychology's successful inclusion in Medicare was a prolonged journey, significantly influenced by Tom's vision and dedication.  For over a decade, I could see Tom's colorful map of West Virginia – highlighting the accessibility of psychology – on Senator Rockefeller's wall.  Psychology's true Medicare champion.  Aloha,

Pat DeLeon, former APA President – West Virginia Psychological Association – January, 2015