ALOHA - D18 Fall column

HONORING THOSE WHO SERVE

            Our colleagues who have chosen to work within the nation’s public sector are overwhelmingly dedicated to fulfilling a higher mission, that of serving society.  The Presidential term of Tim Carmody was very nicely highlighted at our Denver convention.  The presentation of the Harold M. Hildreth Award was particularly moving, honoring long time APA staff Randy Phelps for his decades of support for those working within the Department of Veterans Affairs (VA) and the entire public sector.  President-Elect Tony Puente and former Division President Femina Varghese spoke glowingly of the Division’s appreciation.  Most of us were not aware that APA does not have an office of Veterans or Military Affairs, even though one in 10 adults is a Veteran and one in six Americans is either a military service member, Veteran, or their dependent.  A high priority of President Obama’s Patient Protection and Affordable Care Act (ACA) is the development of interdisciplinary team-based care.  This, of course, has long been the strength of the public sector.

            This summer the VA formally proposed to amend its regulations to permit full practice authority for its Advanced Practice Registered Nurses (APRNs) when they are acting within the scope of their VA employment.  Relying upon its federal supremacy authority, the new regulations would preempt individual State nursing licensure laws to the extent to which they would conflict with full practice authority.  By the close of the public commentary period, an extraordinary 223,000 comments had been received approximately 60% supportive.

            Under the leadership of APA immediate Past-President Barry Anton and President-Elect Tony Puente, 16 former APA Presidents submitted a letter in support of the VA’s proposal.  The APA Practice Organization signed on to a similar statement as a member of the Coalition for Patients’ Rights, along with the American Physical Therapy Association and a number of nursing organizations.  “Our coalition exists because of barriers our members face in providing the care they are trained and certified to deliver….  Efforts to limit scope of practice are unnecessary and impede, rather than enhance, patient access to quality care.”  The American Association of Colleges of Pharmacy also submitted highly supportive comments.  The AMA urged the VA: “to maintain the physician-led model within the VA health system to ensure greater integration and coordination of care for veterans and improve health outcomes.”  One political pundit opined that the AMA had as much credibility on this issue as the NRA did on gun control.

            The Federal Trade Commission (FTC): “FTC staff support the Department’s initiative to maximize its staff capabilities.  Our prior examination of the impact of nursing regulations on health care competition reinforce the VA’s view that the Proposed Rule would: * increase the Veterans Health Administration’s (‘VHA’) ability to provide timely, efficient, and effective primary care services, among others; and * increase veteran access to needed health care, particularly in medically underserved areas, as well as decrease the amount of time veterans spend waiting for patient appointments.  These changes in VA policy may also benefit health care consumers in private markets….”

            “FTC staff recognize the critical importance of patient health and safety, and we defer to federal and state legislators to determine the best balance of policy priorities and to define the appropriate scope of practice for APRNs and other health care professionals.  But even well-intentioned laws and regulations may include unnecessary or overbroad restrictions that limit competition.  Undue regulatory restrictions on APRN practice can harm patients, institutional health care providers such as the VHA, and both public and private third-party payors.  The [FTC] Policy Paper observes, in particular, that state-mandated supervision of APRN practice raises competitive concerns, may impede access to care, and may frustrate the development of innovative and effective models of team-based health care.”

            “Expert bodies, including the Institute of Medicine (‘IOM’), have determined that APRNs are ‘safe and effective as independent providers of many health care services within the scope of their training, licensure, certification and current practice.’  FTC staff have recommended, therefore, that policy makers carefully examine purported safety justifications for restrictions on APRN practice in light of the pertinent evidence, evaluate whether such justifications are well founded, and consider whether less restrictive alternatives would protect patients without imposing undue burdens on competition and undue limits on patients’ access to basic health care services.”

            “FTC staff urge the VA to apply a similar analytical framework.  Granting full practice authority to VA-employed APRNs would benefit both the VA and the patients it serves, consistent with the goals expressed in the Proposed Rule.  APRNs should be able, for example, to evaluate VA patients, order diagnostic tests for them, and manage their treatments without physician involvement or approval as long as they do so within the limits of their education and training.  Furthermore, the VA’s actions and leadership on this issue may send an important signal (and generate useful data) regarding the likely benefits of full practice authority for APRNs.  This, in turn, could influence broader policy considerations, as well as provider market entry outside the VA system, both of which may help to bring the benefits of increased health care competition to an even larger number of U.S. citizens and permanent residents….  We strongly believe that full APRN practice authority can benefit the VA’s patients and the institution itself, by improving access to care, containing costs, and expanding innovation in health care delivery.  To the extent that the VA’s actions would spur additional competition among health care providers and generate additional data in support of safe APRN practice, we believe those benefits could spill over into the private health care market as well.”

Reflections from Senior Visionaries:  Over the past several conventions, the Division has sponsored a panel focusing upon “Meaningful Retirement.”  Each year the audience has steadily increased, and this year we had 75-80 attendees on a Sunday morning.  Long time VA psychologist and most recently fiction book author, Rod Baker, has been a regular.  He reports: “One lament I hear from some who have retired is that they can no longer have Sunday brunch with long-time virtual friends from around the nation.  I have two thoughts.  Those past relationships can still be relevant if you put some time and energy into those friendships, but not if the association is restricted to an annual Christmas card/letter.  Pining for lost relationships will get you nowhere.  If you miss those past contacts, you have to ask yourself what you have done to maintain them or what you can do to re-ignite them as relevant to your new life.  For psychologists who were active in APA, attending a meeting of APA or its Divisions and inviting others to join you to get together to renew friendships might work.  I value, for example, the past presidents’ breakfasts held by Division 18 for the past three APAs.  My second thought is that maybe the focus should be on developing/maintaining and putting new friends and opportunities in your life with those in proximity.  That will still take time and effort.  The decision is yours.”

Bruce Overmier, friend and colleague from APA governance days.  “I also like you sense that we must integrate all levels of care.  To me, this also speaks to APA getting back to recognizing MAs as a valid and appropriate and respected part of the psychological practice (and psychological science) spectrum.  Physicians are finally managing to work with ‘physician assistants,’ maybe we could find it so for our MAs.  I think psychology and APA would be stronger if we did so.  Ah, well; perhaps that is just a foolish hope.  Fighting vested interests is terribly challenging as you well know.”  Aloha,

Pat DeLeon, former APA President – Division 18 – September, 2016

 

 

“A FUNDAMENTAL CONCERN FOR OTHERS....”

Our 124^th Annual Convention:  This year's APA convention in Denver was very pleasant.  The Karl F. Heiser Awards Ceremony, chaired by APA President Susan McDaniel and the Division's Tom DeMaio, was particularly moving.  The Iowa Psychological Association's prescriptive authority success was highlighted; with Bethe Lonning, Brenda Payne, and Greg Febbarro (posthumously) being honored.  Most State Psychological Associations assume that to enact such far reaching legislation over the vocal objections of organized psychiatry is a very expensive undertaking.  It did take Iowa a decade; however, Bethe indicated that since 2011 they had only needed to raise $3,535.50.  The key to their success was grassroots campaigning and sincerely believing that what they were proposing was important for the citizens of Iowa.  It was refreshing that the Board of Directors, under the leadership of Susan and Interim CEO Cynthia Belar, were responsive to engaging society's "issues of the day."  Those supportive of the Black Lives Matter movement had a distinctive presence at the convention and representatives of the Board and Council (Tony Puente and Jennifer Kelly) went out and greeted those marching to show support.  The Board also hosted a meeting of leaders in the police and public safety community to discuss how organized psychology can best help.  We would suggest that our State Psychological Associations should initiate similar involvement at the local level as we know that psychological science has much to contribute in solving societal problems.

Effectively Addressing National and Local Needs:  The Health Resources and Services Administration (HRSA) reports that mental health disorders rank in the top five chronic illnesses in the nation.  An estimated 25% of the adults currently suffer from mental illness and nearly half of all adults will develop at least one mental illness in their lifetime.  In 2007, over 80% of those seen in the emergency room (ER) had mental disorders diagnosed as mood, anxiety, and alcohol related disorders.  The need for integrated care should immediately come to mind.

In Hawaii, Dina Shek, working collaboratively with her colleagues in the William S. Richardson School of Law, has actively engaged students from the various health professional programs (including law) in obtaining clinical experiences within two of the state's federally qualified community health centers (FQHCs).  She is now exploring developing a mental health-focused Medical-Legal Partnership with the Hawaii Disability Rights Center.  During the academic year 2014-2015, the HRSA Graduate Psychology Education (GPE) initiative supported clinical training at 340 partnered sites incorporating interdisciplinary team-based approaches, where approximately 1,900 students and advanced trainees from a variety of professions trained alongside GPE-sponsored trainees.  More than 210 faculty members participated in 42 GPE-sponsored faculty development activities focusing upon a wide variety of emerging topics in mental and behavioral health.  Approximately 22% of the GPE students reported coming from disadvantaged backgrounds and upon graduation 87% intend to pursue employment in medically underserved communities (MUCs).

We would suggest that are these are exactly the types of creative initiatives which State Psychological Associations should explore at annual meetings and/or at interprofessional dinners with their local legal, nursing, pharmacy, social work, and medical associations.  Susan McDaniel's APA Presidency has been all about the opportunities ahead for visionary psychologists.  State Psychological Associations should be the critical catalysts.  "Would go a long way in making the world the better place we so passionately dreamt of."  Aloha,

Pat DeLeon, former APA President – Division 31 – September, 2016

 

Sent from my iPhone

ALOHA - Division 31 September column

“A FUNDAMENTAL CONCERN FOR OTHERS....”

Our 124^th Annual Convention:  This year’s APA convention in Denver was very pleasant.  The Karl F. Heiser Awards Ceremony, chaired by APA President Susan McDaniel and the Division’s Tom DeMaio, was particularly moving.  The Iowa Psychological Association’s prescriptive authority success was highlighted; with Bethe Lonning, Brenda Payne, and Greg Febbarro (posthumously) being honored.  Most State Psychological Associations assume that to enact such far reaching legislation over the vocal objections of organized psychiatry is a very expensive undertaking.  It did take Iowa a decade; however, Bethe indicated that since 2011 they had only needed to raise $3,535.50.  The key to their success was grassroots campaigning and sincerely believing that what they were proposing was important for the citizens of Iowa.  It was refreshing that the Board of Directors, under the leadership of Susan and Interim CEO Cynthia Belar, were responsive to engaging society’s “issues of the day.”  Those supportive of the Black Lives Matter movement had a distinctive presence at the convention and representatives of the Board and Council (Tony Puente and Jennifer Kelly) went out and greeted those marching to show support.  The Board also hosted a meeting of leaders in the police and public safety community to discuss how organized psychology can best help.  We would suggest that our State Psychological Associations should initiate similar involvement at the local level as we know that psychological science has much to contribute in solving societal problems.

Effectively Addressing National and Local Needs:  The Health Resources and Services Administration (HRSA) reports that mental health disorders rank in the top five chronic illnesses in the nation.  An estimated 25% of the adults currently suffer from mental illness and nearly half of all adults will develop at least one mental illness in their lifetime.  In 2007, over 80% of those seen in the emergency room (ER) had mental disorders diagnosed as mood, anxiety, and alcohol related disorders.  The need for integrated care should immediately come to mind.

In Hawaii, Dina Shek, working collaboratively with her colleagues in the William S. Richardson School of Law, has actively engaged students from the various health professional programs (including law) in obtaining clinical experiences within two of the state’s federally qualified community health centers (FQHCs).  She is now exploring developing a mental health-focused Medical-Legal Partnership with the Hawaii Disability Rights Center.  During the academic year 2014-2015, the HRSA Graduate Psychology Education (GPE) initiative supported clinical training at 340 partnered sites incorporating interdisciplinary team-based approaches, where approximately 1,900 students and advanced trainees from a variety of professions trained alongside GPE-sponsored trainees.  More than 210 faculty members participated in 42 GPE-sponsored faculty development activities focusing upon a wide variety of emerging topics in mental and behavioral health.  Approximately 22% of the GPE students reported coming from disadvantaged backgrounds and upon graduation 87% intend to pursue employment in medically underserved communities (MUCs).

We would suggest that are these are exactly the types of creative initiatives which State Psychological Associations should explore at annual meetings and/or at interprofessional dinners with their local legal, nursing, pharmacy, social work, and medical associations.  Susan McDaniel’s APA Presidency has been all about the opportunities ahead for visionary psychologists.  State Psychological Associations should be the critical catalysts.  “Would go a long way in making the world the better place we so passionately dreamt of.”  Aloha,

Pat DeLeon, former APA President – Division 31 – September, 2016

 

ALOHA - HPA column

“ROCKY MOUNTAIN HIGH”

            The 124^th APA Convention:  Denver was a very pleasant convention.  For most of us, the hotels were right across from the convention center and the weather was nearly perfect.  One could take a new train directly to and from the airport.  It was particularly nice to see HPA visionaries Kathy McNamara and Jill Oliveria-Gray being recognized by their peers for their outstanding accomplishments over the years, as well as having the time to chat with Division 55 newsletter editor Judi Steinman and former HPA President Karuna Joshi-Peters.  HPA Executive Officer Ray Folen was naturally ever-present – at times, in his role as President of the National Register.  At one of the events focusing upon prescriptive authority (RxP), Morgan Sammons inquired as to how much money Bethe Lonning (who received the Karl F. Heiser Award) had to raise for her extraordinarily impressive Iowa success earlier this year.  To the amazement of everyone, Bethe indicated that since 2011 they had raised $3,535.50.  The key to their success was grassroots campaigning and believing that what they were proposing was important for the citizens of Iowa.  Accordingly, Hawaii should be in a very good position for the coming legislative year.

Unlike last year at the Toronto convention where, at times, it seemed that the Hoffman report was of intense interest to almost everyone, there was very little discussion of it this year outside of the halls of the Council of Representatives.  APA President Susan McDaniel and Former President Dorothy Cantor co-hosted what I felt was a highly productive meeting of a number APA Past Presidents with the current Interim CEO Cynthia Belar and the Board of Directors, offering our collective wisdom and suggestions on a wide range of issues facing APA today.  During one of the lunch breaks, the Black Lives Matter movement was quite evident and representatives of the Board and Council (Tony Puente and Jennifer Kelly) went out and greeted those marching to show support.  Also, given the times, the Board hosted a meeting of leaders in the police and public safety community to discuss how organized psychology can best help.  We know that psychological science has much to contribute in solving societal problems.

For the past several years, I have had the pleasure of chairing a panel on “Meaningful Retirement.”  Our audience has steadily grown and this year, even on a Sunday morning, there were 75-80 present.  Afterwards, one couple shared with us that they had stayed another day just to attend.  Ellen Cole, Rod Baker, and Walter Penk described their personal journeys and their successes in continuing to be involved in activities which they found personally meaningful.  Ellen, who was Director of Alaska Pacific University’s Master of Science in Counseling Psychology Program and a former President of the Alaska Psychological Association, described being a graduate student once again and obtaining her Masters in Positive Psychology.  Her recent books focus upon the unique experiences of female professionals.  Rod is actively engaged in writing fiction books – two books of the Rune Master Saga and two books describing the adventures of a small town college English professor helping the FBI.  Walter, last year’s recipient of an APA Gold Medal Award, stressed the importance of physical and intellectual stimulation, while continuing to help our nation’s veterans transition back to civilian and university life.

Just prior to the convention, my wife and I had attended a local community theatre presentation addressing the realization of four women that they were “getting old.”  One actress commented that she had always known there were several generations, but she thought the oldest were simply born that way – not that she herself would ever become old.  As Rod keeps pointing out: “If you don’t like what you are doing, you have only one person to talk to.”  As the overall APA membership dramatically illustrates, psychology is a maturing profession and an increasing number of our colleagues are currently facing a new, and for many a totally unexpected, phase of their lives.  Teaching, writing, and seeing patients may at one time have once been all consuming; however, the future requires change.  Over dinner. Francine Butler, who for decades was the CEO for the Biofeedback Society of America (now AAPB), reflected as to how the two of us have developed virtual “villages” of friendships.  Our previous employments allowed us to be in regular contact with colleagues all over the nation.  However, as a direct result, we simply cannot have Sunday brunch with most of our long-time friends, given the distances involved.

The Past Can Provide Vision For The Future:  This summer, we had the opportunity to attend several inspirational events held in our Nation’s Capital, including at the U.S. Botanical Gardens and the National Library of Medicine (NIH), honoring the vision and dedication of Nainoa Thompson and Bruce Blankenfeld representing the Polynesian Voyaging Society, as the Hokule’a continues its travels across the oceans on its world-wide voyage.  Back in 1948, the World Health Organization pronounced that health is “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”  Native Hawaiians, along with other indigenous peoples, experience disproportionately adverse health disparities – including educational and employment opportunities.  The Native Hawaiian Renaissance, which is symbolized by the Hokule’a, hopefully represents an historical turning point.  Listening to Nainoa describe the aspirations of his people, and especially those of the next generation, one could not help but appreciate the importance of the cultural/psychosocial aspects to one’s overall quality of life, including health care.

In April, 1992, Kauai’s Ruby Takanishi served as Executive Director of the Carnegie Council on Adolescent Development when it released it far-reaching report Fateful Choices: Healthy Youth for the 21^st Century.  Ruby also served as a Congressional Fellow in the White House and for U.S. Senator Daniel K. Inouye.  She spent four years working on the APA staff, two of which as Director of the Office of Scientific Affairs.  Nearly a quarter of a century later, the observations of that seminal report are still highly relevant.  “At The Crossroads.  The lives of children and adolescents cannot be put on hold until the larger social, economic, and political problems are solved.  American youth are entitled to health-enhancing action now.  To safeguard their health is not an act of charity.  It is a reaffirmation of a humane society and an investment in the nation’s future.”

Describing our national crisis – “In the 1990s, poor health among American adolescents has reached crisis proportions: large numbers of adolescents suffer from depression that may lead to suicide; they jeopardize their future by abusing illegal drugs and alcohol, and by smoking; they engage in premature, unprotected sexual activity; they are victims or perpetrators of violence; they lack proper nutrition and exercise.  Their glaring need for appropriate health services is largely ignored.”  “Health professionals should be prepared to support the development of adolescents, to understand their problems, and to respond to them with much confidence-inspiring empathy….  Health professionals should aim to work with families of young adolescents.”  The major cause of disability among adolescents between 10-18 was mental disorders with depression affecting between seven to 33 percent of adolescents, depending on its definition, assessment, and severity.  One must rhetorically ask: Have we progressed significantly over the past decade?  The enactment of President Obama’s landmark Patient Protection and Affordable Care Act (ACA) does begin to respond to one critical recommendation: “Full health insurance coverage for all adolescents must include preventive services.  Funding for such services as school-linked health centers and life science education should either be provided or obtained through the reallocation of existing funds.”  Serving on Ruby’s Council were three visionary bipartisan Senate leaders – Daniel K. Inouye, James Jeffords, and Nancy Kassebaum-Baker.  “I’ve seen it raining fire in the sky.”  Aloha,

Pat DeLeon, former APA President -- HPA -- September, 2016

 

“ROCKY MOUNTAIN HIGH"

 The 124^th APA Convention:  Denver was a very pleasant convention.  For most of us, the hotels were right across from the convention center and the weather was nearly perfect.  One could take a new train directly to and from the airport.  It was particularly nice to see HPA visionaries Kathy McNamara and Jill Oliveria-Gray being recognized by their peers for their outstanding accomplishments over the years, as well as having the time to chat with Division 55 newsletter editor Judi Steinman and former HPA President Karuna Joshi-Peters.  HPA Executive Officer Ray Folen was naturally ever-present – at times, in his role as President of the National Register.  At one of the events focusing upon prescriptive authority (RxP), Morgan Sammons inquired as to how much money Bethe Lonning (who received the Karl F. Heiser Award) had to raise for her extraordinarily impressive Iowa success earlier this year.  To the amazement of everyone, Bethe indicated that since 2011 they had raised $3,535.50.  The key to their success was grassroots campaigning and believing that what they were proposing was important for the citizens of Iowa.  Accordingly, Hawaii should be in a very good position for the coming legislative year.

Unlike last year at the Toronto convention where, at times, it seemed that the Hoffman report was of intense interest to almost everyone, there was very little discussion of it this year outside of the halls of the Council of Representatives.  APA President Susan McDaniel and Former President Dorothy Cantor co-hosted what I felt was a highly productive meeting of a number APA Past Presidents with the current Interim CEO Cynthia Belar and the Board of Directors, offering our collective wisdom and suggestions on a wide range of issues facing APA today.  During one of the lunch breaks, the Black Lives Matter movement was quite evident and representatives of the Board and Council (Tony Puente and Jennifer Kelly) went out and greeted those marching to show support.  Also, given the times, the Board hosted a meeting of leaders in the police and public safety community to discuss how organized psychology can best help.  We know that psychological science has much to contribute in solving societal problems.

For the past several years, I have had the pleasure of chairing a panel on "Meaningful Retirement."  Our audience has steadily grown and this year, even on a Sunday morning, there were 75-80 present.  Afterwards, one couple shared with us that they had stayed another day just to attend.  Ellen Cole, Rod Baker, and Walter Penk described their personal journeys and their successes in continuing to be involved in activities which they found personally meaningful.  Ellen, who was Director of Alaska Pacific University's Master of Science in Counseling Psychology Program and a former President of the Alaska Psychological Association, described being a graduate student once again and obtaining her Masters in Positive Psychology.  Her recent books focus upon the unique experiences of female professionals.  Rod is actively engaged in writing fiction books – two books of the Rune Master Saga and two books describing the adventures of a small town college English professor helping the FBI.  Walter, last year's recipient of an APA Gold Medal Award, stressed the importance of physical and intellectual stimulation, while continuing to help our nation's veterans transition back to civilian and university life.

Just prior to the convention, my wife and I had attended a local community theatre presentation addressing the realization of four women that they were "getting old."  One actress commented that she had always known there were several generations, but she thought the oldest were simply born that way – not that she herself would ever become old.  As Rod keeps pointing out: "If you don't like what you are doing, you have only one person to talk to."  As the overall APA membership dramatically illustrates, psychology is a maturing profession and an increasing number of our colleagues are currently facing a new, and for many a totally unexpected, phase of their lives.  Teaching, writing, and seeing patients may at one time have once been all consuming; however, the future requires change.  Over dinner. Francine Butler, who for decades was the CEO for the Biofeedback Society of America (now AAPB), reflected as to how the two of us have developed virtual "villages" of friendships.  Our previous employments allowed us to be in regular contact with colleagues all over the nation.  However, as a direct result, we simply cannot have Sunday brunch with most of our long-time friends, given the distances involved.

The Past Can Provide Vision For The Future:  This summer, we had the opportunity to attend several inspirational events held in our Nation's Capital, including at the U.S. Botanical Gardens and the National Library of Medicine (NIH), honoring the vision and dedication of Nainoa Thompson and Bruce Blankenfeld representing the Polynesian Voyaging Society, as the Hokule'a continues its travels across the oceans on its world-wide voyage.  Back in 1948, the World Health Organization pronounced that health is "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity."  Native Hawaiians, along with other indigenous peoples, experience disproportionately adverse health disparities – including educational and employment opportunities.  The Native Hawaiian Renaissance, which is symbolized by the Hokule'a, hopefully represents an historical turning point.  Listening to Nainoa describe the aspirations of his people, and especially those of the next generation, one could not help but appreciate the importance of the cultural/psychosocial aspects to one's overall quality of life, including health care.

In April, 1992, Kauai's Ruby Takanishi served as Executive Director of the Carnegie Council on Adolescent Development when it released it far-reaching report Fateful Choices: Healthy Youth for the 21^st Century.  Ruby also served as a Congressional Fellow in the White House and for U.S. Senator Daniel K. Inouye.  She spent four years working on the APA staff, two of which as Director of the Office of Scientific Affairs.  Nearly a quarter of a century later, the observations of that seminal report are still highly relevant.  "At The Crossroads.  The lives of children and adolescents cannot be put on hold until the larger social, economic, and political problems are solved.  American youth are entitled to health-enhancing action now.  To safeguard their health is not an act of charity.  It is a reaffirmation of a humane society and an investment in the nation's future."

Describing our national crisis – "In the 1990s, poor health among American adolescents has reached crisis proportions: large numbers of adolescents suffer from depression that may lead to suicide; they jeopardize their future by abusing illegal drugs and alcohol, and by smoking; they engage in premature, unprotected sexual activity; they are victims or perpetrators of violence; they lack proper nutrition and exercise.  Their glaring need for appropriate health services is largely ignored."  "Health professionals should be prepared to support the development of adolescents, to understand their problems, and to respond to them with much confidence-inspiring empathy….  Health professionals should aim to work with families of young adolescents."  The major cause of disability among adolescents between 10-18 was mental disorders with depression affecting between seven to 33 percent of adolescents, depending on its definition, assessment, and severity.  One must rhetorically ask: Have we progressed significantly over the past decade?  The enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA) does begin to respond to one critical recommendation: "Full health insurance coverage for all adolescents must include preventive services.  Funding for such services as school-linked health centers and life science education should either be provided or obtained through the reallocation of existing funds."  Serving on Ruby's Council were three visionary bipartisan Senate leaders – Daniel K. Inouye, James Jeffords, and Nancy Kassebaum-Baker.  "I've seen it raining fire in the sky."  Aloha,

Pat DeLeon, former APA President -- HPA -- September, 2016

 

Sent from my iPhone

FLY DOWN THE HIGHWAY

The Department of Veterans Affairs (VA):  The VA is the largest employer of psychologists and nurses and over the years, has done an outstanding job of providing high quality health care while simultaneously furthering the utilization of non-physician providers of all disciplines.  Thanks to the vision of Toni and Bob Zeiss and the support of Ken Jones the VA, which has long supported psychology internships, is expected to provide approximately 440 postdoctoral positions in the coming academic year.  This spring the VA proposed to amend its regulations to permit full practice authority for advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.  "This would permit VA to use its health care resources more effectively and in a manner that is consistent with the role of APRNs in the non-VA health care sector, while maintaining the patient-centered, safe, high-quality health care that veterans receive from VA."  At the closing of the public comment period on July 25^th, over 214,000 comments had been received.  The AMA urged the VA: "to maintain the physician-led model within the VA health system to ensure greater integration and coordination of care for veterans and improve health outcomes."  One political pundit opined that the AMA had as much credibility on this issue as the NRA did on gun control.

            Under the leadership of APA immediate Past-President Barry Anton and President-elect Tony Puente, 16 former APA Presidents submitted a letter in support of the VA's proposal.  "Dear Mr. Secretary:  As former Presidents of the American Psychological Association (APA), the nation's largest organization of psychologists with over 117,000 members, we urge you to ensure that the Department of Veterans Affairs (VA) allows its professional staff to work to the full scope of their practice to improve access to timely, effective, high-quality care for Veterans.  We, and the current leadership of APA, believe that expanding prescriptive authority within the VA for qualified nurses and doctoral-level psychologists is a fundamental and urgent component of a redesigned, improved 'MyVA' integrated plan.

            "One of the key recommendations from the landmark Institute of Medicine (IOM) report 'The Future of Nursing' stated that 'nurses should practice to the full extent of their education and training.'  As colleagues equally committed to providing care for Veterans both inside and outside the VA system, we concur with the IOM that 'nurses can and should play a fundamental role' in transforming care in this country, and that 'the power to improve the current regulatory, business, and organizational conditions does not rest solely with nurses; government, businesses, health care organizations, professional associations, and the insurance industry must all play a role.  Working together, these many diverse parties can help ensure that the health care system provides seamless, affordable, quality care that is accessible to all and leads to improved health outcomes.'  Mr. Secretary, you have been instrumental in keeping the VA focused on what is best for the Veteran, and we believe that to do so requires the VA to ensure that its clinical staff is operating at its highest capacity.

"In a similar vein, we expect that the VA also will soon make the internal policy changes necessary to recognize prescriptive authority for appropriately trained and certified psychologists within the VA system.  The Department of Defense (DoD) has granted this authority to its specialized psychologists for over 18 years, with zero adverse effects or complaints during this entire period.  The US Public Health Service Commissioned Corps similarly allows psychologists with specific training beyond their doctoral degrees to prescribe a set of medications and meet the urgent needs of their populations, which include citizens in Indian Country.  Illinois became the latest state to grant this authority to psychologists with additional degrees in psychopharmacology and certification.  It is clear that the VA, in the face of increasing demand for mental health care and recognized access difficulties in rural areas specifically, must remain a pioneer in the health care arena by allowing nurse practitioners and psychologists to serve Veterans with the expertise and dedication they employ in the DoD, USPHS, and private sectors.

"We would be happy to meet with you and your Undersecretary of Health, Dr. David Shulkin, to discuss the implementation of prescriptive authority within the VA…."  Two additional Presidential colleagues requested being added to the letter; however, the submission date had already passed.  Our sincerest appreciation to APA's Heather O'Beirne Kelly for her outstanding assistance in making our collective voice heard on behalf of our nation's Veterans.

            A similarly supportive endorsement was submitted by Dr. Lucinda Maine, Executive VP and CEO of the American Association of Colleges of Pharmacy.  "The American Association of Colleges of Pharmacy (AACP) appreciates the opportunity to comment on the proposed regulation… and is supportive of the proposal to 'permit full practice authority for all Veterans Administration advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.'  We draw upon significant experience with advanced practice authority for pharmacists and other health care providers in preparing these comments.

            "AACP recognizes that APRNs are increasingly important providers of primary care services in the non-VA health care sector and applauds the VA for integrating these skilled health professionals into the VHA.  We view this as an excellent opportunity to 'wisely manage its resources and fully utilize the skills of its health care providers to the full extent of their education, training and certification.'  We support the VA taking the initiative to 'establish additional professional qualifications an individual must possess to be appointed as an APRN with VA.'  The VA's proposal to standardize the APRN full practice authority by reducing the confounding factor of state regulation is an important step that allows for more consistent management of patient, provider and administrator expectations within the VHA.  This action is an important step in increasing patient access to primary care services, especially, as you recognize, in medically underserved areas.

            "AACP is a strong proponent of patient-centered team-based care.  As a founding member of the Interprofessional Education Collaborative (IPEC) we have worked closely with our colleagues across academic medicine, nursing, dentistry and public health to teach future health professionals how to most effectively work together.  Quite recently the IPEC organization expanded to include 9 additional health professions education associations.  As this includes the Association of Schools of Allied Health Professions, IPEC now includes virtually all the health disciplines.  Optimizing the deployment of every clinician is the only pathway to insuring access to care for all, especially special populations like veterans who so often are in rural or otherwise underserved communities.  Translating this work into the care delivery systems our graduates will serve is also a high priority for IPEC.

            "AACP shares the VA's concern about the timely provision of high-quality care, particularly primary care, by qualified healthcare professionals in locations readily accessible to the larger percentage of veterans.  Towards that end, AACP also encourages the VA to consider proposing a similar set of rules for pharmacists.  Like APRNs, pharmacists in the VHA are subject to the congressionally mandated qualifications.  The VA… is authorized to regulate the professional activities and establish qualifications and conditions of employment of pharmacists as it does APRNs.  Your proposal reflects a model that is well established in the Indian Health Service where guidance was issued in 1996 regarding designating pharmacists as primary care providers with prescriptive authority (Special General Memorandum 96-2).

            "The VHA has been a valued partner with academic pharmacy for decades and VA leadership recognizes the value pharmacists add to the health care team through their collaborative approach to patient care.  The Patient Aligned Care Team (PACT) provides ample evidence that pharmacists provide great, and could provide even greater, value to veterans and other members of the primary care team if they were consistently supported and privileged in a manner similar to that proposed in this rule for APRNs.

            "With an academy of researchers and practitioners focused on care improvement and team-based care, AACP offers the VA the opportunity to initiate a discussion that can create even greater support for and value in the proposed rules related to APRNs through collaboration with pharmacists and other non-physician providers that are authorized with 'full practice authority.'"  A particularly significant supportive communication also came from the Federal Trade Commission (FTC).

            Interesting Reflections:  "The year was 1988 – now 28 years ago – and I had been appointed as Chief, Behavioral Health Services at the PHS/IHS Santa Fe Service Unit, in Santa Fe, New Mexico.  Limited, dependent prescriptive privileges (RxP) were granted to me by the Medical Director; i.e., a limited formulary excluding scheduled drugs, and dependent upon his supervision.  I had the support of the IHS Albuquerque area psychiatrist with whom I spoke regarding every case; review and support was granted by the New Mexico Psychological Association ethics committee.  Slightly less than two years later I was to leave that post – by which time, after being invited to speak before the U.S. Senate Committee on Indian Affairs, thousands of letters of complaint had been sent to the Medical Director of IHS by psychiatrists across the nation, though over three hundred patients had been seen, with no adverse effects (and with enormous support from the physicians working in IHS).  Note that in the years subsequent, there has been no nimiety of psychiatric physicians seeking to work or even volunteer in those pueblos of the Albuquerque area!

            "From those turbulent beginnings, and due both to vision and persistence, psychologists have been given authority to exercise prescriptive privileges in Iowa, Illinois, New Mexico, and Louisiana, as well as in the Public Health Service, the U.S. military, and Guam.  A cursory look at the New Mexico Board of Psychologist Examiners website reveals 40 names of persons with active certification as prescribing psychologists.  Though by no means thorough, an internet search turns up approximately 11 who are in PHS/IHS, state or federal agencies, or mental health facilities.  Many psychologists having national prominence in this area have now completed careers in federal services in the almost 30 years since those days in PHS/IHS.  We have indeed 'come a long way!'

            "Yet there is much to be done.  For example, in Texas alone, 185 of the 254 counties have no psychiatrist.  Nurse Practitioners have been quite successful in extending their scope of practice to include prescriptive privileges – in many venues.  In fact, the future of primary care may well transfer to nurse practitioners, with the increasing specialization of medicine and the decreased number of young persons seeking careers in primary medicine, where reimbursement rates are far less than in high technology.  Yet, in Texas, and in many other states, the likelihood of expanding the scope of practice for psychology is not great.  I argue that is far more likely to occur when the basis is need (rather than greed).  Wouldn't it be interesting if there were many programs to train psychologists to prescribe – at no cost to the person – in return for a two-year commitment to work in an underserved area?  Wouldn't it be exciting if there were a national recognition of the absolute necessity to increase the array of health resources in now underserved areas – of which psychology could be a part?  At 75, I expect that I shall not live to see it, but I can dream, can't I? (Floyd Jennings)."  Ray Folen, Executive Director of the Hawaii Psychological Association: "Over the last 10 years while at Tripler Army Medical Center I had written 3,178 prescriptions and my colleague Mike Kellar had written 5,780.  No adverse events."  Psychology prides itself on being one of the learned professions.  Yet, whenever Beth Rom-Rymer provides an update on the exciting implementation of her Illinois success, one of our largest Divisions declines to publish her comments on their e-mail list serve; notwithstanding that RxP is APA policy.  "Our progeny have stars in their eyes.  Let's help them realize their dreams (Beth)."  Perhaps this Division hopes to protect their membership from the future?  "You don't know what I've done."  Aloha,

Pat DeLeon, former APA President – Division 29 – August, 2016

 

Sent from my iPhone

Division 29 August column

“FLY DOWN THE HIGHWAY”

            The Department of Veterans Affairs (VA):  The VA is the largest employer of psychologists and nurses and over the years, has done an outstanding job of providing high quality health care while simultaneously furthering the utilization of non-physician providers of all disciplines.  Thanks to the vision of Toni and Bob Zeiss and the support of Ken Jones the VA, which has long supported psychology internships, is expected to provide approximately 440 postdoctoral positions in the coming academic year.  This spring the VA proposed to amend its regulations to permit full practice authority for advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.  “This would permit VA to use its health care resources more effectively and in a manner that is consistent with the role of APRNs in the non-VA health care sector, while maintaining the patient-centered, safe, high-quality health care that veterans receive from VA.”  At the closing of the public comment period on July 25^th, over 214,000 comments had been received.  The AMA urged the VA: “to maintain the physician-led model within the VA health system to ensure greater integration and coordination of care for veterans and improve health outcomes.”  One political pundit opined that the AMA had as much credibility on this issue as the NRA did on gun control.

            Under the leadership of APA immediate Past-President Barry Anton and President-elect Tony Puente, 16 former APA Presidents submitted a letter in support of the VA’s proposal.  “Dear Mr. Secretary:  As former Presidents of the American Psychological Association (APA), the nation’s largest organization of psychologists with over 117,000 members, we urge you to ensure that the Department of Veterans Affairs (VA) allows its professional staff to work to the full scope of their practice to improve access to timely, effective, high-quality care for Veterans.  We, and the current leadership of APA, believe that expanding prescriptive authority within the VA for qualified nurses and doctoral-level psychologists is a fundamental and urgent component of a redesigned, improved ‘MyVA’ integrated plan.

            “One of the key recommendations from the landmark Institute of Medicine (IOM) report ‘The Future of Nursing’ stated that ‘nurses should practice to the full extent of their education and training.’  As colleagues equally committed to providing care for Veterans both inside and outside the VA system, we concur with the IOM that ‘nurses can and should play a fundamental role’ in transforming care in this country, and that ‘the power to improve the current regulatory, business, and organizational conditions does not rest solely with nurses; government, businesses, health care organizations, professional associations, and the insurance industry must all play a role.  Working together, these many diverse parties can help ensure that the health care system provides seamless, affordable, quality care that is accessible to all and leads to improved health outcomes.’  Mr. Secretary, you have been instrumental in keeping the VA focused on what is best for the Veteran, and we believe that to do so requires the VA to ensure that its clinical staff is operating at its highest capacity.

“In a similar vein, we expect that the VA also will soon make the internal policy changes necessary to recognize prescriptive authority for appropriately trained and certified psychologists within the VA system.  The Department of Defense (DoD) has granted this authority to its specialized psychologists for over 18 years, with zero adverse effects or complaints during this entire period.  The US Public Health Service Commissioned Corps similarly allows psychologists with specific training beyond their doctoral degrees to prescribe a set of medications and meet the urgent needs of their populations, which include citizens in Indian Country.  Illinois became the latest state to grant this authority to psychologists with additional degrees in psychopharmacology and certification.  It is clear that the VA, in the face of increasing demand for mental health care and recognized access difficulties in rural areas specifically, must remain a pioneer in the health care arena by allowing nurse practitioners and psychologists to serve Veterans with the expertise and dedication they employ in the DoD, USPHS, and private sectors.

“We would be happy to meet with you and your Undersecretary of Health, Dr. David Shulkin, to discuss the implementation of prescriptive authority within the VA….”  Two additional Presidential colleagues requested being added to the letter; however, the submission date had already passed.  Our sincerest appreciation to APA’s Heather O’Beirne Kelly for her outstanding assistance in making our collective voice heard on behalf of our nation’s Veterans.

            A similarly supportive endorsement was submitted by Dr. Lucinda Maine, Executive VP and CEO of the American Association of Colleges of Pharmacy.  “The American Association of Colleges of Pharmacy (AACP) appreciates the opportunity to comment on the proposed regulation… and is supportive of the proposal to ‘permit full practice authority for all Veterans Administration advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.’  We draw upon significant experience with advanced practice authority for pharmacists and other health care providers in preparing these comments.

            “AACP recognizes that APRNs are increasingly important providers of primary care services in the non-VA health care sector and applauds the VA for integrating these skilled health professionals into the VHA.  We view this as an excellent opportunity to ‘wisely manage its resources and fully utilize the skills of its health care providers to the full extent of their education, training and certification.’  We support the VA taking the initiative to ‘establish additional professional qualifications an individual must possess to be appointed as an APRN with VA.’  The VA’s proposal to standardize the APRN full practice authority by reducing the confounding factor of state regulation is an important step that allows for more consistent management of patient, provider and administrator expectations within the VHA.  This action is an important step in increasing patient access to primary care services, especially, as you recognize, in medically underserved areas.

            “AACP is a strong proponent of patient-centered team-based care.  As a founding member of the Interprofessional Education Collaborative (IPEC) we have worked closely with our colleagues across academic medicine, nursing, dentistry and public health to teach future health professionals how to most effectively work together.  Quite recently the IPEC organization expanded to include 9 additional health professions education associations.  As this includes the Association of Schools of Allied Health Professions, IPEC now includes virtually all the health disciplines.  Optimizing the deployment of every clinician is the only pathway to insuring access to care for all, especially special populations like veterans who so often are in rural or otherwise underserved communities.  Translating this work into the care delivery systems our graduates will serve is also a high priority for IPEC.

            “AACP shares the VA’s concern about the timely provision of high-quality care, particularly primary care, by qualified healthcare professionals in locations readily accessible to the larger percentage of veterans.  Towards that end, AACP also encourages the VA to consider proposing a similar set of rules for pharmacists.  Like APRNs, pharmacists in the VHA are subject to the congressionally mandated qualifications.  The VA… is authorized to regulate the professional activities and establish qualifications and conditions of employment of pharmacists as it does APRNs.  Your proposal reflects a model that is well established in the Indian Health Service where guidance was issued in 1996 regarding designating pharmacists as primary care providers with prescriptive authority (Special General Memorandum 96-2).

            “The VHA has been a valued partner with academic pharmacy for decades and VA leadership recognizes the value pharmacists add to the health care team through their collaborative approach to patient care.  The Patient Aligned Care Team (PACT) provides ample evidence that pharmacists provide great, and could provide even greater, value to veterans and other members of the primary care team if they were consistently supported and privileged in a manner similar to that proposed in this rule for APRNs.

            “With an academy of researchers and practitioners focused on care improvement and team-based care, AACP offers the VA the opportunity to initiate a discussion that can create even greater support for and value in the proposed rules related to APRNs through collaboration with pharmacists and other non-physician providers that are authorized with ‘full practice authority.’”  A particularly significant supportive communication also came from the Federal Trade Commission (FTC).

            Interesting Reflections:  “The year was 1988 – now 28 years ago – and I had been appointed as Chief, Behavioral Health Services at the PHS/IHS Santa Fe Service Unit, in Santa Fe, New Mexico.  Limited, dependent prescriptive privileges (RxP) were granted to me by the Medical Director; i.e., a limited formulary excluding scheduled drugs, and dependent upon his supervision.  I had the support of the IHS Albuquerque area psychiatrist with whom I spoke regarding every case; review and support was granted by the New Mexico Psychological Association ethics committee.  Slightly less than two years later I was to leave that post – by which time, after being invited to speak before the U.S. Senate Committee on Indian Affairs, thousands of letters of complaint had been sent to the Medical Director of IHS by psychiatrists across the nation, though over three hundred patients had been seen, with no adverse effects (and with enormous support from the physicians working in IHS).  Note that in the years subsequent, there has been no nimiety of psychiatric physicians seeking to work or even volunteer in those pueblos of the Albuquerque area!

            “From those turbulent beginnings, and due both to vision and persistence, psychologists have been given authority to exercise prescriptive privileges in Iowa, Illinois, New Mexico, and Louisiana, as well as in the Public Health Service, the U.S. military, and Guam.  A cursory look at the New Mexico Board of Psychologist Examiners website reveals 40 names of persons with active certification as prescribing psychologists.  Though by no means thorough, an internet search turns up approximately 11 who are in PHS/IHS, state or federal agencies, or mental health facilities.  Many psychologists having national prominence in this area have now completed careers in federal services in the almost 30 years since those days in PHS/IHS.  We have indeed ‘come a long way!’

            “Yet there is much to be done.  For example, in Texas alone, 185 of the 254 counties have no psychiatrist.  Nurse Practitioners have been quite successful in extending their scope of practice to include prescriptive privileges – in many venues.  In fact, the future of primary care may well transfer to nurse practitioners, with the increasing specialization of medicine and the decreased number of young persons seeking careers in primary medicine, where reimbursement rates are far less than in high technology.  Yet, in Texas, and in many other states, the likelihood of expanding the scope of practice for psychology is not great.  I argue that is far more likely to occur when the basis is need (rather than greed).  Wouldn’t it be interesting if there were many programs to train psychologists to prescribe – at no cost to the person – in return for a two-year commitment to work in an underserved area?  Wouldn’t it be exciting if there were a national recognition of the absolute necessity to increase the array of health resources in now underserved areas – of which psychology could be a part?  At 75, I expect that I shall not live to see it, but I can dream, can’t I? (Floyd Jennings).”  Ray Folen, Executive Director of the Hawaii Psychological Association: “Over the last 10 years while at Tripler Army Medical Center I had written 3,178 prescriptions and my colleague Mike Kellar had written 5,780.  No adverse events.”  Psychology prides itself on being one of the learned professions.  Yet, whenever Beth Rom-Rymer provides an update on the exciting implementation of her Illinois success, one of our largest Divisions declines to publish her comments on their e-mail list serve; notwithstanding that RxP is APA policy.  “Our progeny have stars in their eyes.  Let’s help them realize their dreams (Beth).”  Perhaps this Division hopes to protect their membership from the future?  “You don’t know what I’ve done.”  Aloha,

Pat DeLeon, former APA President – Division 29 – August, 2016