BEING RESPONSIVE TO SOCIETAL CHANGE

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

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

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

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

 

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

SLOW DOWN, YOU MOVE TOO FAST

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

LOOKING TO THE FUTURE – PERHAPS THROUGH THE LOOKING GLASS?

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

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

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

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

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

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

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

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

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

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

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

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

TIMELY EVOLUTION

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

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

 

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

 

THE LAND OF VISIONARIES

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

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

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

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

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

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

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

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

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

WHAT IS PAST IS PROLOGUE

Looking Back – A View of the Future?  Nearly a decade and a half ago, the President's Committee on Advisors on Science and Technology submitted the report of their Panel on Educational Technology "On the Use of Technology to Strengthen K-12 Education in the United States."  "In an era of increasing international economic competition, the quality of America's elementary and secondary schools could determine whether our children hold highly compensated, high-skill jobs that add significant value within the integrated global economy of the twenty-first century or compete with workers in developing countries for the provision of commodity products and low-value-added services at wage rates comparable to those received by third world laborers.  Moreover, it is widely believed that workers in the next century will require not just a larger set of facts or a larger repertoire of specific skills, but the capacity to readily acquire new knowledge, to solve new problems, and to employ creativity and critical thinking in the design of new approaches to existing problems….  During a period in which technology has fundamentally transformed America's offices, factories, and retail establishments, however, its impact within our nation's classrooms has generally been quite modest."

Psychologist John Bransford served on that Panel which made several high-level strategic recommendations that are clearly relevant today, both for education and for health care reform.  1. Focus on learning withtechnology, not about technology.  Although both are worthy of attention, it is important to distinguish between technology as a subject area and the use of technology to facilitate learning about any subject area.  2. Emphasize content and pedagogy, and not just hardware.  Particular attention should be given to the potential role of technology in achieving the goals of educational reform efforts through the use of new pedagogic methods focusing on the development of higher-order reasoning and problem-solving skills.  3. Give special attention to professional development.  The substantial investment in infrastructure that is necessary will be largely wasted if teachers (and today's clinicians) are not provided with the preparation and support they will need to effectively integrate information technologies into their teaching (and clinical practice).  At that time, only about 15 percent of the typical educational technology budget was devoted to professional development, a figure which the Panel felt should at least be doubled.  Ongoing mentoring, consultative support, and the allocation of time are absolutely necessary.  4.  Engage in realistic budgeting.  While voluntarism and corporate equipment donations may be of both direct and indirect benefit under certain circumstances, White House policy should be based on a realistic assessment of the relatively limited direct economic contribution such efforts can be expected to make overall.  Educational technology is an unusually high-return investment (in both economic and social terms) in America's future.  5. Ensure equitable, universal access.  Access to knowledge-building and communication tools based on computing and networking technologies should be made available to all of our nation's students, regardless of socioeconomic status, race, ethnicity, gender, or geographical factors, and special attention should be given to the use of technology by students with special needs.  The rate of home computer ownership diverges widely for students of different racial and ethnic groups and socioeconomic status.  6.  Initiate a major program of experimental research.  A large-scale program of rigorous, systematic research on education in general and educational technology in particular will ultimately prove necessary to ensure both the efficacy and cost-effectiveness of technology use within our nation's schools.  Funding levels for educational research have been alarmingly low.

Health policy observers of the systematic implementation of President Obama's landmark Patient Protection and Affordable Care Act (ACA) are acutely aware of its investment in, and emphasis upon, the inherent potentially revolutionary contributions of the advances occurring in communications and computer technology; i.e., electronic health records, evidence-based protocols, tele-health, comparative clinical effectiveness research, as well as virtual realities.  And, we would suggest, similar evolutionary obstacles, such as getting too far ahead of practitioners must be expected.  Change is always unsettling.

The Panel urged that in order to ensure high standards of scientific excellence, intellectual integrity, and independence from political influence, a critical education-oriented research program should be planned and overseen by a distinguished independent board of outside experts appointed by the President, and should encompass (a) basic research in various learning-related disciplines and on various educationally relevant technologies; (b) early-stage research aimed at developing new forms of educational software, content, and technology-enabled pedagogy;  and (c) rigorous, well-controlled, peer-reviewed, large-scale empirical studies designed to determine which educational approaches are in fact most effective in practice.  Such a program could well prove critical to the economic security of future generations of Americans and should thus be assigned a high priority in spite of current (1997/2013) budgetary pressures.  Within the ACA, the newly authorized Patient-Centered Outcomes Research Institute (PCORI) might well serve a similar function.

The Panel further noted that if computers are destined to play an increasingly important role in education over the next 20 years, it is natural to ask what roles will be played by human beings (i.e., the Human Element).  Although it seems clear that the expanded use of technology in education will have significant implications for teachers, students, parents, and community members, there is reason to believe that interpersonal interactions among all these groups will be at least as important to the educational process of 2017 as they are in 1997.  Indeed, the changing nature of these interactions is probably as central to the promise of new educational technologies as the hardware, software, and curricular elements.  The Panel also appreciated that there was a growing consensus that technology should be applied in such a way as to foster broader community-wide involvement in the educational process.  It was further thought that the linking of schools with research universities, public libraries, and private companies could make valuable educational resources available to both students and teachers while simultaneously building awareness within each community of the needs of its local schools.  "Real-world" projects initiated by outside organizations often generate considerable enthusiasm among students and frequently prove unusually effective from an educational perspective.  Some educators at that time were even discussing the possibility of instituting "tele-apprenticeship" or "tele-mentoring" programs involving brief, but relatively frequent interactions between students and other community members that would be impractical in the absence of networking technologies due to travel time considerations.

Not surprisingly the Panel found, and we would seriously wonder if the comparable data is any different today, that the most significant disparities in socioeconomic status access to technology is not found in the schools, but in the homes of the students.  As of June 1995, computers were present in only 14% of all households headed by adults who had completed no more than a high-school education, and in which annual household income was less than $30,000; the comparable figure for households headed by college-educated adults having a combined income of more than $50,000 per year was more than five times greater, at 73%.  Similarly, on average girls and boys differed only slightly in their use of computers at school and at home.  On a personal note, at the Uniformed Services University of the Health Sciences (USUHS) graduate school of nursing, it is impressive how graduate students today are able to effectively utilize technology to integrate relevant You Tube (which was created in February, 2005) videos routinely into their classroom presentations.

Integrated Healthcare – New Training Models?  Fundamental to the President's ACA vision is providing patient-centered, integrated primary health care for all Americans in which the various disciplines will work collaboratively, rather than competitively.  Over the past several decades, visionary health psychologist Cynthia Belar, now Executive Director of the APA Education Directorate, has been urging psychology to appreciate the magnitude of change that is approaching.  "There is nothing new about interprofessional education (IPE), team based care, or integrated care.  What is new is the national recognition of its importance for 'Crossing the Quality Chasm' (Institute of Medicine (IOM)) and the increasing calls for such by leaders in medical education.  Indeed the " Interprofessional Competencies for Collaborative Care" have now been endorsed by a number of health professions, and will go to the Council in February for APA's endorsement.  The APA governance groups and the Board of Directors have been uniformly supportive to date.

"Psychologists in health settings have often provided team based care, but training for such has usually begun at the internship or postdoctoral levels.  With the focus on interprofessional competencies there are increased demands for interprofessional education in the earliest stages of training, where students can learn with and from each other and before stereotypes get rigidified.  The IOM Global Forum on Innovations in Health Professions Education, of which APA is a sponsor, has made this the primary topic for its first two forums.  It is being clearly acknowledged that those not trained to work together will not know how to work together after they graduate.

"Early involvement in IPE provides a challenge for doctoral programs housed in colleges of arts and sciences or universities without other health professions students, but not one impossible to meet.  In fact the Graduate Psychology Education program of HRSA, of which APA was the architect, has since its inception required the training of psychologists with at least two other health professions for receipt of grand funds.  To my knowledge, other than the Burdick Rural Interdisciplinary training program which unfortunately has not been funded for a number of years, such requirements are not part of other Title VII, Title VIII, or Medicare GME programs, but one wonders why not.

"We have said before how federally qualified health centers (FQHCs) and departments of internal medicine, pediatrics, and family practice can provide invaluable experiences in training for team-based primary care, which is seen as the foundation for the reformed health care system.  In my opinion, programs that want to prepare health service providers should run, not walk, to these settings and work to establish collaborative opportunities for training.  Psychology has articulated the competencies needed in the healthcare environment, including the special needs of primary care.  Even the Patient-Centered Primary Care Collaborative (an advocacy group of employers, providers, payors, and consumers) recognizes the need for new models of training that require not only team-based skills but a population-based perspective.  (I am currently the co-chair with a family practitioner of the Education and Training Task Force.)  Psychology has some superb programs that provide relevant training, but we need more."

Health Insurance Exchanges:  In 2014 the ACA will ensure that health insurance exchanges will be available in every state with all plans providing the same package of essential health benefits, although they will vary by four different levels of "actuarial value" (percentage of costs that a plan pays on average).  The individual States can decide whether they will set up their own exchanges, or rely upon the federal government.  At the last APA State Leadership conference, Practice Directorate Executive Director Katherine Nordal strongly urged the attendees to get personally involved at the state level.  "We're facing uncharted territory with proposed new models of care.  Change is inevitable….  We're going to have to address health insurance exchanges.  These are exchanges that provide health plans for individuals and small businesses that will be set up at the state level."  The State of Hawaii was the first in the nation to declare its intent to establish a state-certified exchange.  Governor Neil Abercrombie: "The successful establishment of the Hawai'i Health Connector is part of our New Day Plan in transforming healthcare in Hawai'i."

Coral Andrews is executive director of the Hawai'i Health Connector whose aim is to provide an online marketplace that is of Hawai'i-for-Hawai'i, effectively taking into account the state's unique culture and its Prepaid Health Care Act, an employer health mandate in effect since 1974 and incorporated into the ACA.  "We are socializing our vision to the Board and stakeholders-at-large, focused on a community investment model.  Our brand/logo will be built on the host culture's teachings and values.  We are working on it.  If we remain grounded in what we value and the Native Hawaiian cultural ideals, then it will act as a guidepost as we seek to navigate these new blended public-private models.

"Our proposed sustainability plan would draw like-minded community leaders together around the opportunity to improve the overall health and well-being of the population.  We don't just want to teach consumers how to come to an exchange to buy.  We want to focus on the longer term opportunity of social change.  If we can, in that consumer encounter, provide the education and critical thinking tools to them, then we have a greater opportunity of effecting change overall.  If we truly believe in the core values of our host culture, then that should be the basis by which we develop our plan.  Internationally, these ideas of social transformation have been applied to impoverished societies.  The true intent of the ACA is what we're focused on; not just building an IT system.

"We have recruited a development officer from the Hawaii Community Foundation to assist us with strategy and sustainability.  We believe that there are philanthropists and like-minded organizations in Hawai'i who will join us in gaining momentum around the idea of a community investment model.  There are also very cool theories and analyses that have emerged from the Stanford Social Innovation Center and a non-profit called Code for America.  Applying some of these ideas in this market could be interesting.  When all is said and done, we want to be able to look back and know that we have invested time in something that improves the health and well-being of our population and supports a more prosperous Hawai'i.  The end opportunity is a stimulated economy via indirect efforts."

The NMSU/SIAP Interdisciplinary RxP Program:  "The New Mexico State University/Southwest Institute for the Advancement of Psychotherapy Interdisciplinary Master's Degree Program in Clinical Psychopharmacology stands out from other APA "designated training programs" (i.e., meets the APA model curriculum) in many important ways.  We are the only program located in a state with prescriptive authority so we frequently have program alumni and working prescribing psychologists attend our classes for continuing education, enriching class discussion with perspectives from the prescriptive practice world.  We are the only program that offers live in-person instruction throughout the course, fostering more student interaction with our instructors as well as strong collegial relationships among students during breaks, lunches, and before and after class.

"The centerpiece of our program is the nine class integrated Advanced Pathophysiology and Physical Health Assessment module where students are instructed by family practice physicians using a systems-problem based learning approach.  The first day of the weekend is a lecture followed by a day of hands-on assessment skills practice in a real world family practice clinic setting.  The curriculum for this module, though challenging, uses the same texts and instruction methods as the New Mexico State University Nurse Practitioner graduate program, giving our program added clinical rigor.  New this iteration, we have added a section on clinical primary care psychology to each class, helping equip psychologists for work in primary care or other medical settings, with and without a prescription pad.  Another unique experience is our neuroanatomy/brain dissection lab taught by a prescribing neuropsychologist.  If you have never had the opportunity to see exactly what a choroid plexus looks like in person, you should consider our program.  We are also the only program directed by a practicing prescribing/medical psychologist (myself), who became the first prescribing psychologist working at the New Mexico Behavioral Health Institute (the State Psychiatric Hospital) in 2008.

"In 2012, our program established an ongoing part-time residency program for psychologists to do the required physician supervised practicum hours in a primary care clinic setting serving families in southern New Mexico in a partnership with La Clinica de Familia, a Federally Qualified Health Center (FQHC).  Two psychologists are presently doing their practicum hours there and several more are currently being credentialed and plan to begin in 2013.  Another exciting new option is shadowing a prescribing psychologist the day before or the day after the class weekend.  Students sign up to accompany a working prescriber at his/her practice setting on the Friday or Monday around the class weekend, combining the practical and academic in one trip to New Mexico.  Our website for further information ishttp://education.nmsu.edu/cep/siap [Christina Vento]."

The Commonwealth Fund's 2012 Annual Report:  This year was a dramatic one for health care reform and, for several months around the Supreme Court's decision on the constitutionality of the Affordable Care Act (ACA), a time in which an unusually large number of Americans were closely following federal health policy.  As we learned last summer, the Supreme Court ultimately upheld the law, enabling vital health care delivery and health insurance reforms to continue and an estimated 30 million Americans to gain health insurance coverage by the end of the decade.  The United States is finally on the path to join all other major industrialized countries in ensuring near-universal health insurance coverage.  This accomplishment in one that U.S. presidents have struggled to achieve over the past hundred years.  Thanks to the health reform law, we as a nation will no longer have a health care system that allows so many Americans to suffer from treatable diseases because they cannot afford health care – or to lose their savings to pay for treatment.

In many ways, the ACA has been the fruition of work that The Commonwealth Fund and others have conducted over the past 20 years.  The law's principles were articulated a decade ago.  Today, a number of these principles and recommendations are beginning to realize their promise.  There has already been substantial progress in the first two years of ACA's implementation.  After 12 years of increases in the uninsured, the number of people without coverage dropped by 1.3 million in 2011.  Nearly all states have taken legislative or regulatory steps to implement the law's early insurance market reforms and coverage of preventive care services without cost-sharing.  We may be witnessing new models of health care delivery, improved quality and safety, health information technology, and preventive care.  Aloha,

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

 

THE DAWN OF AN EXCITING NEW ERA FOR PSYCHOLOGY

    Creative Educational Initiatives:  Now that I have the opportunity of serving within the academic arena, one of the most personally fulfilling experiences has been being constantly exposed to creative educational endeavors.  "At the Uniformed Services University of the Health Sciences (USUHS) DoD students and faculty can participate in Operation Bushmaster which is a two week field exercise for the School of Medicine fourth year students and the Graduate School of Nursing family practitioner and psychiatric mental health students.  During this period, the students are put into medical platoons as they learn combat casualty care, care of refugees, and the challenges of providing medical aid to detainees.  The students rotate through leadership and medical provider roles where they are evaluated by expert faculty in the areas of leadership, clinical decision making, and the transport of casualties under fire.  For over 350 students this year, the exercise culminated with a simulated MASCAL exercise; a simulated attack during a nighttime operation, resulting in mass casualties.  The students then drew on their education, training, and experience as they tried to make order out of chaos while triaging, treating, and evacuating patients.  The goal of the exercise is for the students to be prepared for being deployed to austere environments to perform any medical support operation.  Thus, the students have fulfilled USU's motto, 'Learning to care for those in harm's way.'

            "Faculty must be invited to serve as evaluators and/or observer controllers.  Most of the faculty selected has been deployed several times to many areas of the world.  The trick for faculty during the exercise is to allow the students the latitude to make decisions while being a 'measuring stick' and guide to steer the students in possibly another direction.  Each exercise performed by the students has an after action report period where the students perform a self-assessment on how they performed while the faculty provides additional feedback.  The faculty has a vested interest in participating in this exercise because they know these students may be serving under or alongside them in medical support operations in the future [Tom Rawlings, GSN]."

            Similarly, former HRSA senior staff Dan Kavanaugh: "I am enjoying my second career pursuing my acting interests, continuing to do standardized patient work at USUHS.  Since the fall, I have had a 'steady gig' with George Washington University School of Medicine (GWU) that uses theatre to work with physicians and other health care professionals around issues of professionalism and 'burnout.'  We have received very high marks from our audience (various specialties at GWU, VA hospital leadership, Society of Anesthesiologists, among others).  We are presenting to the American Association of Medical Colleges in the near future.  Essentially, we perform a short 25 minute one-act play to look at these issues and then an audience interactive piece which is facilitated by a physician from the GWU School of Behavioral Health Sciences [http://charlessamenowmd.com/medicaltheater/]."

            Expanding the RxP Agenda:  Bob McGrath (2006 Division President) estimates that there are 1,700 colleagues who have now completed their advanced RxP training.  APA's Jan Ciuccio reports that the data on achieving the Recommended Passing Score on the national Psychopharmacology Examination for Psychologists (PEP) includes both first-time takers and repeat-test takers combined.  As of November 2012, 289 individuals had taken the PEP and 230 had met the Recommended Passing Score.  Thus, approximately 80% of those taking the exam have eventually passed.  Bob: "The M.S. Program in Clinical Psychopharmacology at Fairleigh Dickinson University has enrolled a new class every year since its inception in 2000.  We have purposely kept our classes small, and will split them if they become too large.  Even so, I'm pleased to say that enrollments have actually been growing in recent years.  Since the program became one of the first designated by APA as meeting its model curriculum for training in psychopharmacology (designed for state licensing board consideration), recent incoming classes have been almost twice the size of those of 4-5 years ago.  It's clear that more and more psychologists recognize the benefits of prescriptive authority in the long term, and enhanced knowledge of psychotropic medications in the immediate future, to their patients and the profession.  Though distance based and completely online, we use a traditional academic course model in which activities, readings, and video lectures are completed weekly under the guidance of a course instructor.  We have been lucky to retain some faculty members who have been with the program since its very early days, including several exceptional pharmacists and prescribing psychologists.  The university has recently established its own School of Pharmacy, so we anticipate even greater collaboration between our program and pharmacists in the future."

During my APA Presidency in 2000, we met several times with pharmacy's national leadership and held our last Board of Directors' dinner meeting at the American Pharmacists Association (APhA) historical building on the National Mall.  The newest RxP training program is at the University of Hawaii at Hilo College of Pharmacy which graduated its first two students this past December, one of whom will soon be sitting for the PEP.  Those who have been involved with this critical legislative agenda from the beginning will recall Linda Campbell's trailblazing efforts with her colleagues at the University of Georgia School of Pharmacy.  With the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA) [P.L. 111-148], pharmacy has been increasingly expanding its primary care role.  Back in 2008, 44 states had already recognized pharmacists' collaborative practice authority which allows for the initiation, monitoring, and modification of medication therapy for patients, typically under protocol.  What better profession to collaborate with to learn about the fundamentals and intricacies of prescribing?

            International Progress:  "The Postdoctoral Master of Science program in Clinical Psychopharmacology at the California School of Professional Psychology (CSPP) at Alliant International University will start its 15^th cohort in 2013.  The program which has also been designated by APA as meeting its model curriculum now includes a course in Molecular Nutrition and RxP.  Three psychologists from South Africa will be included in the new group, as well as at least two additional psychologists from Guam (one having already graduated).  This group will bring the number of Alliant RxP graduates to close to 500.  The program is now delivered through interactive distance education, so students can participate live from their own computers, with no travel necessary.  Classes are also recorded and archived so students can watch at a later time.  For further information contact me at stulkin@alliant.edu.  Additional news is that Dean Morgan Sammons (2009 Division President) and I will be traveling to New Zealand next spring to consult with the New Zealand College of Clinical Psychology and the New Zealand Psychology Board on the development of training programs for prescriptive authority [Steve Tulkin]."

            State Level Advances:  During the past year, we have been particularly pleased to see an increasing number of state psychological associations pursuing legislative RxP agendas.  Rebecca Gordon, one of the RxP lobbyists for the Illinois Psychological Association (IPA): "Illinois has robust discussion on RxP, moves toward passage of bill."  On March 6^th, IPA's bill for prescriptive authority passed out of the Senate Public Health Committee with a 7-5 vote.  This was the first time in Illinois history that the IPA's RxP bill had passed out of a legislative committee.  On May 1^st, the IPA, together with its lobbying and public relations teams, initiated an extensive statewide grassroots campaign to garner broad-based support for RxP.  Under the leadership of IPA President-elect Beth Rom-Rymer (2004 Division President & IPA 2011-2012 President), over 250 IPA psychologists, around the state of Illinois, have been meeting with legislators and the broader mental health care community to educate them on the legislation that would give prescriptive authority for psychotropic medications to psychologists with advanced, specialized training in clinical psychopharmacology.  Interest, accompanied by much intense discussion, has been strong with legislators and others in Illinois who are concerned about mental health treatment options.  By late November, 38 meetings with legislators and RxP supporters in their districts had been completed with an additional 48 meetings in the works.  Whereas five third party statewide organizations have officially endorsed the RxP bill, there have been ongoing discussions with numerous other third party organizations that will yield significant formal endorsements over the next several months.  Jana Martin CEO of the APA Insurance Trust and Elaine LeVine (2007 Division President and the first prescribing psychologist in New Mexico) have been actively engaged in many of these discussions.  The IPA is looking forward to re-introducing the RxP legislation early in 2013 with the hope that the bill will pass out of both Houses of the State Legislature by May 31^st, the date on which the 2013 legislative session ends.  Beth and the IPA membership are well aware of the many challenges that face their RxP bill.  That Illinois is the home of the American Medical Association is only one of those challenges.  We also understand that, as anticipated, the leadership of the Hawaii Psychological Association will again be pursuing RxP legislation at their legislature, following up on their previously vetoed bill.  There have recently been changes in the Administration and State House leadership; as well as renewed interest by rural legislators, which we would expect is a direct result of the University of Hawaii at Hilo's graduation of its first psychopharmacology graduates.

            Enacting RxP legislation at the state level is extremely important not only for psychology's clients but also for the very future of the profession.  In many ways, the President's visionary proposal (ACA) for providing quality health care to all Americans places the primary responsibility for implementation of his overarching schema at the state and local level.  Integrated care, interdisciplinary collaboration, wellness and prevention, and effectively utilizing the extraordinary potential inherent in the advances occurring almost daily within the communications and technology fields are critical to the Administration's patient-centered mission.  Clinical services are to be data-based and represent gold standard care.  Mental health care (i.e., behavioral health) is envisioned as being an important component of primary health care.  There will be an unprecedented opportunity to objectively demonstrate the clinical "cost off-set" which former APA President Nick Cummings has discussed for decades.  However to thrive as a primary care health provider in such an evolving and unsettled environment, psychology must learn and adapt to the culture of primary care and medicine.  This will be a challenge for our traditional training institutions.  Change is always unsettling, especially fundamental change.  And we have come to appreciate over the years that only a small subset of our profession is comfortable being in uncharted waters.  Those colleagues who are on the forefront of the prescriptive authority quest and thereby investing in the future are unique.  The majority of practitioners and our training institutions are unfortunately sitting back and waiting for more concrete personal and institutional benefits to evolve.

Lenore Walker: "I have thought about whether or not to write a paragraph about Nova Southeastern University's psychopharmacology program.  However, there is not much to say.  We are on what we call 'a hiatus' while we re-evaluate the program.  Under consideration is the possibility we will re-design it as an on-line program together with some of the other health science practitioners from our health science programs and include students from our doctoral program, particularly the health concentration students but possibly others also.  Nothing has been finalized yet but if we really do get one or two more states with prescribing privileges that would make a big difference amongst our administrators.  We are also mindful of the national movement towards interprofessional practice so including training psychologists together with other health care practitioners would move us closer to that goal."

Reflecting upon how members of our profession do not appreciate the magnitude of change coming, at the request of the former Dean of the School of Public Health at the University of Hawaii, HPA is attempting to ascertain to what extent Hawaii psychologists are utilizing electronic health records, which is another cornerstone of the ACA.  Alex Santiago: "I have been trying to get the information you requested about psychologists using electronic filings.  We sent a request over our list serve and I have been in touch with the Department of Health.  Very little information is available on this.  Many members report using electronic filing for billing, but only a few reported actually using them in their practice for patient records.  However, Kate Brown over at Tripler Army Medical Center did indicate that the DoD has used electronic medical records for at least the last 10 years.  In Hawaii, this would include Tripler and all outlying military clinics using the AHLTA system and the VA using the JANUS system.  At this time the two systems do not communicate with each other although she believes there are plans for the two to ultimately be integrated, including for psychology.  I am not sure if anyone has any more information on this, however, I will continue to ask."

            Intriguing Developments in Accreditation:  Alan Kraut, executive director of the Association for Psychological Science (APS), addressed our USUHS psychology public policy class this fall and described the new Psychological Clinical Science Accreditation System (PCSAS).   Over the years Alan has had a very positive impact upon professional practice.  For example, APA's first Black Tie event for national politicians was hosted by Alan, honoring U.S. Senator Daniel K. Inouye, in Los Angeles.  Increasingly, professional schools have suggested that the current APA accreditation system makes it very difficult for them to offer public policy courses or psychopharmacology.  The APS Observer reports that PCSAS was recently recognized after a three year review process (including application, several cycles of accrediting programs, and then review) by the Council for Higher Education Accreditation (CHEA), which is the national nongovernmental gatekeeper of accrediting organizations.  This should open the way for graduates of PCSAS-accredited clinical science training programs to work in settings in which graduation from an accredited program is a prerequisite for further training and employment.  CHEA is one of two organizations in the nation with the power to recognize national accrediting bodies, the other being the U.S. Department of Education.

            Under consideration is adoption by the Department of Veterans Affairs (VA) of the PCSAS standards as the federal statute provides considerable flexibility.  Currently the VA only accepts students and hires graduates from APA accredited programs.  Antonette Zeiss, who is the first psychologists and first woman to be appointed as chief consultant for mental health services in the VA, has indicated to Alan that's likely to change.  She has been leading an internal group that is in the process of revising VA qualification standards, potentially including PCSAS as an acceptable accrediting body for clinical programs.  "I think it certainly should happen.  I think the only question is just the time it will take."  The leadership of PCSAS has indicated that a next step will be to gain acceptance from state licensing boards.

            PCSAS was created in late 2007 to promote science-based training and, by extension, to introduce a new culture of scientific clinical psychology.  Their underlying objectives, which are highly consistent with the ACA, is to promote superior science-centered education and training in clinical psychology, and to increase the quality and quantity of clinical scientists, thereby contributing to the advancement of public health, and to enhance the scientific knowledge base for mental and behavioral health care.  The Director of the National Institute of Mental Health called this recognition "an important step towards allowing this brand of clinical psychology to thrive, and to ultimately benefit the public."  Over the years we have come to appreciate that in the long run competition is extraordinarily beneficial to consumers.  With the substantial professional school market for accreditation, perhaps this development will result in sufficient flexibility for an expansion of the underlying mission of psychology's training institutions to include societal-oriented courses, such as public policy and psychopharmacology.

An Interesting Proposal:  "I am very interested in virtual treatment opportunities.  I would start with licensed providers over the age of 65 who want to offer services via a virtual network.  This would allow all of us in the 'retirement' community to keep on working in our areas of expertise and not necessarily be confined to geographical borders.  If a person is licensed in State A on a doctoral level this should hold for States B, C, etc., if the National Register is the clearing house.  We certainly could refine and define the best networking possibilities (Helen Ackerman)."  Aloha,

Pat DeLeon, former APA President – Division 55 – January, 2013