TAKE ME HOME, COUNTRY ROADS

 Newly Evolving Horizons:  Over the past several years, Ruth Paige, Rod Baker, and I have been exploring what our senior colleagues are doing with their lives after decades of active involvement within psychology – including hosting an intriguing symposium at APA.  Kris Ludwigsen was recently interviewed by the national media on this topic, reflecting upon her own experiences and those of other colleagues.  Kris has concluded that psychologists have more options for validation in retirement than many other professions as losing one's professional identity does not seem to be a major issue.  "Becoming a psychologist opened the doors to an exciting career that encompassed teaching, research, psychotherapy, consultation, program development, supervision, coaching, advocacy (even prescription privileges), and a military career.  Now boomers and beyond are facing the challenges of retirement.  Some want to work up to the very end; some choose to go part-time, perhaps in a different venue; and others opt for a new life.  So retirement requires a realignment of one's priorities and values after due consideration.  For some, family, creativity, hobbies and travel become paramount.  Others find volunteering a natural extension of the desire to be of service.  There may be a period of floundering before finding new fulfillment and a new mission; but psychologists are fortunate in having a rich diversity of roles that we can return to, tailored to our time and energy now."

Mike Sullivan represents a non-work related success.  "Coming Full Circle:  I've had many experiences in life where my interests and enthusiasms have come full circle.  But I've found the circle to be more of an ascending spiral – the later evolutions build on earlier experiences in new and surprising ways.  For example, I've done volunteer work out of enjoyment that has morphed into professional careers.

"Another example involves my longstanding enjoyment of women's basketball, for its cerebral play and pure teamwork.  While working at APA, I attended college games at George Washington University and professional games of the WNBA Washington Mystics.  (My good friend, APA's Randy Phelps and I were season ticket holders for five years.)  One of the stars I saw in both college and pro venues was Dawn Staley.  She was head coach of women's basketball at Temple University while playing in the WNBA for the Charlotte and Houston teams.  She was unique in doing both at the same time, achieving great success as both player and coach.

"Fast forward several years and my wife and I decided to move to Columbia, South Carolina.  I knew there was a women's basketball program at the University of South Carolina that I could follow.  Lo and behold, the year we arrived was the same year South Carolina made a big-time hire to bring in Dawn Staley to coach their women's basketball team.  This turned out to be a stroke of genius.

"Coach Staley has transformed a last place team that she inherited into a national powerhouse currently ranked #2 in the country.  This has been a fan's dream come true.  I've attended every game and have become a super fan in my support of the program.  Dawn Staley is known for her community work and charitable foundations, as well as being a member of both the women's and men's basketball Halls of Fame.  I've had the good fortune to get to know her, and I follow her inspiring work closely.  It has led me to become a resource for her on Twitter (@mikesullivan08) and to manage my own fan email list.  It's been a huge thrill that keeps me feeling vibrant.  Go Gamecocks!"  Mike is also passionately engaged with his local Meals on Wheels program, recently finishing second in a national volunteer recognition contest.

Anne Petersen personifies the different professional venue to which Kris alluded.  Currently Research Professor at the Center for Human Growth and Development, University of Michigan, Anne formally served as Senior Vice President for Programs at the W.K. Kellogg Foundation and prior to that, as Deputy Director of the National Science Foundation (NSF).  She is a Fellow of the APA, APS, and AAAS.  Anne chaired a committee for the Institute of Medicine (IOM) Board on Children, Youth, and Families, directed by psychologist Kimber Bogard, which conducted a study culminating in an updated version of the 1993 National Research Council (NRC) publication entitled Understanding Child Abuse and Neglect.  This updated consensus report, New Directions in Child Abuse and Neglect Research, provides recommendations for allocating existing research funds and further suggests funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected.

The committee's vision included: * Building on the review of literature and findings from the evaluation of research on child abuse and neglect; * Identifying research that provides knowledge relevant to the programmatic, research, and policy fields; and * Recommending research priorities for the next decade, including new areas of research that should be funded by public and private agencies and providing suggestions regarding fields that are no longer a priority for funding.  Four particularly pertinent areas focused upon the development of a coordinated research enterprise in child abuse and neglect which would be relevant to the programs, policies, and practices that influence children and their caregivers.  These were: * Development of a national strategic research plan that is focused on priority topics identified by the committee and that delineates implementation and accountability steps across federal agencies; * Creation of a national surveillance system; * Development of the structures necessary to train cohorts of high-quality researchers to conduct child abuse and neglect research; and * Creation of mechanisms for conducting policy-relevant research.  In September, 2013 the IOM/NRC hosted a public release event for the report resulting in widespread coverage across the nation.  Copies of the full report and dissemination materials are available on the IOM web.

An Exciting and Expanding Agenda:  "Since we passed our prescriptive authority bill on May 30^th of this year, and Governor Pat Quinn signed the bill into law on June 25^th, we at the Illinois Psychological Association (IPA) have been very busy working on implementation.  I have realized that while bill passage was one big mountain to climb, implementation gives us, yet, a higher peak to reach.  Because our law was passed by a consensus of IPA; the American Nurses Association, Illinois Chapter; the Illinois Society for Advanced Practice Nursing, the Illinois Medical Society, and the Illinois Psychiatric Society, we have the advantage of the full support of our state healthcare medical providers as we explore training venues in hospitals and medical centers.  Our first step has been to draft our rules and regulations for our law.  That process is ongoing.  Simultaneously, we are pursuing the additional steps of meeting with hospital and medical center administrators and signing on those facilities that agree to take prescribing psychologist trainees.  We have encountered many successes and continue to travel around the state to meet with hospital administrators.

Other facets of this journey include: 1) Meeting with graduate psychology directors of training and discussing their initiating the curriculum in Clinical Psychopharmacology for our prescribing psychologist trainees.  2) Meeting with undergraduate advisers in psychology and undergraduate students who are pre-med, pre-vet, nursing, biology, chemistry, and/or psychology majors and talking to them about opportunities for students to become prescribing psychologists with a strong undergraduate foundation in the hard sciences as well as a foundation in psychology courses.  3) Meeting with executives, including chief psychologists, in various Illinois governmental departments and agencies who have a tremendous need for prescribing mental health providers and discussing the options for their staff psychologists to become trained as prescribing psychologists for their special populations.  We are encountering palpable excitement in our meetings from all of our constituent groups: undergraduate students, graduate students, agency administrators, university administrators and faculty, and practicing psychologists.  There is certainly a feeling that there is change in the air and that psychology is leading this charge.  And, beyond what we are doing in Illinois, more than 10 states are re-igniting their RxP initiatives or are quickly gearing up from ground zero.  As I travel around the country, meeting with various state leaders, there is evidence of tangible progress and elevated expectations of success.  Nice to connect with Arlo Guthrie in these moments: 'And, friends, they may think it's a Movement'" (Beth Rom-Rymer).  To The Place I Belong.  Aloha,

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

 

TO REACH A PORT WE MUST SET SAIL

Possessing That Critical Global Vision:  One of the most enjoyable experiences of my approximately quarter of a century of involvement within the APA governance was having the opportunity to work closely with Bruce Overmier on the Board of Directors on behalf of all of psychology.  In May of this year, Bruce retired from the University of Minnesota after 49 years of service – a truly amazing accomplishment.  "I did not stay for the 50^thyear as some friends suggested; after all, 50 is just a number."  It is fascinating to reflect upon the extent to which those elected to the APA Board come to appreciate that they must represent all facets of the field – science, education, and practice – and not merely that "special interest" which might have elected them to the Board.  Although we did not succeed, we worked diligently to bring APS back into APA by ensuring that our national association would be responsive to the unique needs of the scientific community.  Similarly, it is important for those training our next generation of clinicians to appreciate, and be responsive to, the underlying mission of the various federal agencies seeking to improve the quality of life of those subpopulations in which one is particularly interested.  For those concerned about the unique needs of our nation's children and their families, we would suggest that the Fiscal Year 2015 Budget Justification for the Health Resources and Services Administration (HRSA), and particularly for its Maternal and Child Health program, should be of considerable interest.

            The Administration's Priorities:  The stated objective of the Maternal and Child Health block grant program is to improve the health of all mothers, children, and their families.  These legislated responsibilities reduce health disparities, improve access to health care, and improve the quality of health care.  As one of the nation's bona fide healthcare professions, psychology must appreciate that it is our responsibility to ensure that the critical psychosocial-economic-cultural element of quality care is affirmatively included.  As the then-President of the Institute of Medicine (IOM) stated in 2006: "Dealing equally with health care for mental, substance-use, and general health conditions requires a fundamental change in how we as a society and health care system think about and respond to these problems and illnesses.  Mental and substance-use problems and illnesses should not be viewed as separate from and unrelated to overall health and general health care."

Specifically, the Maternal and Child Health program seeks to: (1) assure access to quality care, especially for those with low-incomes or limited availability of care; (2) reduce infant mortality; (3) provide and ensure access to comprehensive prenatal and postnatal care to women (especially low-income and at risk pregnant women); (4) increase the number of children receiving health assessments and follow-up diagnostic and treatment services; (5) provide and ensure access to preventive and primary care services for low income children as well as rehabilitative services for children with special health needs; (6) implement family-centered, community-based, systems of coordinated care for children with special health care needs; and (7) provide toll-free hotlines and assistance in applying for services to pregnant women with infants and children who are eligible for Medicaid.  Of particular interest to psychology should be the Special Projects of Regional and National Significance (SPRANS) initiative for which $77 million has been requested for the coming year.  Over the years, we have come to appreciate the vision and creativity behind this particular approach.  It was instrumental, for example, in fostering a special federal focus upon the unique and pressing needs of Native Hawaiian children and their families during the earliest stages of what has today become the Native Hawaiian Resonance.  HRSA's budget request further notes that in an era of expanding health care coverage under the Patient Protection and Affordable Care Act (ACA), the Maternal and Child Health programs serve to assure continuity of care and to reduce coverage gaps.  It is both a safety net program and a major public health program serving mothers, infants, children (including children with special health care needs), and their families.  Perhaps most significantly for the mental health/behavioral health professions: "In order for there to be measurable gains towards improving the nation's maternal and child health, insurance coverage expansion will need to be accompanied by a significant investment in health promotion and disease prevention strategies that focus on this population."

            The Institute of Medicine (IOM):  Cognitive, affective, and behavioral disorders incur high psychological and economic costs for the young people who experience them, for their families, and for the communities in which they live, study, and will work.  This Spring, the IOM Board on Children, Youth, and Families, directed by psychologist Kimber Bogard, hosted the first workshop of its Forum on Promoting Children's Cognitive, Affective, and Behavioral Health.  The workshop focused on Strategies for Scaling Tested and Effective Family-Focused Preventive Interventions, featuring presentations on and discussion of successes and challenges in scaling family-focused preventive interventions; financing and infrastructure to support implementation, including how provisions of the ACA may affect programs in primary care settings; and innovative models in scaling family-focused interventions.  A perspective paper on unique opportunities and implementation barriers for family-focused interventions for children with neurodevelopmental disorders has been developed for the project's web site.  Their second workshop focused on Harvesting Best Practices from Prevention Science to Promote Child Wellbeing.  This November, another public workshop will be convened addressing Innovations in Design and Utilization of Measurement Systems to Promote Children's Cognitive, Affective, and Behavioral Health.  Presentations will feature the use of data linkage and integration to inform research and practice; the use of quality measures to facilitate system change in health care, classroom, and juvenile justice settings; and tools developed to measure implementation of evidence-based prevention programs at scale to support sustainable program delivery, among other topics. 

            Unprecedented Change Continues:  The National Center for Medical-Legal Partnership, a project of the Milken Institute School of Public Health at George Washington University has recently been awarded a three year grant from HRSA to cultivate and support medical-legal partnerships at community health centers (FQHCs) across the country.  These partnerships will bring together civil legal aid agencies and law schools with healthcare institutions to integrate legal care into the delivery of healthcare and treat individuals' health harming social and legal needs related to housing, insurance, benefits and education.  Legal and healthcare professionals will work together to identify and improve policies and laws that affect community health.  The three year award designates the Center as a technical assistance center for health centers.  It will build relevant toolkits and provide trainings that will assist health centers develop and sustain medical-legal partnerships.  Integrated, interdisciplinary care is a priority of the ACA.  Sail, Not Tie at Anchor.  Sail, Not Drift.  Aloha,

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

 

GO WHERE YOU WANNA GO

With Washington State's Barry Anton soon to be assuming the Presidency of APA, our national Association should be very well served.  Barry has a long history of being a visionary advocate for addressing the pressing holistic needs of our nation's children and their families.  He truly appreciates the "bigger picture" and the critical importance of psychology being actively involved in shaping health policy.  Recently, Barry was instrumental in celebrating the 40^th anniversary of the APA Congressional Fellowship program at our Washington, DC convention.  As the first social science organization to participate in the AAAS Science and Technology Policy Fellowships Program, this is an extremely important program for all of psychology.  The very first fellow, Pamela Ebert Flattau, who frequently still wears her Walter Mondale button, is prominently involved in shaping national science policy as Director of a new start-up known as The PsySiP Project.  In 1994-1995, Libby Street (Central Washington University) served as a Fellow with U.S. Senator Edward Kennedy in his education office.  The following year, another Washington State former Fellow, Margie Heldring, was instrumental during her tenure with U.S. Senator Bill Bradley in having the federal government modify private health insurance benefits for the first time in our nation's history; effectively addressing "drive-through baby deliveries."  Her efforts were signed into Public Law by President Bill Clinton on September 26, 1996 [the Newborns and Mothers' Health Protection Act (P.L. 104-204)] in a Rose Garden ceremony which she got to attend.  Our President-elect has most recently focused upon the importance of psychology learning from international efforts to further integrated care models, pursuant to the proactive vision underlying President Obama's Patient Protection and Affordable Care Act (ACA).

            The Children's Defense Fund (CDF):  The CDF Overview of The State of America's Children 2014 reports that in 2012, for the first time the majority of children in the U.S. under the age of two were children of color, as were the majority of all children in 10 states.  By 2019, the majority of all children nationwide are expected to be children of color.  Child poverty has reached record levels; one in five children (16.1 million) was poor in 2012.  More than 7.1 million children (over 40% of poor children) live in extreme poverty at less than half the poverty level (for a family of four, $11,746 annually).  Children in single-parent families are nearly four times more likely to be poor than children in married-couple families.  Although almost 70% of all children live with two parents, more than half of Black children and nearly one in three Hispanic children live with only one parent, compared to one in five White children.  Nearly 1.2 million public school students are homeless, 73% more than before the recession.  More than one in nine children lack access to adequate food, a rate 23% higher than before the recession.  Guns kill or injure a child or teen every half hour; gun violence disproportionately affects children of color.  Child poverty costs the nation at least $500 billion annually in extra education, health, and criminal justice costs and in lost productivity.  Child abuse and neglect costs $80.3 billion each year in direct costs and lost productivity.

            The Institute of Medicine (IOM):  The IOM Board on Children, Youth, and Families, directed by psychologist Kimber Bogard, in conjunction with the IOM Board on Global Health, has recently launched its Forum on Investing in Young Children Globally.  This initiative seeks to create and sustain, over three years, an evidence-driven community of stakeholders across northern and southern countries who aim to explore existing, new, and innovative science and research from around the world and translate this evidence into sound and strategic investments in policies and practices that will make a difference in the lives of children and their caregivers.  Forum activities will highlight the science and economics of integrated investments in young children living in low resourced regions of the world across the areas of health, nutrition, education, and social protection.  The Forum will promote a holistic view of children and caregivers by integrating analyses and disciplines – e.g., from the microbiome to culture.  It will support an integrative vision linking human capital of individuals with the economic sustainability of nations.

            A concerted effort will be made to build bridges across sectors and partner with other organizations, including other science academies and coalitions working toward improving investments in young children globally.  Activities and products will be used to inform practices from local communities to government systems; policies at the country, state, and local levels; and research agendas.  Inter-generational approaches to investing in young children globally will be an important lens for developing future activities, with a particular emphasis on empowering women and girls.  Another lens to be used to view the science, implementation, and policies under consideration is the cultural contexts, including belief systems and visions of optimal child development from the familial and community perspective.

            Forum goals include identifying an integrated science on children's health, nutrition, education, and social protection and working with policymakers, practitioners, and researchers to raise awareness of integrated approaches to improve the lives of children and their caregivers.  Objectives include:  * To shape a global vision of healthy child development across cultures and contexts, extending from pre-conception through age eight, and across current "silo" areas of health, nutrition, education, and social protection.  * To identify opportunities for inter-sectorial coordination among researchers, policymakers, implementers/practitioners, and advocates to implement quality practices and bring these practices to scale, in the context of the economics of strategic, integrated investing in young children, spanning health, education, nutrition, and social protection.  * To inform ongoing conversations and activities of groups working on issues related to young children globally.  And, * To identify current models of program and policy financing across health, education, nutrition, and social protection, within the framework of reproductive, maternal, newborn and child health that aim to improve children's developmental potential.  This information could be used to illuminate opportunities for new financing structures and forms of investments that may be more effective in improving child outcomes and potentially drive economic development.  Aspirational goals to be sure, and exactly where APA's next President has been engaged for decades.  On a personal note, my fondest memory of WSPA was having the honor of presenting Colleen Hacker with an APA Presidential citation in 2000 for her years of dedication to our nation's female athletes, including those on the U.S. Women's Olympic teams -- my very last APA Presidential event.  Barry's soccer playing daughter attended that event.  These are indeed exciting times.  Do What You Want.  Aloha,

Pat DeLeon, former APA President – WSPA – November, 2014

 

I’M SITTING IN THE RAILWAY STATION

  The Institute of Medicine (IOM):  As one of the "learned professions," it is incumbent upon psychology and nursing to become aware of, and contribute meaningfully to, efforts by colleagues in other disciplines to address society's most pressing needs.  The Board on Children, Youth, and Families of the Institute of Medicine (IOM), directed by Kimber Bogard, released its most timely report Sports-Related Concussions in Youth: Improving the Science, Changing the Culture almost exactly one year ago.  This visionary effort has received considerable attention in the popular media and the White House.  With the intense focus currently on the health status of retired NFL players, and increasingly on those who played sports in college, the groundwork has perhaps been laid for fostering an important and scientifically-based national discussion – one for which psychological expertise should be highly relevant.  A major conclusion of the IOM report is that while some studies provide useful information, much remains unknown about the extent of concussions in youth; how to diagnose, manage, and prevent concussions; and the short- and long-term consequences of concussions, as well as repetitive head impacts that do not result in concussion symptoms.

            Interestingly, among male athletes at the high school and collegiate levels, football, ice hockey, lacrosse, wrestling, and soccer consistently are associated with the highest rates of concussions.  Among female athletes, soccer, lacrosse, basketball, and ice hockey are highest.  There has been little research on the frequency of concussions among those playing intramural and club sports and in those younger than high school age.  Accordingly, the IOM called upon the Centers for Disease Control and Prevention (CDC) to establish and oversee a national surveillance system to accurately determine the incidence of sports-related concussions among those aged 5 to 21.  Although some research indicates that a series of molecular and functional changes take place in the brain following injury, little research has been conducted specifically focusing upon changes in the brain or on the differences between females and males.  Diagnosis is currently based primarily on the symptoms reported by the individual rather than on objective diagnostic markers and there is little empirical evidence as to the optimal degree and duration of physical rest needed to promote recovery.

            The IOM specifically noted that today's culture of sports negatively influences athletes' self-reporting of concussion symptoms and their adherence to return-to-play guidance.  Athletes, their teammates, as well as coaches and parents may not fully appreciate the health threats posed by concussions.  Similarly for the nation's military population, recruits are immersed in a culture that includes devotion to duty and service before self; thus, the critical nature of concussions may often go unheeded.  It is postulated that if the youth sports community can adopt the belief that concussions are serious injuries and emphasize care for players with concussions until they are fully recovered, then the culture in which they compete will become much safer.

            AARP:  At the other end of the demographic continuum, around the same time, the AARP Public Policy Institute released its report exploring the probable availability (or lack thereof) of Family Caregivers in the foreseeable future.  As Lynn Feinberg discussed at our interdisciplinary USUHS health policy class, today the majority of long-term services and supports are provided by family members.  In 2010, the caregiver support ratio was more than 7 potential caregivers for every person in the high-risk years of 80-plus.  By 2030, this ratio is projected to decline significantly to 4 to 1; and is expected to fall further to less than 3 to 1 by 2050, when all "boomers" will be in the high-risk years of late life.

            Family caregivers – including family members, partners, or close friends – are a key factor in the ability to remain in one's home and in the community when disability strikes.  More than two-thirds (68%) of Americans believe that they will be able to rely on their families to meet their eventual long-term services and support needs when they require help.  However, if fewer family members are available to provide everyday assistance to frail older people, more individuals are likely to need institutional care – at significantly greater cost both to themselves and to society.  In recent years, the role of family caregivers has greatly expanded from coordinating and providing personal care and household chores to include medical and nursing tasks (such as wound care and administering injections).  These nursing tasks used to be provided in hospitals and nursing homes and by home care providers, but increasingly are now being provided by family members.  One of the major challenges facing the nation is addressing the sequela from possessing multiple chronic conditions (MCC).  Currently 26% of adults have MCC; 67% of Medicaid beneficiaries with disabilities have three or more conditions.  As conditions increase, so does the frequency of mortality, poor functional status, hospitalizations, readmissions, and adverse drug events.  Today 66% of health care costs are for individuals with MCC, a vulnerable population which we would suggest could benefit significantly from the ready availability of behavioral health expertise.

            AARP's report notes that research has demonstrated the critical importance of family support in maintaining independence and reducing nursing home use among older people with disabilities.  Between 1984 and 2004, institutional use declined by 37% among the older population, as the number of older people living in the community with two or more needs for assistance with activities of daily living (such as bathing, dressing, or using the toilet) rose by two-thirds.  Medicaid costs for institutional care would have been an estimated $24 billion higher in 2004 had utilization rates remained unchanged after 1984.  It is impossible to document the exact portion of these savings that is due to family caregiving; however, the high rates of family support among the growing number of older people with high levels of disabilities who live in the community strongly suggest that such support has been a critical factor in the dramatic decline of institutionalization and Medicaid use during the past couple of decades.

            Notwithstanding, AARP projects that the caregiver support ratio is expected to plummet as boomers transition from caregivers into old age with the decades of the 2010s and 2020s being a period of transition.  The population aged 45-64 is projected to increase by only 1% between 2010 and 2030; during the same period, the 80-plus population is projected to increase by 79%.  The impact of these demographic changes will undoubtedly be further complicated by recent data indicating that the declines in disability rates may have stalled (and perhaps even reversed) among the young old and pre-retirees, largely because of the increases in obesity (which clearly has relevance to behavioral health).  Accordingly, AARP has called for a national comprehensive person- and family-centered Long-Term Services and Supports policy that would better serve the needs of older persons with disabilities, support family and friends in their caregiving roles, and promote greater efficiencies in public spending.

            The Accountable Care Act (ACA):  On March 23, 2010, President Obama signed into public law the Patient Protection and Affordable Care Act (ACA) [P.L. 111-148].  The ACA represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation.   The Commonwealth Fund recently issued a report card on its status.  Four Defining Questions:  * Are the marketplaces fully functional?  Needs Improvement.  * Did people enroll in the law's new coverage options?  Good To Excellent.  * Are fewer people uninsured?  Good To Excellent.  * Is the quality of insurance improving?  Is underinsurance declining and are people satisfied with their plans?  Grade Pending.  For Extra Credit:  * Are people using their new insurance to get health care?  Grade Extra Credit:  * Is growth in health care costs moderating?  Grade Pending.  And finally, * Is the quality of care improving?  Grade Pending.  In summary: "It seems clear that where we have data, the ACA's implementation has been associated with significant progress.  Equally important, some of the potential problems it could have created such as much higher premiums in the individual market or a lack of insurer participation (which has actually increased for 2015) has not materialized.  If the question is: Is the health care system better off in September 2014 than it was in 2010, the answer would seem to be yes."  Impressively, the Commonwealth Fund found that the percentage of adults ages 19-64 who are uninsured has declined from 20% just prior to open enrollment to 15%, which means there are an estimated 9.5 million fewer uninsured adults.

            A critical component of the ACA's commitment to improving access to quality health care throughout the nation is a significant investment in the Federally Qualified Community Health Centers (FQHC) program.  Established during the Great Society Era of President Lyndon Johnson, when psychologist John Gardner was Secretary of the Department of Health, Education, and Welfare (HEW), these centers represent the true safety net for many Americans.  Accordingly, we were very pleased to learn that prescribing psychologist Earl Sutherland was recently appointed medical director for the Big Horn County FQHC where he is actively implementing their integrated care program – another key element of the ACA.  "Some people complain about getting older, but I prefer it to the alternative [Charles Brewer, APF benefactor extraordinaire]."  Homeward Bound.  Aloha,

Pat DeLeon, former APA President – Division 55 – October, 2014

 

OVER THE RAINBOW

    An Exciting Vision:  Upon occasion, I have been "accused" of being overly optimistic about the future of psychology, especially by senior colleagues who might be emotionally invested in the past.  Without question, the health care environment of the 21^st century is rapidly changing.  However, as long as the field continues to attract "the best and brightest," I am confident that psychology and our colleagues in nursing and pharmacy will do very well.  We must appreciate that the vision of our educational leadership is critical to the future.

I am currently serving on the nursing and psychology faculty of the Uniformed Services University of the Health Sciences (USUHS).  Since we are located near our nation's Capital, we are fortunate to be able to interact with psychology leaders from across the country, as well as senior APA staff.  Former APA Presidents Ron Fox and Don Bersoff have addressed our interdisciplinary health policy class, as well as several Directorate Executive Directors.  The students have been invited to a number of APA events, including the annual State Leadership conferences, the recent APA-ABA judicial conference, not to mention being included in ongoing convention activities.  A typical initial response to a very last minute expression of interest in the APA Education Leadership Conference:  "We would be happy to have some of your students participate.  At this point in time we have space limitations or I would try to make this work" (Catherine Grus, Education Directorate).  We fully expect that next time it will be possible.  Throughout these experiences the palpable enthusiasm of the next generation has been very evident, as has been their interest in shaping their own destiny.  USUHS recently announced that our current APA President Nadine Kaslow will be visiting with students and faculty.  APA's genuine responsiveness to the interests of our next generation is most impressive – Mahalo, Norman Anderson.

            Postdoctoral Opportunities:  One of the most exciting developments within the profession has been the establishment of psychology's postdoctoral training initiatives.  As we have evolved from being an exclusively mental health focused discipline into a bona fide health care profession, the breath of clinical opportunities for psychological expertise to improve the quality of patients' lives has been exponential.  During his APA Presidency, World War II Army veteran Jack Wiggins visited with VA Secretary Tony Principi, a Vietnam veteran, and as a result of that discussion, the Secretary called for the VA to begin a psychology postdoctoral training program.  Over the subsequent years, this initiative has steadily expanded, both in numbers and in its clinical focus.  Visionary VA senior psychologist Bob Zeiss:

            "Health professions education, across disciplines, is a core mission of the Department of Veterans Affairs (VA), with a general goal of providing high quality experiential learning opportunities to develop well educated and well trained health professionals for VA and for the nation.  VA's Office of Academic Affiliations (OAA) funds and oversees these training opportunities.  During my tenure at OAA (2005-2013) and continuing today (under the leadership of Kenneth Jones, Director of Associated Health Education), the number of funded postdoctoral training positions increased from 52 to 402.  Phase III of the five year Mental Health Expansion Initiative will increase those numbers even more for the 2015-2016 academic year.

            "Working closely with Mental Health Services and supporting VA's major initiatives to enhance both access to and quality of mental health care in VA, OAA committed to increase the number of trainees in all mental health disciplines.  Because of the strength of psychology staff across the nation, psychology as a discipline was particularly poised to develop new internship and postdoctoral programs and enhance existing ones.  In recent years, we have increased the focus on developing training opportunities in smaller and rural VA health care settings.  These programs provide the same kinds of opportunities as do larger, more traditional programs; they also are intended to generate a cadre of health care professionals eager to remain in and serve in those smaller and more rural settings.

            "The focus on postdoctoral training is based on the premise that VA training provides a particularly highly qualified set of candidates from which to recruit future VA staff.  Though graduating interns are generally experienced and skilled, the internship does not allow sufficient depth of training to become highly skilled in an emphasis or specialty area.  Adding a postdoctoral year to training provides precisely that opportunity.  Thus, not only does VA ensure that these new professionals have the skills relevant and necessary for quality care of Veterans, but we are also in a position to determine exactly which developing practitioners have the skills, attitudes, and dedication to VA care that we treasure in our employees."

            President Obama's Patient Protection and Affordable Care Act (ACA) envisions the health care environment of tomorrow as providing interdisciplinary data-based care, with a priority on wellness, prevention, and services which are high quality and cost-effective (i.e., the "Triple Aim" – simultaneously improving population health, improving the patient experience of care, and reducing per capita cost).  Combined with the Mental Health Parity legislation, the ACA represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation.  And, as Bob indicated, the Administration has demonstrated a concerted effort to engage all health care professions.  Mary Dougherty, Director of Nursing Education OAA, reports that the VA supports academic partnerships with Schools of Nursing via the VA Nursing Academic Partnership (VANAP) which funds both baccalaureate and graduate students.  The graduate programs are focused on Psychiatric Mental Health Nurse Practitioners (PMHNPs).  Both programs require a residency – a post baccalaureate nurse residency or a PMHNP residency.  The OAA provides funds for graduate and undergraduate faculty for both schools of nursing and VA, as well as stipends for graduate trainees, post baccalaureate nurse residents, and PMHNP residents.  The development of a standard PMHNP competency, curriculum, and accreditation standards are expected outcomes of this program.

            Population Focused Health Care:  I have recently been appointed to the national advisory committee on Interdisciplinary Community-Based Linkages of the Health Resources and Services Administration (HRSA).  The committee is charged with providing advice and recommendations on policy and program development to the Secretary of HHS concerning its various Title VII (Health Professions) training programs and is to submit an annual report to the Secretary and to Congress.  Included within its jurisdiction is the Psychology Graduate Education program, as well as the Area Health Education Center, Geriatric Education Center, Quentin N. Burdick Program for Rural Interdisciplinary Training, Allied Health, Mental and Behavioral Health Education and Training initiatives, Education and Training in Pain Care, and the Integration of Quality Improvement and Patient Safety Training into Clinical Education of Health Professionals programs.

            One of the challenges facing the nation is addressing the sequela from possessing multiple chronic conditions (MCC).  Currently 26% of adults have MCC; 67% of Medicaid beneficiaries with disabilities have three or more conditions.  Not surprisingly, as conditions increase, so does the frequency of mortality, poor functional status, hospitalizations, readmissions, and adverse drug events.  Sixty-six percent of US health care costs are for individuals with MCC and 93% of Medicare expenditures are for individuals with MCC.  For those inpatients 18-44 years of age with more than two chronic conditions, depression is the most prevalent.  The HHS Multiple Chronic Conditions Strategic Framework overarching goals include: * Fostering health care and public health system changes; * Maximizing the use of proven self-care management; * Providing better tools and information to workers who deliver care to those with MCC; and, * Facilitating research to fill knowledge gaps.  The poor health outcomes of individuals with serious mental illnesses and other behavioral health problems warrants special attention because of the co-occurrences of these conditions with other chronic conditions.  This is a priority patient population for which psychology's postdoctoral training would seem most appropriate; including those with specialized training in psychopharmacology.

            Ron Rozensky, who served as a former chair of the committee: "It was a great experience representing psychology and having the opportunity to work with the chairs and vice chairs of other advisory committees representing the full range of health care disciplines.  We collaborated on writing a letter to Congress during the drafting of the ACA underscoring the importance of the inclusion of interprofessional education, training, and service.  Our 10^th Report to Congresshighlighted the importance of health behavior as a key component of a truly integrated health care system – what a great honor to chair that report!"

Reflections:  I am intrigued by how our senior colleagues respond to retirement.  Margy Heldring, former APA Congressional Fellow:  "I am nearly full time with the group I founded, Grandmothers Against Gun Violence, after Sandy Hook.  It is amazing to build a new organization of 'Women of a Certain Age' and see everyone feel empowered and turn (return!) to activism.  What an experience!  Psychology seems farther and farther behind me, as I move out and back into policy and politics as a psychologist!"  Why, Oh, Why Can't I?  Aloha,

Pat DeLeon, former APA President – Division 55 – September, 2014

 

A VISION SOFTLY CREEPING

Congressional Engagement:  These are interesting times for our nation's non-physician health care providers, and particularly for those in the mental health/behavioral health field.  In deliberating on the Fiscal Year 2015 Appropriations bill for the Department of Defense (DoD), the U.S. Senate noted: "Mental Health Professionals. – The Committee recognizes that service members and their families face unique stresses beyond those of everyday life.  After over a decade of war, the need for mental health professionals in the Department is at an all-time high, and the Committee believes that every beneficiary of the Military Health System should have timely access to mental health services.  However, the Committee is concerned with the Department's inability to recruit and retain enough psychiatrists, psychologists, social workers, nurse practitioners, and registered nurses to provide adequate mental healthcare.  The Committee has asked the Government Accountability Office to review this issue including the Department's current inventory of mental health providers, current and future needs for providers, challenges the Department faces in recruitment and retention, actions taken to mitigate these challenges, and recommendations going forward to ensure an adequate inventory of mental health professionals within the Military Health System.  The Committee looks forward to receiving the results of this review and working with the Department to provide the tools necessary to implement any recommendations."  We would suggest that this is an excellent time for psychology to showcase its innovative treatment initiatives, communicate the ways in which the integration of behavioral and mental health services into primary care improves health outcomes, as well as its success in appropriately expanding its clinical scope of practice in obtaining prescriptive authority (RxP).

            The Patient Protection and Affordable Care Act (ACA):  President Obama's landmark Patient Protection and Affordable Care Act (P.L. 111-148) provides an exciting opportunity to make a real difference for those colleagues with vision and the willingness to demonstrate leadership.  Combined with the enacted Mental Health Parity legislation, this represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation.  Mental health and substance-use treatments are deemed "essential health benefits" under the ACA.  Priority will be given to prevention, wellness care, and services which are high quality and cost-effective, as our nation moves our health care system towards population health-based care, rather than stressing individual acute care episodes.  The ACA calls for the development of integrated, interdisciplinary systems of patient-centered care which will be transformational.  Chief among these is the integration of behavioral health and medical health care, where the public sector has consistently demonstrated proactive leadership.

The foundation is steadily being put in place for bringing the advances occurring within the communications and health information technology (HIT) fields into the health care environment.  As a nation, we are moving from reimbursement for specific clinical procedures towards encouraging value-based care – including the critical psychosocial-economic-cultural gradient of quality care.  This fundamental shift in emphasis is expected to result in the U.S. no longer being ranked by the Commonwealth Fund as last among developed nations on overall measures of health system quality, efficiency, access to care, equity, and healthy lives, as compared with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom.  This is in spite of the fact that we presently spend more on health care than anywhere in the world.

            The Need for Greater Public Awareness:  At the Uniformed Services University of the Health Sciences, we are fortunate to have a number of APA elected officials and senior staff address our interdisciplinary health policy seminar.  Rhea Farberman recently described APA's efforts to ensure that the value of psychological expertise is appreciated by health policy experts, other disciplines, and the public.  There is a surprisingly significant knowledge gap with only 4% of Americans being aware of the Mental Health Parity and Addiction Equity Act and what it means for their access to mental health and addictions care.  Consumers report that psychology can help people lead healthier lifestyles (51% somewhat agree and 42% strongly agree).  And, that health care can be improved through better understanding of human behavior (49% somewhat agree and 26% strongly agree).  Consumers believe that psychological research has a role to play in finding ways to address health issues such as obesity and smoking (49% somewhat significant and 23% very significant).  Yet, the public often doesn't pursue psychological services for themselves or loved ones when it could make all the difference in their treatment outcome.  This action gap could be the result of stigma; it could be due to access issues.  Regardless, it presents both an opportunity and responsibility for psychology.  As highly educated professionals, we may understand how psychology can contribute to improving the overall quality of health care in our nation if appropriately recognized.  However, we have a significant way to go before the rest of society does.  And, this is particularly true with our physician colleagues!  When physicians were asked:  Does psychological research have a role in finding ways to address health issues such as obesity and smoking – 45% responded somewhat significant and 40% very significant.  Even more telling: How helpful do you think a psychologist would be when it comes to assisting your patients in making lifestyle and behavior change?  Fifty-eight percent indicated somewhat helpful and 24% very helpful.

            Prescriptive Authority (RxP):  In her recent mailing to the membership, APA's Katherine Nordal praised the Illinois Psychological Association for their success in obtaining RxP.  "It's good news for our profession and very good news for the residents of Illinois….  Right now in our country, nearly 80% of psychotropic medications are being prescribed by primary care physicians who have very little training in mental health.  I'm sure you agree that mental health patients are well served by having qualified mental health professionals available to prescribe.  That's why the victory in Illinois is so important."  The World Health Organization (WHO) defines an adverse drug reaction as "harmful, unintended reactions to medicines that occur at doses normally used for treatment" and points out that these are among the leading causes of death in many countries.

Reflecting upon their success in Illinois, Beth Rom-Rymer reminds us that: "The Illinois Medical Society and the Illinois Psychiatric Society vigorously and vociferously lobbied against our RxP bill until they realized that we wouldn't stop fighting and until they had already spent $1 million to keep us out of the prescribing community!"  Persistence and community involvement are the key to long term change, which Beth and her colleagues vividly demonstrated.  Why is it that more colleagues within the VA have not sought prescriptive authority?  The experiences of their DoD colleagues clearly demonstrate that they can obtain these clinical skills and that the quality of care they would provide would be excellent.  The need is there.  There are a significant number of psychologists who are veterans and who belong to veterans' organizations -- the true beneficiaries.  Under President G.W. Bush, VA Secretary Tony Principi was quite open to initiating a pilot project, similar to the way that the DoD program initially began.  At that time psychology's leadership was not willing to demonstrate proactive leadership; notwithstanding that a number of individual VA psychologists had informed me that they were, in fact, prescribing.  Have we matured sufficiently as a bona fide healthcare profession to affirmatively accept this clinical responsibility?  The Sounds of Silence.  Aloha,

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

 

I’M SO PROUD TO KNOW

It was extraordinarily satisfying to learn from Beth Rom-Rymer that the Illinois Psychological Association (IPA) was successful in enacting your prescriptive authority (RxP) legislation this past June.  It has been a decade since Louisiana achieved their startling success, during which time leaders in the RxP movement have been steadily working to develop a "critical mass" of postdoctoral trained psychopharmacology clinicians.  Bob McGrath, Director of the Fairleigh Dickinson University Clinical Psychopharmacology training program, estimates that today there are 1750 graduates.  As vigorous as your opposition has been, it was impressive from a public policy perspective to see that, in the end, the Illinois Psychiatric Society and the Illinois Medical Society conceded that psychologists can prescribe.  Clearly this was a concession that only came after a hard-fought battle.  It was the perseverance and the determination of your IPA leaders, looking after the interests of the most vulnerable and at-risk residents in Illinois, that ultimately won the day.  And, as you now move quickly to implement your RxP legislation, with the drafting of the rules and regulations of the law and the signing up of various training facilities and universities and colleges throughout the state to train Illinois's prescribing psychologists, undoubtedly you will find that achieving the collaborative partnership of psychiatrists and medical directors has been greatly facilitated by your eleventh hour negotiated bill.  Congratulations!

            Our collective RxP discussions frequently refer to the successes of New Mexico (2002), Louisiana (2004), and colleagues in the Department of Defense (DoD) and U.S. Public Health Service (particularly, the Indian Health Service [IHS]).  Few seem to appreciate that the first state to pass RxP legislation was actually Indiana (1993, thanks to Mike Murphy), which was followed by Guam (1998, thanks to Mamie Balajadia).  Neither of these states has implemented their statutes to date; although progress has been reported in Guam.  Interestingly, Floyd Jennings was prescribing in the IHS back in 1988-1989 under the authority of the Santa Fe Indian Hospital bylaws.  Former APA President Ron Fox: "As of December 31, 2013 when I was chair of the APA Insurance Trust, I can attest to the fact that prescribing psychologists do NOT have to pay higher premiums for professional liability insurance as the Trust deemed an increase unnecessary; and, because the Trust policy provides insurance to cover expenses related to licensing board complaints I know that there have been NO complaints or actions taken by state licensing boards regarding prescribing abuses by appropriately trained psychologists."

Having been an informed observer throughout psychology's RxP quest, I was particularly pleased that your legislation recognizes, for the first time, the importance of encouraging pre-doctoral training.  This is an educational policy position that had been urged by practice visionary Gene Shapiro from the beginning and most recently by APA Past President Bob Resnick.  The initial requirement for postdoctoral training was a reasonable political compromise, addressing the sincere concerns of those who feared that our next generation of colleagues might never appreciate what psychological expertise could contribute to our patients' quality of life.  Their view was that otherwise "we would take the easy way out and become junior psychiatrists; substituting medication for therapy."  Over the years, the evidence has clearly not supported that contention.  In fact, our prescribing colleagues frequently report significantly modifying previously ordered medication protocols.  "The power to prescribe is the power to unprescribe," as New Mexico's Mario Marquez has stated on numerous occasions.

            The 1992 report submitted to the APA Council of Representatives by the ad hoc Task Force on Psychopharmacology, chaired by Mick Smyer, clearly appreciated the long term significance of "the importance of developing a subspecialty of psychology with comprehensive knowledge and experience in psychopharmacology.  Practitioners with combined training in psychopharmacology and psychosocial treatments can reasonably be viewed as a new form of health care professional, expected to bring to health care delivery the best of both psychological and pharmacological knowledge.  The contributions of this new form of psychopharmacological intervention have the potential to improve dramatically patient care and make important new advances in treatment."  And, as you have successfully demonstrated, the Task Force then focused on "the potential impact of the proposed training on two important concerns of consumers: (1) meeting unmet need for mental health services, and (2) effectively serving special populations."  Anita Brown was one of the APA staff liaisons to the Task Force.  She subsequently became one of the DoD prescribing psychologists.

            During his 2009 APA Presidency, James Bray hosted a Presidential Summit on the "Future of Psychology Practice."  One of the major themes presented was that "mental health care cannot be divorced from primary medical care, and that all attempts to do so are doomed to failure."  The enumerated Summit Principles were * Expand the focus of traditional psychological practice.  * From mental health to health care providers: Integrated health care.  * Integrating technology into practice.  * Meeting the needs of our diverse society.  And, * Apply basic and applied scientific evidence in our practice.  Shortly after the signing of your historic legislation James noted: "To stay as a viable profession psychology needs to take advantage of new opportunities in health care and business, otherwise we are likely to continue to financially decline.  Reimbursement rates for traditional mental health services have decreased in the past 10 years, while health care insurance premiums have seen double digit increases – Why is this?  Psychologists are being replaced by Masters level trained clinicians who will work for less and provide many of the same services.  We need to evolve into new positions of clinical leadership, consulting with business and gaining prescriptive authority where our services of doctoral trained psychologists will be rewarded.  If we don't step up now, other professions will and we will continue to see our incomes and opportunities drop."

            President Obama's landmark Patient Protection and Affordable Care Act (ACA) provides many opportunities for non-physicians with vision.  Combined with the recently enacted Mental Health Parity legislation this represents the largest expansion of health insurance coverage, particularly for behavioral health, in the history of our nation.  It provides a priority for prevention, wellness care, and services which are high quality and cost-effective, and aims to move our health care system towards a population health-based system.  The ACA affirmatively calls for the development of integrated, interdisciplinary systems of patient-centered care which will be transformational.  Chief among them is the integration of behavioral health and medical health care systems.  Under the law mental health and substance use treatment are deemed "essential health benefits."  The foundation now exists for the steady integration of the advances occurring within the communications and health information (HIT) technology fields into the health care environment.  From this perspective alone, your success in obtaining the support of the American Nurses' Association-Illinois chapter and the Illinois Society for Advanced Practice Nursing for your RxP legislation is extraordinarily futuristic.

Substantive change always take time; often far longer than one expects.  Throughout today's discussions regarding the appropriateness and cost-effectiveness of integrating behavioral health/mental health within primary care settings, the high incidence of depression among patients is frequently noted.  The Agency for Health Care Policy and Research (AHCPR) was established by the Omnibus Budget Reconciliation Act of 1989 to enhance the quality, appropriateness, and effectiveness of health care services and access.  Among its responsibilities was facilitating the development and updating of clinical practice guidelines to assist practitioners in the prevention, diagnosis, treatment, and management of clinical conditions.  More than two decades ago (April 1993), AHCPR issued its guideline on Depression in Primary Care: Detection and Diagnosis – then-APA's Deputy Executive Director for Professional Practice, Russ Newman, was involved in ensuring that psychology's voice would be heard.

"Depression was selected as a topic for guideline development because: * Depressive disorders are commonly encountered in primary care, as well as in other treatment settings.  * Most depressed patients seek care from primary care practitioners.  * A range of effective treatments are available and commonly provided for these conditions.  * There is a large body of scientific evidence on which to base these guidelines.  * Practice surveys indicate that improvements are needed in primary care practitioners' ability to recognize and treat depressive disorders.  * Depressive disorders result in significant morbidity and mortality.  (And) * Depressive disorders have a high prevalence in the general population….  Despite the high prevalence of depressive symptoms and full major depressive episodes in patients of all ages, depression is underdiagnosed and undertreated by primary care and other nonpsychiatric practitioners, who are, paradoxically, the most likely to see these patients initially….  The social stigma surrounding depression is substantial and often prevents the optimal use of current knowledge and treatments.  The cost of the illness in pain, suffering, disability, and death is high….  Clinically significant depressive symptoms are detectable in approximately 12 to 36 percent of patients with another nonpsychiatric, general medical condition…. "  More than two decades ago….  GOOD DAY SUNSHINE.  Aloha,

Pat DeLeon, former APA President – Illinois Psychological Association – September, 2014