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

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

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

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

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

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

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

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

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

 

THE FOUNDING FATHERS

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

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

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

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

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

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

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

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

 

 

COLLEAGUES MAKING A REAL DIFFERENCE

   The Affordable Care Act (ACA):  With the steady implementation of President Obama's Patient Protection and Affordable Care Act (ACA), psychology's practitioners and nursing's Doctors of Mental Health Nursing Practice (DNP) are increasingly being held to the requirements of the more generic healthcare system.  This evolution is especially relevant to integrated care models; for example, the Accountable Care Organizations and Patient-Centered Medical Homes fostered by the Act.   Central to this evolution is the necessity of appreciating the common procedural terminology (CPT) system which has become the most widely accepted nomenclature used in the reporting and reimbursement of health services under public and private health reimbursement programs.  From a policy perspective, it is evident that the CPT system is just beginning to address the complexity involved in recognizing that mental health and physical health are intimately intertwined, as well as the critical contributions of the psychosocial-economic-cultural gradient to "quality" health care.

            Tony Puente has been working at the interface of practice and policy with the CPT system since the late 1980s.  He served as APA's first representative to AMA and for 15 years has been working with them.  He is presently a voting member of their CPT Editorial Panel.  Tony's report: "The CPT was developed almost 50 years ago by surgeons and physicians and today is copyrighted by the AMA and owned by the Centers for Medicare and Medicaid Services (CMS).  A new code for psychological services would be developed by a Health Care Professional Advisory Committee, all non-physicians, then is edited and researched by a selected work group and referred to the CPT panel on which I serve for review and possible approval.  If successful, this process can take anywhere from two years to twelve years.

            "Out of the approximately 8,000 codes, around 60 are possible codes for psychologists to utilize.  These fall within a few major categories including Psychiatric/Mental Health, Central Nervous System Assessment, and Health and Behavior.  Miscellaneous codes also cover preventive measures, evaluation and management (E&M), and telehealth.  Psychiatric/Mental Health codes were added in the 1970s, testing codes 20 years later, and Health and Behavior codes soon thereafter.  Biofeedback codes have also been included.  Due to changes in practice patterns and increasing recognition of co-morbidities, codes established for psychotherapy underwent major changes last year.  Most current procedure codes reimburse for 'silo' or non-interactive procedures, such as psychotherapy.  There is an expanding vision to create codes that financially incentivize professionals to integrate health services.  APA is well represented by Neil Pliskin and James Georgoulakis in the AMA process and Randy Phelps as Director of APA's new Office of Healthcare Financing."  Tony ran for APA President in 2014 and we fully expect he will be on the ballot for 2015.

            Being at the Table:  At the annual APA State Leadership Conferences (SLC), Katherine Nordal has consistently stressed the importance of psychology becoming actively involved in policy discussions at the local and national level -- "If we're not at the table, it's because we're on the menu."  A Longtime Friend to Hawaii, now in our Nation's Capital:  Diane Elmore: "After spending summers in Hawaii as a child and completing my doctoral internship at the Honolulu VA Medical Center/National Center for PTSD, Pacific Islands Division, I moved to Washington, DC in 2002 to pursue a career in health policy.  I spent nearly a decade at the APA where I served as Associate Executive Director of the Public Interest Government Relations Office, Director of the APA Congressional Fellowship Program, and Coordinator of APA's military and Veterans activities.  During my tenure at APA, I worked on key federal legislation focused on the needs of underserved/priority populations, including indigenous populations, older adults, survivors of trauma across the lifespan, and military service members and Veterans.  As a member of the APA health care reform policy team, I helped to successfully secure key provisions in the ACA related to issues including integrated health care, prevention and wellness, and workforce development.

            "As the former Director of the APA Congressional Fellowship Program, I served as a mentor to dozens of psychologists who came to Washington, DC to experience the policymaking process up close and personal.  My own experience as an APA Congressional Fellow inspired me to help other Fellows navigate and adjust to the fast-paced and exhilarating landscape on Capitol Hill.  I served in the Office of then-U.S. Senator Hillary Rodham Clinton, where I was a member of the health team working on a range of health policy issues.  Among the federal policies the Senator helped to advance were new mental health initiatives for older adults (as part of the reauthorization of the Older Americans Act) and federal legislation to address the needs of family caregivers across the lifespan (Lifespan Respite Care Act), which both became law in 2006.  I helped to share scientific/clinical expertise on timely initiatives related to the mental health of military service members and Veterans and the psychological consequences of terrorism, in the aftermath of 9/11.

            "My passion for engaging scientists and practitioners in policy and advocacy efforts led to a multi-year collaboration with colleagues in the APA Education Government Relations Office to develop the APA PsycAdvocate® Series, which is available on the APA Continuing Education website.  This series of training modules provides psychologists, psychology students/trainees, and others with the skills to become effective public policy advocates at the federal, state, and local levels.

            "Last year, I joined the UCLA/Duke University National Center for Child Traumatic Stress as its Washington, DC-based Policy Program Director.  In this role, I help to lead the National Child Traumatic Stress Network (NCTSN) efforts to educate and inform federal, state, and local policymakers about the critical issue of child trauma.  Today, nearly two-thirds of children in the U.S. are exposed to a traumatic event before age 16.  The cost of child trauma is not only felt in human terms (e.g., physical and mental health effects), but also in billions of dollars in estimated associated costs.

            "The NCTSN was created by Congress in 2000 to raise the standard of care and increase access to services for children and families who experience or witness traumatic events.  Our policy team works closely with current NCTSN grantees and affiliates (formally funded centers) working in hospitals, universities, and community based programs in 43 states across the U.S.  Included among the NCTSN affiliate programs is Catholic Charities Hawaii, Youth Enrichment Services Division.  NCTSN grantees and affiliates provide clinical services, develop and disseminate new interventions and resource materials, offer education and training programs, collaborate with established systems of care, engage in data collection and evaluation, and inform public policy and awareness efforts.  Please visit http://www.nctsn.org/."

With the future stressing integrated and interprofessional care, it is exciting that nursing's leadership is strategically implementing a vision similar to that proposed by Katherine and Diane.  The American Academy of Nursing has announced their participation in the Nurses on Boards Coalition, which is a group of national nursing organizations dedicated to increasing nurses' presence on corporate and non-profit health-related boards of directors throughout the nation.  The coalition is working on implementing a national strategy to bring nurses' valuable perspective to governing boards, as well as to state-level and national commissions with an interest in health.  Their goal is to put 10,000 nurses on boards by the year 2020, pursuant to the recommendations of the Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health (2011).  This effort is being supported by the Robert Wood Johnson Foundation and AARP.  Pursuant to this challenge the Nursing Campaign for Action, which has coalitions in all 50 states and the District of Columbia, is actively seeking to promote healthier lives, supported by a system in which nurses are essential partners in providing care and promoting health.

True Quality Care:  Mike Sullivan, who was instrumental in passing psychology's earlier RxP bills in his APA Practice Directorate State Leadership role: "The September Monitor's article 'On the Reservation' about the Crow/Northern Cheyenne Indian Health System hospital in Montana with RxP is outstanding!  Marie Greenspan's quote 'We maintain a policy of no pills without skills.  If we're giving medication, people also need to come in and talk with us and learn non-pharmacological ways of managing their issues as well.'  That's psychology's contribution to prescribing in a nutshell.  Especially when these services would otherwise be unavailable."  Aloha,

Pat DeLeon, former APA President – Hawaii Psychological Association – December, 2014

 

A LONG DISTANCE RUN

 Hills and Valleys:  During the exciting 2013 APA State Leadership Conference (SLC), Katherine Nordal noted: "The clock is ticking toward full implementation of the law and January 1, 2014 is coming quickly.  But January 1^st is really just a mile marker in this marathon we call health care reform….  We can't hope to finish the marathon called health care reform if we're not at the starting line.  Fortunately, many psychology leaders have embraced our call to action."  With the steady implementation of President Obama's Patient Protection and Affordable Care Act (ACA), our nation's mental and behavioral health providers (regardless of professional discipline) are increasingly being held to the standards and nuances of the overall healthcare system.  For over two and a half decades, Jim Georgoulakis has represented psychology's voice on the American Medical Association's (AMA's) Resource Value Update Committee, which is responsible for advising the Centers for Medicare and Medicaid Services (CMS) on payment policy for services contained in the Current Procedural Terminology (CPT) reimbursement system.  His visionary perspective on the considerable challenges facing our practitioners as they face the inevitable integration of federal, state, and private sector requirements:

"Psychologists and Compliance Plans:  Recently various lit-serves and publications have raised the issue of compliance plans which have unfortunately left a number of psychologists confused as to whether they should develop compliance plans for their practices.  The answer is clearly an unequivocal 'Yes' and there should be no further debate on this matter.  This fall, in an AntiFraud newsletter, the former Department of Health and Human Services (HHS) Inspector General (IG) Richard Kusserow made a number of statements regarding Medicare and Medicaid mental health fraud to the effect that mental health benefits have been 'a special enforcement problem that stretches back decades.'  'Many healthcare fraud investigators believe mental health caregivers such as psychiatrists and psychologists have the worst fraud record of all medical disciplines.'  Support for this assertion comes from Assistant U.S. Attorney Ted Radway, who stated that in Medicaid there has been 'an explosion of fraud in community-based mental health treatments, including billing for services not rendered.'

            "The current IG of HHS Daniel Levinson is also very clear on the need for a compliance plan.  In his keynote address to the Health Care Compliance Association 2014 meeting, he stated that every provider should have a compliance plan.  He noted that a one or two person practice will have a different compliance plan than a large organization.  He also emphasized that each compliance plan should be unique to the practice – he cautioned against an off the shelf program.  The IG also discussed the training materials (written, audio, and video) that his office has produced to assist providers.  These materials can be located on the OIG web site which includes a section titled Compliance 101.  In this package it is important to note specific videos on compliance program basics, documentation, and operating an effective compliance program.  Additionally, there is a caption that states 'ultimate responsibility for complying with federal fraud and abuse laws lies with the provider of the service.'

            "In the main psychologists were very supportive of the passage of the ACA.  However, the ACA included a new section [Section 6401 (a)] which established a new Section 1866 (j) (8) which reads that a provider of medical or other items or services or a supplier shall, as a condition of enrollment in Medicare, Medicaid, or CHIP, establish a compliance program that contains certain 'core elements' of a Federal Compliance Program.  The core elements of such a compliance program have been available on the OIG web site since 1999.  As to be expected when reviewing the compliance plan requirements of the 50 states, there is considerable variability among the states with New York having the most comprehensive and the oldest requirements (i.e., mandatory plans since 2009).

            "The AMA provides CE credit for participating in the OIG training on compliance.  This training is web based and is included in the OIG's web site.  Similar to physicians, I would hope at some time in the near future psychologists would stop debating on whether compliance plans are necessary, develop similar training CE programs, and move forward and improve our standing in the health care compliance community."

            Exciting New Faces and New Agendas:  The Illinois Psychological Association, with the guidance and leadership of Beth Rom-Rymer, in particular, succeeded this year in passing prescriptive authority legislation, which is the first RxP bill to be signed into public law since Louisiana's on May 6, 2004.   "With the passage of our prescriptive authority bill, that gives opportunity for graduate students to take the core component of their training in Clinical Psychopharmacology pre-doctorally, close observers have wondered if only the young students will take the training.  Others have asked, 'Will access to care issues really be addressed?'  Still others have questioned, 'In what ways will the identity of the clinical psychologist change as (s)he also takes on the identity of the prescribing psychologist?  As we are only at the beginning of our prescriptive authority journey, I will, today, address the question of 'Who wants to prescribe' by drawing some portraits of just a few psychologists who have expressed their intention to prescribe in Illinois and/or who are already in the process of gaining their eligibility to prescribe.  These examples are in no way exhaustive but represent the diverse spectrum of psychologists, in Illinois, who will be prescribing.

"* Karla is an early career psychologist, is Director of Behavioral Health and Pastoral Care at a Federally Qualified Healthcare Center (FQHC) that serves a largely Hispanic and African American population on the west side of Chicago.  She has almost completed her training in clinical psychopharmacology from Fairleigh Dickinson University and is looking forward to soon completing the other components of her training.  * Jane has wanted to be a prescribing psychologist since she was a teenager and she is now 62 years old!  A practicing clinical psychologist, she is currently taking the core training in clinical psychopharmacology from Fairleigh Dickinson University.  She is looking forward to taking the undergraduate science courses on-line and/or at a nearby community college.  * Dick is a mid-career clinical psychologist who had been in a joint practice with his pediatrician father for 25 years.  He had been a pre-med major as an undergraduate and has completed all of the undergraduate sciences courses; the core training in clinical psychopharmacology from NOVA Southeastern University; and has taken and passed the PEP.  These dedicated colleagues are leading the way to our future.

            "Since the passage of our legislation, I have been in contact with leaders in more than 10 states in which prescriptive authority initiatives have been reinvigorated.   Indiana is one of those states, where, although never implemented, their original effort became public law back in 1993.  Other states include Hawaii, California, Idaho, Arizona, Texas, Nebraska, Missouri, Michigan, Ohio, Florida, Virginia, and Maryland.  It was a particular pleasure to be able to speak at the convocation of the most recent graduating class of the New Mexico State Psychopharmacology training program where we honored Elaine LeVine for the monumental pioneering work that she has done for all of us in the RxP arena.  The enthusiasm at the grass roots level is contagious!" (Beth Rom-Rymer).  A journey of a thousand miles begins with a single step.  Aloha,

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

 

YESTERDAY, ALL MY TROUBLES SEEMED SO FAR AWAY

 The Newly Elected 114^th Congress:  With the Republican Party having an outstanding election eve, the Grand Old Party controls both the U.S. House of Representatives and the U.S. Senate for the first time since 2006, when President George W. Bush occupied the White House.  Their margin of victory in the House takes them close to surpassing their largest majority of the post-World War II era.  Accordingly, one must expect an extensive public debate regarding the fundamental role of government in our society through a number of different venues, including whether Obamacare (or critical aspects of it) should be repealed.  During my tenure on the U.S. Senate staff, Bob Ax, who worked for the federal Bureau of Prisons for 20 years and before that for the Trenton State Prison in New Jersey, was a frequent visitor, bringing his psychology interns to the Hill to get a firsthand glimpse of the public policy/political process.  From his vantage point of retirement, he has been reflecting upon whether our current federal and state health care systems (including that of DoD and the VA) might undergo a significant privatization evolution in the foreseeable future – as he personally experienced with the prison system.  And, if so, what might be the impact on quality of care and psychology. 

            "The private prison initiative began in America three decades ago and has grown exponentially since then.  Since 2000, an increasing percentage of federal and state inmates have been housed in private facilities, even as the overall prison population plateaued and then dropped slightly.  Privately owned or operated prisons now exist in many first-world countries.  Notwithstanding numerous criticisms about their operations, private prisons are less accountable than those operated through the civil service.  More information can be legally withheld as proprietary, a problem that led to Representative Sheila Jackson Lee introducing the Private Prison Information Act of 2011 as a corrective measure.  The Act died in committee.

            "Many of the immigrant detainee facilities around the country are privately owned and/or operated.  Since 2009, the Department of Homeland Security's funding appropriations bills have included a provision mandating that 34,000 beds in these facilities be available each day, ensuring that tax-payer dollars continue to flow into the coffers of for-profit corporations.  In 2013, Immigration and Customs Enforcement (ICE) detained almost 441,000 aliens.  About half of these were housed in privately-owned or operated facilities.

            "To ensure the continuity of the revenue streams, private prison corporations have contributed directly to political campaigns and otherwise funneled money to politicians to influence the passage of favorable legislation.  They favor states with some of the toughest sentencing laws, particularly those that had enacted legislation to lengthen the sentence given to any offender who was convicted of a felony for the third time.  Between 2000 and 2004, private-prison interests gave almost $2.1 million in 22 states that had a so-called 'three strikes law,' compared with $1.2 million in 22 states that did not pass such legislation.  That is to say, they are actively engaged in the public policy/political process.

The underlying business model relies in part on monetizing inconvenient people: individuals whose behavior and/or status (e.g., as a person with serious and persistent mental illness, indigent, or a member of racial minority group) renders them disproportionately vulnerable to arrest and incarceration.  More behavior criminalized means more prisoners and a greater return on investment.  Tax dollars follow them out of the 'free world' community (where the funds might have been spent on schools, hospitals, or job programs) and into housing these men, women, and children in the criminal justice system.  Private prisons seemed at first to be a necessary stop-gap solution to the burgeoning prison population in the 1980s and 1990s.  Now they've become entrenched within the so-called prison-industrial complex.

            "Under the best of circumstances, correctional health care, whether delivered through the private or public sector, is going to be problematic.  On a day-to-day basis, treatment is inevitably a mission subordinated to safety and security concerns.  Whereas health care providers are trained to consider individual differences, the criminal justice system emphasizes uniformity.  Too often ignored as health care issues are the iatrogenic effects of incarceration, both on those incarcerated and on those impacted by extension: family members and communities.

            "If we want healthier inmates, we should have fewer of them.  Prevention is good health care, but bad business for a company that gets reimbursed for keeping prison cells full.  The public needs to decide where it wants its tax dollars to go: toward healthier, stronger individuals, families and communities, or prisons and jails.  We spent the last four decades tearing down psychiatric hospitals and building prisons.  Now the discourse has begun to shift, with intimations of a move towards reducing incarceration.  However, the incarceration rates – still near, if slightly below, record highs – reflect our abiding ambivalence toward prison reform, which would necessarily impact private prison companies" (Bob Ax).

            The Long Term Policy Contributions of "Think Tanks":  As those currently responsible for determining the role of government (i.e., our elected officials) engage in their ongoing debates, it is incumbent upon healthcare professionals and those of other disciplines to systematically bring to the nation's public consciousness agendas and concerns which should be addressed.  To the extent to which the best of science informs this process, the nation will be well served.  The Board on Children, Youth, and Families, directed by psychologist Kimber Bogard, of the Institute of Medicine (IOM) and the National Research Council recently released its report entitled Investing in the Health and Well-Being of Young Adults.

            Young adulthood – ages approximately 18 to 26 – is a critical time in life.  What happens during these years has profound and long-lasting implications for future employment and career paths and for their economic security, health, and well-being.  Young adults are key contributors to the nation's workforce and military services and, since many are parents, to the healthy development and well-being of the next generation.  In recent decades, the world has changed to place greater demands on young adults and provide less latitude for failure.  The disruption and lengthening of established social and economic pathways into adulthood have presented more choices and opportunities for some young adults and more barriers for others.  Providing educational, economic, social and health supports will help young adults assume adult roles, develop marketable skills, and adopt healthy lifelong habits that will benefit them, their children, and the nation.  Despite popular attention to some of the special circumstances of young adults, however, they are too rarely treated as a distinct population in policy, program design, and research.  Instead they are often grouped with adolescents or, more often, with all adults.

Focusing on the health and well-being of the current cohort of young adults is especially important because of the powerful (and perhaps transformative) economic and social forces now at work – the restructuring of the economy, widening inequality, a rapidly increasing "elder dependency ration" (i.e., the ratio of the population aged 65 and older to the working-age population).  The future well-being of the nation rests on the investments made in all young adults today – particularly those whose background and characteristics put them at risk of experiencing the greatest struggles.  Providing more of the educational, economic, social, and health supports they need will help ensure equal opportunity, erase disparities, and enable more young adults to successfully embrace adult roles as healthy workers, parents, and citizens.

            The IOM report emphasized that: * Young adulthood is a critical developmental period; * The world has changed in ways that place greater demands on young adults; * Young adults today follow less predictable pathways than those in previous generations; * Inequality can be magnified during young adulthood; * Young adults are surprisingly unhealthy; And, * Supporting young adults will benefit society.  Addressing the health status of young adults: Young adulthood is a critical period for protecting health, not just during the transitional years but over the life-course.  Unfortunately, the dominant pattern among young adults today is declining health, seen most clearly in health behaviors and related health statuses.  As adolescents age into their early and mid-20s, they are less likely to eat breakfast, exercise, and get regular physical and dental checkups, and more likely to eat fast food, contact sexually transmitted diseases, smoke cigarettes, use marijuana and hard drugs, and binge drink.  In many areas of risky behavior, young adults show a worse health profile than both adolescents and older adults.  For example, they are more likely to be injured or die in motor vehicle crashes and to have related hospitalizations and emergency room visits.  Many risky behaviors peak, but it is also the time when involvement in risky behaviors begins to decline.  It is a time of heightened psychological vulnerability and onset of serious mental health disorders, a problem compounded by failure to recognize illness or to seek treatment.  Almost one-fifth of young adults had a mental illness in the past year and four percent had a serious mental illness.  Yet, two-thirds of those with a mental illness and almost half of those with a serious mental illness did not receive treatment.  Not surprisingly, the current generation of young adults appears to be in the forefront of the obesity epidemic and is more vulnerable than previous generations to obesity-related health problems consequences in later years.

The higher levels of poor health in young adulthood have important consequences for future health, educational attainment, and economic well-being.  Rapid technological changes, economic challenges, and a prolonged transition to adulthood appear to be contributing to the health problems of young adults by increasing their stress and sedentary habits.  Nevertheless, the report made it clear that it was not intended to imply the creation of an extensive set of new programs targeted only at young adults as this would have the potential to create new silos and concerns about lack of coordination across various ongoing programs.  Rather the intent is to increase focus on how policies and programs are working for young adults.  New policies, programs, and practices should be recommended only when the evidence indicates that young adults' specific needs are not being met.  Three common themes emerged: 1.) Current policies and programs addressing this population too often are fragmented and uncoordinated.  2.) These policies and programs often are inadequately focused on the specific developmental needs of this population.  And, 3.) The evidence base on interventions, policies, programs, and service designs that are effective for young adults is limited in most areas.

            Retirement:  "If you've been a workaholic, it's important to have plans for a 'new mission' in retirement to give your life focus and meaning.  Otherwise, retirement can feel empty initially.  There are unexpected disruptions, financial expenses or losses, deaths of significant friends and family.  But most of those who functioned at a high level in their careers get through it with new activities and new values appropriate to the post-retirement phase of life" (Kris Ludwigsen).  Oh, I Believe In Yesterday.  Aloha,

Pat DeLeon, former APA President – Division 29 – November, 2014

 

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