FUTURE TRAILS -- FROM TWO UNIQUE PERSPECTIVES

      * Exciting Opportunities for the Profession:  As our nation steadily implements President Obama's landmark Affordable Care Act (ACA), visionary early career psychologists will appreciate the importance of positioning themselves within expanding and challenging niches.  The FY'2013 HRSA budget highlights the Institute of Medicine report that there are three shortfalls in our current health care system: 1.) Health care needs of older adults will be difficult to meet by the current health care workforce.  2.) There will be severe shortages of geriatric specialists and other providers with geriatric skills. And, 3.) There will be increased demand for chronic care management skills.  Thanks to the continuing efforts of APA's Cynthia Belar,Diane Elmore, and Nina Levitt psychology is eligible for support under the HRSA Geriatric Education Centers Program in order to provide high quality interdisciplinary geriatric education and training and the Graduate Psychology Education (GPE) initiative.  HRSA points out that mental disorders rank in the top 5 chronic illnesses in the nation, accounting for significant economic and productivity costs, as well as an overall poorer quality of life for those affected.  During the academic year 2010-2011, 20 GPE grantees taught 620 trainees and graduated 90 psychologists.  These trainees provided psychology services to over 46,000 individuals, including special minority populations and children living with diabetes, trauma, and ADD.  These two initiatives are providing our next generation with unique and highly valued clinical skills, addressing a truly national priority.  Mahalo.

 

It is affirming that support for psychology's programs has been expressly included in the HHS budget.  HRSA also requested $10 million for the National Centerfor Health Workforce Analysis to obtain information to inform public policies and programs related to the health workforce, including projections of future health workforce needs in order to assure access to high quality, efficient care for the nation.  ACA provides the States with considerable flexibility to develop the health care system which best fits their unique needs and expertise.  Similarly, the Center intends to actively develop a Federal-State infrastructure in order to coordinate and collaborate with its State partners in building the foundation for more effective and useful health workforce analysis to address their individual needs.  Our training programs must become active participants in this far reaching discussion at the local level and craft programs addressing state and national needs; for example, through federally qualified community health centers (FQCHCs) which remain a high Administration priority.

 

            ** A Personal View:  Having retired from the U.S. Senate staff after 38+ years, I have become particularly interested in the experiences and stories of senior colleagues who have embarked upon similar journeys or transitions.  Many of us have never really thought about this next phase of our lives until the time, seemingly suddenly, arrives.  Ellen Cole and Mary Gergen have recently editedRetiring But Not Shy: Feminist Psychologists Create Their Post-Careers, a moving compilation of the stories of pioneering feminist psychologists who, during their illustrative careers, have revolutionized the field, if not society.  The timely thoughts of a long time friend and colleague, Linda Garcia-Shelton, former Executive Director of the California Psychology Internship Council, who recently returned to rural Michigan:

 

            Reflections On a (so far) Short Retirement:  "I have found retirement to be a state with many experiences and challenges, some consciously expected, others vaguely familiar from different times in my life.  So far I have experienced nothing that flatly surprised me, but I am not so sure that is necessarily a good thing.  Like many other females of my age (a war baby), I helped care for my younger brothers earlier than I can remember and began paid work for neighbors as mother's helper when I was 10.  Each year I expanded my scope of work and increased my hourly pay, finally running a baton lesson business the last three years of high school.  By the time I entered college I had saved enough for spending money to accompany my scholarship and NDEA loan funds.  When my savings were exhausted I secured several part time on-campus jobs using federal work-study allocations.  Coming from a blue collar immigrant family background, and a girl besides, there was no possibility of financial support for college from my family.  I did not consider this a problem, although I recognize that current high school graduates coming from families like mine are seldom able to attend or complete a baccalaureate degree because of financial constraints.  Times were different then.

 

            "The pace and nature of work continued throughout my life in the same way that it began in my youth – there were always jobs, I loved what I did, I enjoyed going to work, and I was one of those people who generally say 'yes' to requests.  Typically, I juggled many projects, worked on time-lines of from 4 months to 6-8 years, and seldom was limited by borders, at least not consciously.  One of the most difficult aspects of retirement is that I am seldom asked to do something for others, and I must create structure for myself.  Since, for the most part, I defined my own work roles and tasks throughout my work life I have been surprised to find it quite challenging to define my retirement roles and tasks.  Even writing 'roles and tasks' makes me wonder if I am missing something – do some people have pleasurable days and weeks without defined 'roles and tasks'?

 

            "During weeks that I am working on professional tasks (research and writing projects mostly) I am happily busy and oblivious to feelings of 'drift' – that is, What to do next?  Who cares about this?  What did I do today?  However, I really don't want to continue AS IF I am still at work.  I do believe I need to develop more ways to live in the non-professional world.  I have started this self-development project by doing some of the activities I have always loved, but which fell by the wayside over the years or simply timed-out (e.g., raising children).

 

            "I am doing a lot more non-psychology reading.  I finished a history of World War II, focusing most heavily on areas my father and uncles were involved in, and am now readingCarthage Must be Destroyed.  I read some fiction (Saramago, Russo, Rushdie, and others), and am reading magazines and books about heritage plants that we might include in our garden this coming Spring and Summer.  My mother died a year ago, and I have been slowly going through her possessions, hastily boxed up last Winter and Spring to empty her house for sale.  This has been both difficult and, in some cases, quite surprising.  I can only do it for a few days at a time before I must drift off to another project for awhile.

 

            "It has occurred to me that my retirement has taken on a similar structure to my professional activity of many long years – blocks of time focused on a project, followed by another block of time on another project – but without the external impetuous of multiple ongoing projects each with their own deadlines.  The difference is that now there are no natural deadlines to prompt me to shift from one project to another, hence a sense of drifting when I become aware of myself.  I am now thinking I should enlist the help of others (my husband, my friends, my family) to create some regular place-keepers in my day and week (a group exercise class, a theatre night, etc.) to both improve my health (I am a natural couch potato) and inject some expected/planned social activities in what are becoming fairly solitary days.  I am hoping that committing to participate with others in an activity will make it more likely that I will do it.  When I was working my colleagues were always around, offering regular interaction with others and issuing many invitations to get involved; now I must find ways to do this myself.

 

            "This last Fall I traveled to Italy andSpain to spend time with friends (Italy) and family (Spain) as a way of announcing a transition in my life, and inviting participation from them in it.  My Italian friends have been professional collaborators for nearly 2 decades, and while our professional collaborations will continue, they also are dedicating more time to retirement activities.  From a distance, they seem to be doing better than me at the retirement portion of their life.

 

            "My family is large and very spread out, so connecting with them in my new mode will hopefully increase the attention we give to each other.  I am now (January-March, 2012) in the midst of a 2 ½ month auto caravan with my husband to spend concentrated time with our 3 sons and their families (2 in Californiaand 1 in North Carolina), and shorter visits with a bunch of cousins spread across the Southern States (California, Arizona, Texas, and Florida).  An ongoing cousin project that I am belatedly joining is to collect more family information than our parents provided to us about our ancestors, their immigration and non-immigration decisions, and tracking down varying versions of 'the distant past' (3-5 generations) and comparing this with whatever contemporaneous information we can dig up.  Now that I have announced openly that I will join this project, I know that my cousins will give me many invitations to take on pieces of the project – indeed I am depending upon them.  Besides increasing interaction with my cousin group, I think this project will reconnect me with my larger family (both historical and current) that I somewhat withdrew from during my busy years in the working world.  This reconnection feels like a fitting activity for this time in my life.

 

            "A major thought project I am in the midst of is making sense of the drastic changes in the U.S. social system over my lifetime, and doing this in a way that allows me to stay engaged with that system.  I grew up in a family that strongly believed in facing challenges directly by working to make changes so that the world around you becomes a better one, a more fair one, and a happier one.  My grandparents were political activists in the country they were born and in the country of their chosen citizenship, the U.S.  My father and his brothers were very active in unionizing activities in the Detroit auto plants in the 1930s, and my father was a low level elected union officer during much of my childhood.  I was involved in the mid-1960s in civil rights work in Mississippi that was initiated and supported by the SCLC, and my work in primary care health psychology was heavily oriented toward public health and access to care.

 

            "Now I see a nation that seems to be forsaking the majority of its citizens.  I see an ever widening income gap between the extremely wealthy and the middle and working classes.  I see massive de-investment in public education that still is responsible for the overwhelming majority of children and youth.  I see basic health outcomes in communities I have worked in getting worse, while as a nation we spend more and more money to no good effect.  I see basic freedoms that drew my grandparents to this nation – predominately our then secular civil state – being eroded to the point where religious beliefs of some are being forced upon all through the power of the law.  All this makes me feel old, tired, and very sad.  A lifetime of work that has apparently resulted in a nation with reduced opportunity and freedom for the majority of its citizens.

 

            "On some days I am greatly depressed (with the accompanying sense of helplessness and hopelessness) that I am leaving a dysfunctional country to my grandchildren.  This is my definition of failure, since family is at the center of my world.  On better days I talk with like-minded folks in my small rural home town about how we can affect the coming state and national elections; how we can maintain and advance a health system that provides universal access; how we can support our local school as it struggles with an ever shrinking state-allocated budget and increasing student numbers; and how we can influence our tiny village council and county supervisors to seriously consider the environmental dangers of 'fracking' for gas that they approved several years ago without making clear to any of us the dangers of the method for our formerly pristine northern Lake Michigan shore side community.  So, I am trying to use my energy to preserve a secular political system, good health care, schools for the future leaders of this nation, and a home that is not the twenty-first century equivalent of a garbage dump.  I don't know if I have enough energy."  Aloha,

 

Pat DeLeon, former APA President – Division 42 – March, 2012

FUTURE TRAILS -- FROM TWO UNIQUE PERSPECTIVES:

     * Exciting Opportunities for the Profession:  As our nation steadily implements President Obama's landmark Affordable Care Act (ACA), visionary early career psychologists will appreciate the importance of positioning themselves within expanding and challenging niches.  The FY'2013 HRSA budget highlights the Institute of Medicine report that there are three shortfalls in our current health care system: 1.) Health care needs of older adults will be difficult to meet by the current health care workforce.  2.) There will be severe shortages of geriatric specialists and other providers with geriatric skills. And, 3.) There will be increased demand for chronic care management skills.  Thanks to the continuing efforts of APA's Cynthia Belar,Diane Elmore, and Nina Levitt psychology is eligible for support under the HRSA Geriatric Education Centers Program in order to provide high quality interdisciplinary geriatric education and training and the Graduate Psychology Education (GPE) initiative.  HRSA points out that mental disorders rank in the top 5 chronic illnesses in the nation, accounting for significant economic and productivity costs, as well as an overall poorer quality of life for those affected.  During the academic year 2010-2011, 20 GPE grantees taught 620 trainees and graduated 90 psychologists.  These trainees provided psychology services to over 46,000 individuals, including special minority populations and children living with diabetes, trauma, and ADD.  These two initiatives are providing our next generation with unique and highly valued clinical skills, addressing a truly national priority.  Mahalo.

It is affirming that support for psychology's programs has been expressly included in the HHS budget.  HRSA also requested $10 million for the National Centerfor Health Workforce Analysis to obtain information to inform public policies and programs related to the health workforce, including projections of future health workforce needs in order to assure access to high quality, efficient care for the nation.  ACA provides the States with considerable flexibility to develop the health care system which best fits their unique needs and expertise.  Similarly, the Center intends to actively develop a Federal-State infrastructure in order to coordinate and collaborate with its State partners in building the foundation for more effective and useful health workforce analysis to address their individual needs.  Our training programs must become active participants in this far reaching discussion at the local level and craft programs addressing state and national needs; for example, through federally qualified community health centers (FQCHCs) which remain a high Administration priority.

            ** A Personal View:  Having retired from the U.S. Senate staff after 38+ years, I have become particularly interested in the experiences and stories of senior colleagues who have embarked upon similar journeys or transitions.  Many of us have never really thought about this next phase of our lives until the time, seemingly suddenly, arrives.  Ellen Cole and Mary Gergen have recently editedRetiring But Not Shy: Feminist Psychologists Create Their Post-Careers, a moving compilation of the stories of pioneering feminist psychologists who, during their illustrative careers, have revolutionized the field, if not society.  The timely thoughts of a long time friend and colleague, Linda Garcia-Shelton, former Executive Director of the California Psychology Internship Council, who recently returned to rural Michigan:

            Reflections On a (so far) Short Retirement:  "I have found retirement to be a state with many experiences and challenges, some consciously expected, others vaguely familiar from different times in my life.  So far I have experienced nothing that flatly surprised me, but I am not so sure that is necessarily a good thing.  Like many other females of my age (a war baby), I helped care for my younger brothers earlier than I can remember and began paid work for neighbors as mother's helper when I was 10.  Each year I expanded my scope of work and increased my hourly pay, finally running a baton lesson business the last three years of high school.  By the time I entered college I had saved enough for spending money to accompany my scholarship and NDEA loan funds.  When my savings were exhausted I secured several part time on-campus jobs using federal work-study allocations.  Coming from a blue collar immigrant family background, and a girl besides, there was no possibility of financial support for college from my family.  I did not consider this a problem, although I recognize that current high school graduates coming from families like mine are seldom able to attend or complete a baccalaureate degree because of financial constraints.  Times were different then.

            "The pace and nature of work continued throughout my life in the same way that it began in my youth – there were always jobs, I loved what I did, I enjoyed going to work, and I was one of those people who generally say 'yes' to requests.  Typically, I juggled many projects, worked on time-lines of from 4 months to 6-8 years, and seldom was limited by borders, at least not consciously.  One of the most difficult aspects of retirement is that I am seldom asked to do something for others, and I must create structure for myself.  Since, for the most part, I defined my own work roles and tasks throughout my work life I have been surprised to find it quite challenging to define my retirement roles and tasks.  Even writing 'roles and tasks' makes me wonder if I am missing something – do some people have pleasurable days and weeks without defined 'roles and tasks'?

            "During weeks that I am working on professional tasks (research and writing projects mostly) I am happily busy and oblivious to feelings of 'drift' – that is, What to do next?  Who cares about this?  What did I do today?  However, I really don't want to continue AS IF I am still at work.  I do believe I need to develop more ways to live in the non-professional world.  I have started this self-development project by doing some of the activities I have always loved, but which fell by the wayside over the years or simply timed-out (e.g., raising children).

            "I am doing a lot more non-psychology reading.  I finished a history of World War II, focusing most heavily on areas my father and uncles were involved in, and am now readingCarthage Must be Destroyed.  I read some fiction (Saramago, Russo, Rushdie, and others), and am reading magazines and books about heritage plants that we might include in our garden this coming Spring and Summer.  My mother died a year ago, and I have been slowly going through her possessions, hastily boxed up last Winter and Spring to empty her house for sale.  This has been both difficult and, in some cases, quite surprising.  I can only do it for a few days at a time before I must drift off to another project for awhile.

            "It has occurred to me that my retirement has taken on a similar structure to my professional activity of many long years – blocks of time focused on a project, followed by another block of time on another project – but without the external impetuous of multiple ongoing projects each with their own deadlines.  The difference is that now there are no natural deadlines to prompt me to shift from one project to another, hence a sense of drifting when I become aware of myself.  I am now thinking I should enlist the help of others (my husband, my friends, my family) to create some regular place-keepers in my day and week (a group exercise class, a theatre night, etc.) to both improve my health (I am a natural couch potato) and inject some expected/planned social activities in what are becoming fairly solitary days.  I am hoping that committing to participate with others in an activity will make it more likely that I will do it.  When I was working my colleagues were always around, offering regular interaction with others and issuing many invitations to get involved; now I must find ways to do this myself.

            "This last Fall I traveled to Italy andSpain to spend time with friends (Italy) and family (Spain) as a way of announcing a transition in my life, and inviting participation from them in it.  My Italian friends have been professional collaborators for nearly 2 decades, and while our professional collaborations will continue, they also are dedicating more time to retirement activities.  From a distance, they seem to be doing better than me at the retirement portion of their life.

            "My family is large and very spread out, so connecting with them in my new mode will hopefully increase the attention we give to each other.  I am now (January-March, 2012) in the midst of a 2 ½ month auto caravan with my husband to spend concentrated time with our 3 sons and their families (2 in Californiaand 1 in North Carolina), and shorter visits with a bunch of cousins spread across the Southern States (California, Arizona, Texas, and Florida).  An ongoing cousin project that I am belatedly joining is to collect more family information than our parents provided to us about our ancestors, their immigration and non-immigration decisions, and tracking down varying versions of 'the distant past' (3-5 generations) and comparing this with whatever contemporaneous information we can dig up.  Now that I have announced openly that I will join this project, I know that my cousins will give me many invitations to take on pieces of the project – indeed I am depending upon them.  Besides increasing interaction with my cousin group, I think this project will reconnect me with my larger family (both historical and current) that I somewhat withdrew from during my busy years in the working world.  This reconnection feels like a fitting activity for this time in my life.

            "A major thought project I am in the midst of is making sense of the drastic changes in the U.S. social system over my lifetime, and doing this in a way that allows me to stay engaged with that system.  I grew up in a family that strongly believed in facing challenges directly by working to make changes so that the world around you becomes a better one, a more fair one, and a happier one.  My grandparents were political activists in the country they were born and in the country of their chosen citizenship, the U.S.  My father and his brothers were very active in unionizing activities in the Detroit auto plants in the 1930s, and my father was a low level elected union officer during much of my childhood.  I was involved in the mid-1960s in civil rights work in Mississippi that was initiated and supported by the SCLC, and my work in primary care health psychology was heavily oriented toward public health and access to care.

            "Now I see a nation that seems to be forsaking the majority of its citizens.  I see an ever widening income gap between the extremely wealthy and the middle and working classes.  I see massive de-investment in public education that still is responsible for the overwhelming majority of children and youth.  I see basic health outcomes in communities I have worked in getting worse, while as a nation we spend more and more money to no good effect.  I see basic freedoms that drew my grandparents to this nation – predominately our then secular civil state – being eroded to the point where religious beliefs of some are being forced upon all through the power of the law.  All this makes me feel old, tired, and very sad.  A lifetime of work that has apparently resulted in a nation with reduced opportunity and freedom for the majority of its citizens.

            "On some days I am greatly depressed (with the accompanying sense of helplessness and hopelessness) that I am leaving a dysfunctional country to my grandchildren.  This is my definition of failure, since family is at the center of my world.  On better days I talk with like-minded folks in my small rural home town about how we can affect the coming state and national elections; how we can maintain and advance a health system that provides universal access; how we can support our local school as it struggles with an ever shrinking state-allocated budget and increasing student numbers; and how we can influence our tiny village council and county supervisors to seriously consider the environmental dangers of 'fracking' for gas that they approved several years ago without making clear to any of us the dangers of the method for our formerly pristine northern Lake Michigan shore side community.  So, I am trying to use my energy to preserve a secular political system, good health care, schools for the future leaders of this nation, and a home that is not the twenty-first century equivalent of a garbage dump.  I don't know if I have enough energy."  Aloha,

Pat DeLeon, former APA President – Division 42 – March, 2012

NEW CHALLENGES -- NEW FRONTIERS

Having retired from U.S. Senator Daniel K. Inouye's staff after 38+ years, I am beginning my new career as a faculty member at the University of Hawaii Schools of Nursing, Law, and Pharmacy.  The 21^stcentury will be an era of interdisciplinary collaboration, with educators and clinicians being actively encouraged to leave their historically isolated "silos" and engage in cross-disciplinary activities.  What better place to spend the next decade?  This will also be a time for capitalizing upon the exciting opportunities provided by the advances occurring almost daily in the communications and technology fields.  Electronic medical records, telehealth (telepsychology), and data-driven effectiveness comparisons across patients and populations will become the norm.  President Obama's landmark Affordable Care Act (ACA) places a high priority on patient-centered primary care, prevention and wellness activities; as well as providing the various States, such as Hawaii, with considerable flexibility to craft the health care environment which best fits their unique needs and strengths.  HPA has a major responsibility to be "at the table" during these crucial deliberations, as APA Practice Directorate Katherine Nordal has so elegantly proclaimed at the annual State Leadership conferences.  Being personally involved in crafting the future of the profession is yourresponsibility.

            The Administration (HHS) recently announced that the number of hospitals utilizing health information technology (HIT) and electronic health records (EHRs) has more than doubled in the last two years from 16% to 35%, with 85% of hospitals expecting to accept HHS's incentive payments by 2015.  This past January, CMS provided $519 million to eligible providers.  At the time that the President signed his Economic Stimulus legislation, providing $19+ billion in incentives for utilizing HIT, only 5% of physicians had fully functional EHR systems – the goal is 90% by 2019.  This evolution is expected to ultimately result in afundamentally different health care environment.  One which will no longer take on average 17 years for new scientific knowledge to be incorporated into practice.  It will have a dramatic impact upon the practice of psychology and highlights the importance of licensure mobility, as 24/7 consultations (for example with schools of pharmacy) become readily available, and today's geographically imposed barriers are no longer considered relevant.

            The Joint Task Force for the Development of Telepsychology Guidelines:  This effort is a joint venture between APA, the Association of State and Provincial Psychology Boards (ASPPB), and the APA Insurance Trust, and is co-chaired by Linda Campbell (APA) and Fred Millan (ASPPB).  The Task Force (TF) members have backgrounds, knowledge, and experience reflecting expertise in the broad issues that practitioners must address each day in the use of technology -- ethical considerations, mobility, and scope of practice.  A two-day meeting was held in Atlanta in November; the second face-to-face meeting of the TF.  Prior to this meeting the members were grouped into four teams to summarize and outline the various issues identified during its July, 2011 meeting.  Team members reviewed at least 14 content areas that will provide a foundation for telepsychology guidelines (i.e., informed consent, access to care, inter-jurisdictional practice, competence, education, etc.) and produced documents and draft statements which were reviewed electronically.  Conference calls and e-mail discussions facilitated their work between July and November.

            In November, the TF members discussed the work done by the various teams, as well as reviewed the current research and policy literature related to international, national, and state statutes and regulations; as well as guidelines on the use of technology in the delivery of psychological services.  In addition they reviewed the current guidelines related to the delivery of psychological services.  Considerable time was also spent gaining an understanding of the APA process for developing practice guidelines.  Various models for inter-jurisdictional practice were discussed, noting the importance of the issue to many stakeholders.

            Taking into account comments gathered prior to the meeting, the TF worked on the development of an outline for guidelines to be drafted by the four working teams formed by TF members.  The outline reflects the knowledge gained from the review of the literature and research, current and draft documents outlining the use of technology in the delivery of services; and input and feedback from experts, organizations, and individuals.  As a next step, the TF members outlined the key areas and assigned guideline writing teams to begin the preparation of draft guidelines.  Efforts to reach out to identified individuals and groups with expertise in the various content areas will be made.  A time-line was established with the four writing teams sharing their first drafts with the entire TF early this year.  The next step will be to share the evolving draft during a public comment period in the Spring.  APA will host a special session at the APA convention inOrlando.  The convention presentation will focus upon presenting details of the newest draft, discussing feedback received during the public comment period, and providing a face-to-face interaction with the TF members.  Additional input and comments from the field and public will be broadly sought throughout the year [Deborah Baker].

            HHS Fiscal Year 2012 Budget Request:  The Administration's request notes that there are nearly 50 million people living in rural America who face ongoing challenges in accessing health care.  Rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than their urban counterparts.  Rural areas also continue to suffer from a shortage of diverse providers for their health care needs.  The goal for the President's "Improving Rural Health Care Initiative" is to build healthier rural populations and communities through evidence-based practices, with the HRSA Office of Rural Health Policy improving the coordination of rural health activities.  These programs are among the only non-categorical grants within HHS which allows grantees to determine the best way to meet local needs.  The $11.5 million telehealth grant initiative will link rural health providers with specialists in urban areas and strengthening rural health care infrastructure.  Has HPA worked with the Lanai FQCHC or HRSA?

            Retirement Really?  These are indeed exciting times.  Upon learning of my "retirement," John Sexton, former U.S. Navy psychologist and one of the first two graduates of the Department of Defense psychopharmacology training program: "Aloha, Thank you for your continued strong efforts on RxP.  I might stick my toe back into the pool, but I have been enjoying my retirement too much.  After retiring on July 1, my wife, son, and I went to Oahu for a month to join our daughter, as she lived there briefly. Hawaii is paradise.  We returned to San Diego, brought a motor home, and have been travelingNorth America ever since.  Knowing your large amount of energy, retirement may be something not in the cards for you.  I thought I would have some trouble with it, but have found it to be wonderful.  Take care."  We shall see….  Aloha,

 

Pat DeLeon, former APA President – HPA – March, 2012

MAKING A DIFFERENCE

As I begin my new career on a university faculty after 38+ years on the U.S. Senate staff, I am impressed by the opportunities the behavioral sciences (including psychology) have to "make a difference."  David Krantz, Chair of the Department of Psychology at the UniformedServices University of the Health Sciences (Department of Defense) and I visited their Center for Deployment Psychology (CDP).  Courtnee Pelton serves as the Military Programs Training Course Coordinator.  Commissioned into the Army in 2006 through the Health Professions Scholarship Program, she completed her Army psychology internship at Tripler Army Medical Center, Honolulu and her residency at Madigan Army MedicalCenter, Joint Base Lewis-McCord, Tacoma.  She was then assigned to the 162^nd Infantry Brigade, Ft. Polk, serving as Brigade Psychologist for two years.  At the CDP she directs the 8-day "Topics in Deployment Psychology" conference, in addition to presenting on issues related to the deployment cycle.  This conference provides in-depth training on a variety of deployment related issues; specifically, Warrior trauma and resilience, behavioral health care of the wounded, and military families.  While geared towards all uniformed behavioral health care providers, the training focuses on preparing behavioral health interns and residents with the skill set and confidence needed to successfully treat service members on deployment and in the garrison environment.  David Riggs serves as Director and William Brim, a health psychologist with over 10 years of USAF experience, as Deputy Director.  The Congress approved the mission of training military and civilian health care providers to work with service members, veterans, and their families around psychological health and traumatic brain injury related to deployment, emphasizing evidence-based training.  Since 2007, CDP has trained over 20,000 mental health providers.  It is estimated that there are 700,000+ service members or veterans experiencing psychological health or traumatic brain injury concerns (www.DeploymentPsych.org).

            Health Care Reform:  With the enactment of President Obama's landmarkPatient Protection and Affordable Care Act, our nation's health care environment is undergoing unprecedented change.  Health care will become patient-centered, based upon gold standard protocols, and utilize the most up-to-date advances in the communications and technology world.  No longer will practitioners (or educators) live in isolated professional silos.  Instead, interdisciplinary, integrated care will be the norm with transdisciplinary scientific expertise readily available.  Virtual 24/7 consultations with, for example, colleges of pharmacy will be possible.

The new law provides the States withconsiderable flexibility to craft the health care environment that works best for them.  It is extremely important that our next generation be actively involved in the Georgia Psychological Association – to be at the table when decisions impacting their careers are made, as Katherine Nordal of the Practice Directorate elegantly describes.  They will be practicing collaboratively with Doctors of Nursing Practice, Clinical Pharmacists, and Physical Therapists.  Wellness, prevention, and primary care will become priorities – including for reimbursement.  With care available for an additional 32+ million Americans for the first time in their lives, there will be renewed necessity for allowing each discipline to practice in expanded roles.  Already there are 48 Nursing State Action Collations working to implement the Institute of Medicinerecommendations that nursing be allowed to practice to the full extent of their training and education and further, to achieve higher levels of training through an improved education system that promotes seamless academic progression.  Historical anti-competitive restrictions must be overcome.  With 251,000 advanced practice nurses (APNs), the health care world is definitely evolving.  Change is always unsettling and yet provides exciting opportunities for those involved.

Prior to becoming the first non-physician and first female U.S. Army Surgeon General, Patty Horoho commented: "Maureen's [USAF Nurse Congressional Fellow] comments on the behavior health effort of the services to care for and build resiliency in our soldiers and their family members are right on target.  Preserving the mental and physical well being of our service members is absolutely critical to improving resilience.  The services have collectively initiated a number of programs that support behavior health issues in military and civilian personnel.  Behavioral health care is one of my top priorities, and in my dual hatted role as Deputy Surgeon General and Chief of the Army Nurse Corps, I'm responsible for the health and well being of all soldiers, to include Army Nurses.  Therefore in addition to Army initiatives, we've implemented a number of Corps initiatives and research studies focused on the care of the caregiver.  I'm very pleased to share that the programs have had a very positive effect on improving and maintaining resiliency among Army Nurses.  The Nurse Corps evaluates the health and resiliency of our caregivers in many ways.  The Army Nursing Research Team is conducting research on compassion fatigue, nurse burnout, stress, hardiness, resilience and PTSD in military health care personnel (nurses, physicians, technicians, ancillary, and behavioral health) in Landstuhl Germany, San Antonio, and Bagram Afghanistan.  The team is also collecting data examining post deployment reintegration of nurses.  From the results of these studies, we anticipate the development of tools and training to ensure that Army Nurses remain mentally healthy and fit."  These are, indeed, exciting times for our next generation.

            Ode To Retirement:  "As a LTJG in the U.S. Navy, I was being encouraged to stay in and probably reach the Admiral level, but even then I thought that life would get to be boring with shipboard drills and so forth.  Hence, with a wife who did not want the Navy and enjoyed teaching and helping children to grow as much as I, I decided to return to a plan which she and I made for me to become a child psychologist.  It seemed far more sensible to be able to practice in that capacity as long as I wanted.  Even then, retirement was not an attractive option.

            "Now, after 51 years as a practicing psychologist, I have again confronted the 'retirement' issue.  I even announced to friends that I was 'about' to retire.  Many were already retired, some for 25 years.  I began to stop taking new patients and just planned to finish with those lingering cases that were also not ready to retire.  Many were sailing, traveling, golfing, and/or writing books.  Most of those things I had already done and they were blocked now by an aging body, and my ongoing enjoyment of working with patients.  I found that giving up what I liked to do and felt proficient at was not as attractive as others had found it.  So now, here I am, accepting a couple of new clients and enjoying it for now.  You would think that I would give up the battle with hearing aids and 3^rd party payors, but no.  The challenge and good feeling is still there, so I am only semi-retired.  Thus, I can keep doing what I like and still play golf and travel" [Jay Benedict].  Yes, psychology can be a very fulfilling life IF one is actively involved.  Aloha,

 

Pat DeLeon, former APA President – Georgia Psychological Association – February, 2012

 

EVOLVING PERSPECTIVES

Fascinating Training Opportunities:  After having served on the U.S. Senate staff for 38+ years (i.e., the legislative branch), it is a wonderful experience to now have the opportunity to serve within a university system and specifically, the Uniformed ServicesUniversity of the Health Sciences (USUHS) of the Department of Defense (DoD).  Almost all of the USUHS students are active duty personnel, or have demonstrated a clear commitment for eventual federal service.  Recently, one of the nursing students informed me that she had already been in the military for 17 years.  To put it mildly, collectively, they are very impressive; as are the faculty.  Over the years, I have been impressed by the opportunities within the public sector to develop truly creative programs, especially within the federal sector with its considerable resources and broad responsibilities.  This past month I had the opportunity to visit theUSUHS National Capital Area MedicalSimulation Center with David Krantz, chair of the Department of Psychology.  We saw first hand their vision for psychology's training programs in the 21^st century.  A report from USUHS Professor Jeanette Witter:

            "The use of in vivo encounters with specially trained individuals, known as standardized patients (SPs), has become an established part of medical education in theUnited States.  SPs are professional actors, retired teachers, and laypersons trained to simulate specific challenges in outpatient, inpatient, and critical care settings.  The simulated patient encounters transition students from the classroom to real patient contact in safe environments.

            "The Department of Medical and Clinical Psychology at USUHS trains active duty military and civilian students to become the clinical psychologists practicing within the military and/or researchers in the field of medical/clinical psychology.  Since the inception of the clinical psychology program 17 years ago, it has trained approximately 40 doctoral level clinicians who have gone on to serve the military in a range of clinical and leadership positions.  One of the program's innovations has been to use SPs as a major component of the clinical training of the students, utilizing resources at the NationalCapital Area Simulation Center (USUHS SimCenter).  This medical simulation center is a world leader in the development and application of medical simulation programs for a range of disciplines and specialties.  In the clinical skills laboratory, consultation rooms are equipped with two video cameras and microphones to record the encounter.  An observation area at the center of the lab allows faculty and students to observe the encounters live or view digital recordings for subsequent analysis.

            "I currently direct the clinical skills courses in conjunction with Michael Feuerstein, the director of clinical psychology training.  In the first year of clinical training, students are trained to conduct comprehensive psychological assessments through academic and practical instruction.  They also receive instruction in the Foundations of Psychotherapy and Cognitive Behavioral Therapy.  Through the SimCenter, students simultaneously experience the practical application of the academic instruction they are receiving.  In patient encounters with SPs at the SimCenter, students learn how to conduct Intake Interviews, to utilize the techniques of Motivational Interviewing, to perform formal psychological evaluations, and to give feedback to patients.  They are observed in real time by teaching assistants and through videotape by their instructor, Clare Delabar, an adjunct faculty member and practicing psychologist, and they receive verbal and written feedback in supervision.  The ability to review their taped encounters allows the students to observe themselves and to see and hear the specific areas highlighted in supervision.

            "In the second year of clinical training, students begin their first practicum in the community and continue their academic and practical training in psychotherapy.  In the past two years, we have radically revised the approach to teaching psychotherapy in order to expose the students to a wider range of theoretical approaches and techniques.  Therefore in the second year of Clinical Skills Training, students take "The Art of Psychotherapy" with Leslie Cooper, another adjunct faculty member and a psychologist who works with cancer patients at Walter ReedNational Military Medical Center, the hospital with which USUHS is affiliated.  They are exposed to Humanistic Theory and Techniques with an emphasis on building rapport and listening to the patient's narrative.  Again they are able to practice techniques taught in this class with SPs at the SimCenter and to receive immediate supervision from advanced level students who serve as teaching assistants and from their faculty advisers.  Students are then instructed in Brief Dynamic Psychotherapy.  In that quarter students have the experience of conducting a course of Brief Therapy (6 sessions) using the techniques of Time Limited Dynamic Psychotherapy.  Finally, the students are instructed in Integrated Psychotherapy with Barry Wolfe, an adjunct faculty member with extensive experience in private practice in the community.  In an innovation begun in the current academic year, the three courses are linked through patient encounters with one consistent SP.  The students are introduced to the SP in Leslie's class by conducting an Intake Interview.  They then conduct a six session psychotherapy course with the patient in my class, followed by two sessions in Barry's class.  In total, the students see a single patient for nine visits with exposure to three therapeutic modalities.  This approach to training also allows advanced graduate students the opportunity to learn to supervise beginning clinicians in conjunction with the supervising faculty member.

            "The integration of hand-on-experience with didactic instruction in the risk free environment of the SimCenter allows the novice clinician to develop confidence and facility with the techniques of assessment and therapeutic intervention.  It affords the clinical faculty the opportunity to assess the students directly and to adapt instruction rapidly to the needs of individual students.  The realistic portrayal of the SPs, due to the skill of the actors and the training provided by the outstanding staff of the SimCenter, affords the students the opportunity to experience the challenges of clinical practice in a safe environment.  That the SimCenter reflects a realistic portrait of clinical work was highlighted by one student who is assigned in the Washington VA Hospital for his first practicum.  After a session in Brief Dynamic Therapy with the SP, the student, in supervision, stated: 'That's exactly the same session I had with a patient at the VA last Thursday and I didn't know what to do then either!'  With the amazing technology available to the students and faculty at the SimCenter, the student was able to receive immediate feedback on a session that had direct relevance to his experience working with 'real world' patients."

As organized psychology addresses the complex professional issues surrounding telehealth and telepsychology, we would hope and expect that the profession will learn from the actual experiences of our colleagues within the federal sector, and especially those in the VA.  Former U.S. Army Surgeon General (1996-2000) Ron Blanck, who is presently the Chair of the USUHS Board of Regents, noted over a decade ago that mental health/behavioral health professionals were the most frequent users of the Army's telehealth capabilities.  As with the visionary SimCenter, psychologists in academia and the private sector can definitely learn from our federal colleagues.  Our nation's health care environment of the future will be patient centered, feature interdisciplinary and/or integrated care, and affirmatively utilize the incredible potential inherent in the advances occurring with communications and technology fields.

A More Personal Perspective:  While transiting to a new career, I have become particularly interested in the views of respected senior colleagues who also decided to "retire." Gene Shapiro, visionary psychologist and now Professor Emeritus at Nova SoutheasternUniversity, whose U.S. Senate testimony resulted in psychology being included in the federal workers' compensation legislation:  "You asked for my thoughts on retirement.  Retirement for me was necessary but not what I desired.  My wife, Doris, needed full time help in ambulating and the drive to work, especially during rush and evening hours, became a bit frightening.  Having worked from the age of 15 to age 85, waking up without a productive goal to accomplish was difficult.  My background seemed to make retirement all the more difficult.  Having completed my B.S., M.S., and Ph.D. while I held various full time jobs, save a one year scholarship to Rutgerswhen I picked up 67 credits in the one year.  What I'm trying to say is that not working was something for which I was completely unprepared.  Fortunately, I had tennis to fall back on.  While my game is less than it was, I've been told it is excellent for my age of 92.  That keeps me occupied four mornings a week.  The problem is: What to do with the rest of the hours?  My Home Health Care Aide takes good care of Doris most of the time so I am reasonably free to do things, but what?  I found an area of interest.  Doris has been diagnosed with NPH and we have had some 'miraculous' (but limited) improvement with a very high dosage of Vitamin D.  Of course, it is impossible to pinpoint the Vitamin D effect.  I assembled a research team of very highly qualified neuropsychologists and developed a reasonable research design.  However, everyone has his/her other responsibilities and in spite of our good intentions the process is slow.  We haven't given up and will probably present the case history at the next APA convention.  My advice to everyone who asks me is: If you possibly can, never retire!"  Aloha,

 

Pat DeLeon, former APA President

AN IMPRESSIVE EVOLUTION

  On March 6, 2002, Governor Johnson signed New Mexico's HB.170 into public law, authorizing appropriately trained psychologists to prescribe.  On January 7, 2005, Mario Marquez applied for his "conditional certification."  In May 2004, Louisianafollowed suit and medical psychologist John Bolter wrote his first script on January 20, 2005.  Both the New Mexico and Louisiana State Psychological Associations had been working on their ultimately successful legislation for over five years.  When did psychology's prescriptive authority quest actually begin?  In 1984, U.S. Senator Daniel K. Inouye urged the Hawaii Psychological Association to seek this authority.  In 1972, visionary APA President, Nick Cummingsraised this possibility with his Board of Directors.  In August, 1995, the APA Council of Representatives formally endorsed prescriptive authority as APA.  By the end of 2008, Glenn Ally estimated that 200,000 psychotropic medication orders had been written by his Louisiana colleagues.  Today, now CSPP Dean Morgan Sammons postulates that between 800-1,000 colleagues have completed their formal psychopharmacological training.  The numbers are indeed impressive.

            With the passage of President Obama's landmark Patient Protection and Affordable Care Act (P.L.111-148), 32+ million Americans will soon have access to high quality, patient-centered primary care for the first time in their lives.  The President's vision calls for the utilization of the most up-to-date advances in communications and computer technology, an emphasis upon prevention and wellness care, and the steady development of comprehensive systems of care (Accountable Care Organizations (ACOs)) throughout the land.  Under previous Administrations, these would probably have been considered Health Maintenance Organizations (HMOs – President Nixon) and/or Managed Care (President Clinton).  Interdisciplinary care, comparison across diagnoses and patient populations, and reliance upon objective gold standards will increasingly become the norm.  The Administration is providing the States with sufficient flexibility to craft the health care environment which best fits their unique situations.  Within this broader policy frame of reference, I would suggest that psychology's prescriptive authority quest fundamentally represents an important evolution of the field into primary care health psychology.  And, I would also suggest that over the next decade there will be an increasing number of psychologists providing integrated care as employees in organized systems such as federally qualified community health centers (FQCHCs) and ACOs, rather than working in a traditional independent small practice or community mental health center.  Times are changing.

            As I reflect upon the professional literature over the past 25years, there have been consistent and increasing calls for the integration of mental health (now frequently called "behavioral health") services within primary care.  Whether one considers Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention(1979) or the Institute of Medicine reportHealth and Behavior: Frontiers of Research in the Biobehavioral Sciences (1982), the underlying message is very clear.  Primary care providers, with considerably less mental health training than psychologists, have been providing care for 60-80% of those with discernible mental health disorders.  Most practicing psychologists have been trained in a traditional mental health setting, pursuant to the community mental health center movement of President Kennedy' era, the psychological services organization of the VA, and/or university-based mental health clinics.  Collectively we have not been aware of the far reaching community health center initiatives of President Johnson's Great Society era, which represent the federal safety net for millions of Americans.

Those federal (and increasingly civilian) psychologists who do possess prescriptive authority have emphasized that their clinical skills are in definite demand and that their integrated skills have allowed them to clinically modify prescribed regimens of psychotropic medications more appropriately for their patients' benefit.  Within the Indian Health Service, pioneers such as Floyd Jennings prescribed with standing orders at the Santa Fe Indian hospital, New Mexico, during the mid-1980s, where quality assurance reviews of cases were quite positive.  In June 1994, APA President Bob Resnick attended the graduation ceremony for the first two Department of Defense psychopharmacology training graduates, John Sexton and Morgan Sammons. When one studies the literature for various subpopulations, such as the elderly, children, ethnic minorities, etc., the picture is again quite clear: psychologists with prescriptive authority provide the highest quality of care.

Although I have been involved in this movement over the years, it is impossible to predict with any sense of certainty which will be the next state to enact prescriptive authority legislation.  Will, for example, Hawaii andOregon be successful in overcoming their vetoed bills?  The numbers of psychologists completing their advanced training continues to grow.  As of the Fall of 2010, 276 graduates had been admitted to take the APA PEP (Psychopharmacology Examination for Psychologists) developed by the APAPO Practice Organization's College ofProfessional Psychology.  With the advances occurring in educational technology, I would expect that those on their clinical internships will soon have ready access to medication decision protocols.  Over the years, slightly more than one third of our State Associations have established task forces to coordinate prescriptive authority activities, with nearly a quarter having introduced relevant legislation.  Fundamental change always takes time; oftentimes, longer than one might initially expect.  Today, several of the States pursuing prescriptive authority, such as Arizona and New Jersey were initially considered to be among those that their leaders felt would be the "last in the nation" to undertake such action.

            Leadership changes, as does the nation's health care environment.  Looking over the Congressional landscape, it is evident that we will continue to see an increasing number of non-physician primary care providers adopting the doctoral level of training as their standard and expanding their scopes of practice to fully utilize their clinical expertise.  The right to prescribe medications by nurse practitioners and doctors of nursing practice, as well as by clinical pharmacists, for example, continues to mature exponentially across the nation and to be appropriate for their training.  They are calling for patients to have the freedom to choose the practitioner of their choice.  Sound familiar?

I am confident that psychology's leadership will appreciate the growing importance of proactive vision and action.  As the President of the Institute of Medicine has stated: "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 systems 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 (2006)."  Aloha,

 Pat DeLeon, former APA President

The National Psychologist – February, 2012

THE ADMINISTRATION’S VISION

     Earlier this year HHS Secretary Kathleen Sebelius highlighted the ability of President Obama's Patient Protection and Affordable Care Act (ACA) to significantly curtail the ever escalating costs of health care.  "The rising cost of health insurance coverage has imposed a heavy burden on our nation….  If health-care costs continue to rise unchecked, they will threaten America's ability to compete and will become unaffordable for most families.  One of the major reasons we passed [ACA] was to bring down costs… tackling the underlying cost of medical care….  [ACA] gives us tools to reduce costs by promoting better health and providing better care, especially in Medicare and Medicaid, which can be tremendous forces for positive change across the entire health-care system.  The law emphasizes prevention because we know it is far less expensive to prevent disease than to treat it….    The health-care law gives us dozens of tools to improve chronic-disease management, coordinate care among multiple providers and foster innovation.  Experts who have studied the law, from the Medicare trustees to the independent Congressional Budget Office, agree that it will put the brakes on skyrocketing Medicare costs.  And last January, 272 of America's top economists wrote to the House Budget Committee that the ACA 'contains essentially every cost-containment provision policy analysts have considered effective in reducing the rate of medical spending.'  It won't be easy and it won't happen overnight.  But at a time when some claim that our only options are to allow health-care costs to continue to skyrocket or to make some of the most dramatic cuts to our health-care programs ever proposed, the Affordable Care Act provides a better way forward."

            It is important for all of the health care professions to appreciate the magnitude of change that our nation's health care environment will soon be experiencing.  Watching the President's State of the Union Address every practitioner should understand that unprecedented change is coming.  "I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny you coverage, or charge women differently from men.  And I will not go back to the days when Wall Street was allowed to play by its own set of rules…."  From our perspective, significant policy decisions will evolve at both the local and national level.  Are we sufficiently engaged?

ACA is fundamentally patient-centered, heralding a major commitment, over time, to data-based decision making.  "What objectively works and under what conditions?" might be seen as its underlying orientation.  And yet, given the intensity of efforts being made by various health interest groups (including professional associations), one must expect that active engagement in the public policy/political process will become a major element of decision making.  Will, for example, the conceptualized "medical home" require physician direction under an historical "captain of the ship" philosophy or will it embrace true interdisciplinary care, facilitating each discipline practicing to the fullest extent of its training?  One factor will undoubtedly be the extent to which the various non-physician professions are successful in modifying federal statutes (e.g., Medicare and Medicaid) to ensure that their training institutions and practitioners have ready access to the same resources that medicine has historically possessed (e.g., financial support for implementing electronic medical record systems and telehealth/telepsychology reimbursement).  In the abstract, moving from historically isolated silos of practice and training to interdisciplinary care makes sense, especially under ACA.  How to accomplish this monumental change in orientation will be the evolving question.

            A Renewed Focus:  I recently accepted the exciting opportunity to join the faculty of the Uniform Services University of the Health Sciences (USUHS) of the Department of Defense.  I will be located within the School ofNursing and the Department of Psychology, the latter having been on the forefront of the Health Psychology movement thanks to the vision of former APA President Joe Matarazzo, as a member of the Board of Regents.  The chair of the Department is David Krantz, another of the original visionaries.  I will have the opportunity to become increasingly familiar with the culture and literature of our health profession colleagues.  For example, how do they (and perhaps psychology) address the needs of the growing number of individuals with chronic diseases?  The Centers for Disease Control and Prevention (CDC) estimates that 7 of 10 deaths among Americans each year are from chronic diseases with obesity becoming a major public health concern (almost 1 in every 3 adults being obese; as is almost 1 in every 5 youth, between the ages of 6 and 19).  Seventy-six percent of Medicare spending is currently on patients with 5 or more chronic diseases.  By 2020, our nation is projected to spend $685 billion a year in direct medical costs for individuals with chronic diseases.

            David and I visited the USUHS Centerfor Deployment Psychology (CDP) which was established 5 years ago, after considerable involvement by the APA Education Directorate (Cynthia Belar and Nina Levitt).  Since 2007, the Center has trained more than 20,000 mental health providers working throughout the deployment cycle.  The Deputy Director, Bill Brim, is a health psychologist with over a decade of service within the USAF.  Former APA Congressional Fellow Paula Domenici is the Director of Training Programs, overseeing several initiatives educating mental health providers about the unique needs of service members, veterans, and their families; and the best strategies to assist them.  Since many veterans seek help from community-based clinicians, both immediately and years after their deployment, CDP trains military and non-military providers who care for the warriors and their loved ones.  One of CDP's hallmark offerings isAddressing the Psychological Health of Warriors and Their Families, a 1-week course that has been presented in 27 cities, includingHonolulu, San Diego, Albuquerque,Minneapolis, Austin, Nashville, andPittsburgh, to reach civilian audiences across the country.  Through this program, over 2,300 psychologists, social workers and other professionals have learned about military culture, the deployment experience, and evidence-based psychotherapies to treat PTSD.  Congressman Tim Murphy, a clinical psychologist, emphasized the value of CDP's mission after completing this course: "Although PTSD is treatable, we simply do not have enough trained military and civilian clinicians to meet the needs….  These (CDP) courses provide solid foundations in that critically important training."  [www.DeploymentPsych.org].

            Clinical Pharmacy:  The USPHS Report to the Surgeon General from the Office of the Chief Pharmacist is entitled: ImprovingPatient and Health System Outcomes through Advanced Pharmacy Practice.  "The 2011 Report provides rationale and compelling discussion to support health reform through pharmacists delivering expanded patient care services.  In collaboration with other providers, this is an existing, accepted, and additional model of improved health care delivery that meets growing health care demands in theUnited States.  Health care delivery (including preventive or supportive care) in the United States is challenged by demands of access, safety, quality, and cost.  These challenges are amplified by provider workforce shortages and dramatic increases in primary and chronic care visits.  Projections suggest worsening of this situation.  New or additional paradigms of care must be implemented to reduce these burdens.  Current health care demands provide an opportunity for health leadership to recognize and adopt additional and significant health care delivery models….

            "The federal sector has already implemented and embraced such a health care delivery model through physician-pharmacist collaboration.  This collaboration, through extensive performance data, has demonstrated that patient care services delivered by pharmacists can improve patient outcomes, promote patient involvement, increase cost-efficiency, and reduce demands affecting the health care system.  For over forty years, federal pharmacists have collaboratively managed disease through medication use, and other cognitive and clinical pharmacy services.  Although these models are accepted in the non-federal sector, utilization is often impeded due to policy, legislation, and compensation barriers…."

            Once a diagnosis is made by the primary care provider, pharmacists do manage disease and provide primary care.  Pharmacists -- Perform patient assessment (subjective and objective data including physical assessment).  Have prescriptive authority (initiate, adjust, or discontinue treatment) to manage disease through medication use and deliver collaborative drug therapy or medication management.  Order, interpret and monitor laboratory tests.  Formulate clinical assessments and develop therapeutic plans.  Provide care coordination and other health services for wellness and prevention of disease.  And, Develop partnerships with patients for ongoing (follow-up) care.  Under ACA, HHS has considerable flexibility in defining "preventive services" and "essential health benefits" as broadly as desired.  Those following psychology's prescriptive authority (RxP) quest will not be surprised to learn that in 1996, the then Director of the Indian Health Service (IHS) issued a Special General Memorandum (SGM 96-2) recognizing Clinical Pharmacy Specialists (CPSs) as primary care providers with prescribing authority.  The Dean of one of the nation's leading schools of pharmacy emphasized that clinical pharmacists must complete a four-year postgraduate program focusing on managing complex medications and are extraordinarily cost-effective.  At Kaiser PermanenteColorado, pharmacists worked with physician-approved protocols targeting patients with coronary artery disease and hit their blood pressure and cholesterol targets.  They achieved an 89% reduction in their patients' overall mortality and nearly $22,000 annual savings in health care costs per patient.  Similarly, targeting city employees with diabetes, pharmacists were successful in reducing the annual direct medical costs per worker, on average, by $1,200 to $1,872 – an estimated savings of $4 for every $1 invested.  Not surprisingly, the city has since expanded this program to cover other chronic diseases, including hypertension and asthma.

            Looking Forward:  Having retired from the U.S. Senate staff after 38+ years, I have become quite interested in the experiences of senior colleagues.  Reflections from Ed Sheridan, a pioneer in Health Psychology and now Professor/Senior Vice President & Provost Emeritus, University ofHouston:  "You certainly are correct that most of us do not think much about retirement until we decide to do it.  One reason seems to be that we are among the first generations to be free to work or retire while previous generations had mandatory retirement at age 65 (if you lived that long!).  I have only a few suggestions to offer that may be important.  If there is a prominent mistake couples seem to make, it is they do not spend enough time in discussing what each person wants from retirement before deciding to retire.  Since couples likely will spend much more time together, especially if they retire at the same time, it is essential they share what they desire and what each hopes the partner will want to do.  These discussions need to include each partner's strongest wishes for a quality life, whether each finds the other's desires compatible, what to do with potential challenges (e.g., caring for a very ill parent), and what household duties each will agree to accept.  Additionally, couples especially need to discuss what they want as a life style in the next few years.  There are lots of choices.  One consideration is to downsize one's home and use that money for other initiatives (e.g., seeing more of the grandkids, traveling, developing new interests or improving on former ones -- bridge, tennis, dancing, etc. --  teaching part time, consulting).  In my case, I find teaching undergraduates (something I did very little of in my first 35 postdoctoral years) is real fun.  It is like having an unlimited number of eager grandchildren.  Even with such discussions, couples need to realize that retirement requires that each person be willing to be very flexible since no one anticipates all the challenges that eventually will come with this new lifestyle.

            "Speaking of homes, I find many couples decide to own two homes, one in a warm environment for the winter and one near the grandchildren.  Most eventually realize this was a mistake.  As the grandchildren get older, they only desire a limited amount of time with the grandparents and the grandparents find they are spending a lot of money on the upkeep of two homes and this limits travel and other opportunities for stimulation.  Most people wonder what they will do with 'all their free time.'  Actually, I find there still is not enough time to accomplish what I wish to do.  I suspect our colleagues will find the same.  The one big change is that you have more control over your time but it still is not enough.

            "Having read some literature on financing retirement from organizations like AARP, I did not find their predictions were helpful to us.  One common proposal was a couple needs about 80% of their preretirement income.  In our case, we spend as much in retirement as we previously spent.  One reason may be that as a Dean and Provost, I had almost every lunch and most dinners paid for.  I also had a free car.  In addition, we received free tickets to most sports events, plays, musicals, etc. and now we pay for these items.  One item that does cost less is clothing.  In terms of finances, I do think it is important to talk with a financial planner who has no stake in how you invest and get good direction on how you can achieve your income goals.  We were fortunate in that we anticipated the Bush fiasco and we were not hurt.  However, we have numerous friends who lost 20%-35% of their retirement income by not anticipating the downturn.  It also is hard to anticipate what your needs will be if you live 30 or more additional years.

            "Healthcare opportunities also is an important topic for consideration.  Kathy and I always intended to retire to Kauai (we already had land there to build a home).  Then, having spent decades working closely with the leadership of the various health professions, we realized that we would not want to rely on obtaining care at Wilcox Hospital with its considerable rural challenges, while the closest medical center was on Oahu.  We understand that subsequently the leadership of MauiMemorial Medical Center has been seeking to fulfill this historical neighbor island gap.  Nevertheless, making the decision to be near good health care has paid important dividends for us and we are very appreciative that we recognized this need.  Aloha."

PatDeLeon – Division 29 – February, 2012