HERE COMES THE SUN

I recently had the opportunity of meeting with graduate students and several faculty members at Purdue University where I obtained my doctorate.  Long time RxP supporters Chuck Faltz and former APA President Jack Wiggins are also Boilermakers, as is APA journal editor extraordinaire Michael Roberts.  My sincerest appreciation to Don Lynam and Chris Agnew for making this visit possible.  It was truly special to be able to visit once again with Cliff Swensen, my major professor.  Two of the messages which I shared with our next generation were that every one of the prescribing psychologists that I have met has been very pleased with their decision to obtain this extra training even though, almost without exception, it was at their own personal expense.  And, that in my judgment, almost all of those colleagues who are adamantly opposed to psychology obtaining this clinical responsibility do not work with those patient populations who would benefit from our expertise – especially in ensuring that appropriate medications and dosages are utilized.  Providing quality care has always been the underlying issue.

Far from being the "public health hazard" that organized psychiatry predicted, our prescribing colleagues in New Mexico, Louisiana, and the federal system have done an outstanding job.  Former APA and Division President Ron Fox notes: "As of December 31, 2013 when I was chair of the APA Insurance Trust, I can attest to the fact that prescribing psychologists do NOT have to pay higher premiums for professional liability insurance as the Trust deemed an increase unnecessary; and, because the Trust policy provides insurance to cover expenses related to licensing board complaints I know that there have been no complaints or actions taken by state licensing boards regarding prescribing abuses by appropriately trained psychologists."  Another visionary former Division President, Bob McGrath, who is spearheading the New Jersey RxP legislative effort, estimates that 1750 colleagues have already completed their advanced psychopharmacology training.  Working at the Uniformed Services University of the Health Sciences (DoD), we would be particularly interested in having those veterans who have completed their RxP training share their experiences with APA's Heather Kelly, who is working on a relevant VA agenda [hkelly@apa.org].

            SAMHSA:  During its deliberations on last year's budget for the Substance Abuse and Mental Health Services Administration (SAMHSA), the Senate Appropriations Committee expressed its concern regarding the current utilization of psychotropic medications for children.  "The Committee has become increasingly concerned about the safe, appropriate, and effective use of psychotropic medications and children, particularly children in foster care settings.  According to a December 2012 GAO report, an alarming 18 percent of foster children are prescribed psychotropic medications, compared with 4.8 percent of privately insured children.  The Committee strongly encourages SAMHSA to establish meaningful partnerships with Medicaid, the foster care program, medical specialty societies, and treatment centers to develop new strategies for treating this vulnerable population.  The Committee would like an update in next year's congressional justification on the steps SAMHSA has taken to promote the most effective and appropriate treatment approaches, including the use of evidence-based psychosocial therapies instead of, or in combination with, psychotropic medications."

            During this year's budget justification, SAMHSA reported: "SAMHSA has taken a significant leadership role to address the safe, effective and appropriate use of psychotropic medication in children and youth.  The agency has collaborated extensively with the Administration on Children and Families (ACF) and the Centers for Medicare & Medicaid Services (CMS) to address this issue for children in foster care; has partnered with professional groups to create more stringent guidelines related to prescribing and medication oversight practices; and has worked closely with parents and youth to improve consumer decision-making with regards to the use of medications.  Below reflect a number of activities and developments that SAMHSA has been engaged in to address the issue.

            "SAMHSA supported the American Academy of Child and Adolescent Psychiatry's (AACAP) development of guidelines on issues that community agencies should address when prescribers are considering the use of psychotropic medications.  Titled, 'A Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents,' this document provides information to community agencies about safely and effectively prescribing psychotropic medications, describes the phases in treatment when medication could be considered part of an overall treatment plan, and provides information about the use of community based alternatives that child serving systems and agencies should consider in addition to psychotropic medications.  SAMHSA has also collaborated with AACAP to support a Child and Adolescent Psychiatry Fellow at SAMHSA one day a week (20% FTE).  For the past four years each Fellow has undertaken a project to improve psychiatric service delivery, connect with community agencies and organizations, and identify evidence-based treatment strategies.  Perhaps one of the most significant advances SAMHSA has helped to support has been the development of a Youth Advisory Group at AACAP that provides advice, guidance and information about medication use and empowers youth to make their own informed decisions regarding using medications.  One accomplishment supported through this youth group was the development and expansion of the AACAP website as a resource to youth and families.  Via a simple click on the 'families and youth' toolbar on the AACAP homepage, youth and families can obtain a wealth of resources that include a section on how to choose a child and adolescent psychiatrist; 'Facts for Families' on a wide range of topics; a patient education section that provides information about mental health conditions; and an entire section dedicated to youth resources.  Going forward, SAMHSA will be continuing its efforts to address the importance of using psychotropic medications safely and effectively in collaboration with AACP.

            "In addition to the work with AACAP, SAMHSA has also supported efforts by the Center for Health Care Strategies of the Robert Wood Johnson Foundation to provide technical assistance on strategies to improve oversight of psychotropic medication use in foster children.  The technical assistance has included a webinar series, 'Psychotropic Medication Use among Children in Foster Care: Technical Assistance Webinar Series.'  As part of this series, in September of 2013, a webinar was held titled, 'The Use and Financing of Non-Pharmacologic Evidence-Based Practices: Alternatives to Psychotropic Medications.'  Evidence-based psychosocial interventions were identified that may offer a more comprehensive and cost-effective means of addressing behavioral health and social challenges experienced by children and youth in foster care, as well as other child populations with significant behavioral health challenges.  SAMHSA also supported the Center for Health Care Strategies recently released 'Faces of Medicaid Analysis,' which identified areas to improve behavioral health treatment, including the use of psychotropic medications and alternative approaches.

"SAMHSA was also one of the sponsors of an Administration on Children, Youth and Families conference and dialogue about the appropriate use of psychotropic medication for foster children.  SAMHSA provided training to nearly 100 early career child and adolescent psychiatrists on community and public sector psychiatry, systems of care and youth and family engagement.  As part of SAMHSA's ongoing commitment, SAMHSA will maintain its meaningful partnerships with other federal agencies, guilds and organizations to further the important agenda to address psychotropic medication use in America's children and youth."

There can be no question that SAMHSA's efforts to be responsive to the Committee and to the needs of our nation's children, including those placed in foster care, is highly commendable.  We would ask, however: Where is psychology's voice/presence?  We are confident that those colleagues who specialize in serving children and who have completed their RxP training could contribute significantly to addressing this national need.  Yet, one of Hawaii's most rural, and perhaps smallest, federally qualified community health center (FQCHC) on the island of Lanai recently applied for a HRSA behavioral health integration grant which would, among other needed services, provide for part-time child and adolescent psychiatry services utilizing telehealth/telemedicine, at the request of their psychology staff, estimating that approximately 10 patients a year will need these services.  If psychology is unwilling to focus upon national and pressing local priorities, others will; especially as President Obama's Patient Protection and Affordable Care Act (ACA), with its emphasis upon integrated care, is systematically implemented.  Long time health psychology visionary Susan McDaniel reports: "I had a nice surprise last week.  As part of promoting psychology as essential to health, I have done two episodes on the nationally-syndicated PBS show on health called 'Second Opinion.'  The directors are very in tune with a whole person approach to health, and always have a multidisciplinary group of professionals along with a patient, focused on some specific health problem.  I've done one on Grief, and then one 5-minute spot on the show on Teen Depression.  The show heard last week that this episode on Teen Depression won a Telly award (a national award for the best in television programming)."

Meaningful Journeys:  "Reflections of a Peace Corps Volunteer – A Decade Later.  Tempus fugit, time indeed seems to have the habit of proceeding on a logarithmic path.  Could it really be almost a decade since I completed Peace Corps service in Guatemala?  Yes, it is so, time to reflect once again on that experience.  Many questions come to mind.  How did I get there?  What was it like?  What do I tell other people about the Peace Corps?

"I had been retired from 37 years active duty in the U.S. Army.  The last 20 years of my Army career was as an operational psychologist.  For five years I had a great retirement, crewing on sailboats in Hawaii, Mexico and the Caribbean and backpacking in Europe and New Zealand.  I thought about how fortunate I have been in life.  I decided maybe it was a good time to give to others for the many blessings I have received.  I was around when John F. Kennedy founded the Peace Corps.  I greatly admired the idea of the Corps.  I went on line and applied.

"I was in Washington, DC on September 11, 2011, when the terrorists crashed into the Pentagon.  I watched the smoke from the roof of my condo.  Then and there I resolved to do my enlistment in the Peace Corps.  I knew at age sixty-six, the Army would probably not allow me back on active duty.  I decided the best thing I could do for my country and for others was to accept the invitation I had received from the Peace Corps to serve in a Healthy Schools Project in Guatemala.

"Thirty-nine of us gathered in Miami to process and to travel to Guatemala to begin fourteen weeks of training for the Peace Corps.  Of the 39 volunteers, 29 completed the full two year tour.  Each volunteer had to live with a local family during training to learn Spanish and to learn the culture.  I was blessed to live with a wonderful family, with whom I maintain contact.  I have returned to Guatemala to visit them.  The Peace Corps does an excellent job in training volunteers in language, technical skills and cultural interaction.  The Peace Corps nurse clinicians do a superb job in teaching individual preventive care and self-care.  They impressed upon us that you are to a great extent responsible for your own health.  If any of us required definitive care, the Peace Corps ensured the best doctors in Guatemala treated us.  After completing training, we took the Oath of Service from U.S. Ambassador John Hamilton.

"I was fortunate in being assigned to Santiago Atitlan, a Mayan village on the shore of Lake Atitlan.  An awed Aldous Huxley described the Lake as 'too much of a good thing.'  As Lonely Planet states: 'Simply put, Lago de Atitlan is one of the world's most spectacular locales, period.'  The grinding poverty of many of the people is in sharp contrast to the surrounding beauty.  The Mayan people of the Central Highlands probably suffered the most during the tragic 36 year civil war in Guatemala.

"As a psychologist, I really appreciated the behavioral objectives of our Healthy Schools program.  The major objective was to have the children practice good health habits in school on a daily basis.  For example, we strove for at least 80 percent of the students brushing their teeth after the school snack.  And yes, we had to figure out little games to teach the kids how to brush properly.  For some students, it was the first time in their lives that they had a tooth brush.  If a school met the long list of behavioral objectives, it would be certified as a 'Healthy School.'  This certification increased the school's prestige in the community.  In addition, it also helped in obtaining international assistance.  We started out teaching and we trained the teachers in instructing health material.  We encouraged them to adopt experiential learning techniques as opposed to straight lecture.  We conducted workshops, where teachers would create their own material and games.  Another dimension of our job was to work with the parents, local authorities, and nongovernmental organizations (NGOs) to improve sanitary conditions in the schools and in the village.  We ended up with one of the few rural schools in Guatemala that has running potable water, clean bathrooms and even toilet paper.  The kitchen now has a propane stove instead of a wood fire with the dangerous emission of smoke.

"Most days were good.  And then there were the other days.  I remember a day of stumbling over my Spanish words, hoping the children could understand me.  At the same time, I was trying to unobtrusively scratch my flea bites and hoping to control the diarrhea until recess.  That was the day at long last when I could consider myself a real Peace Corps volunteer.  Fortunately days like that were rare.  Most days you were happy to be doing what you were doing.  Living in the village and becoming part of the community was a great experience.  The Mayan people have respect for the family, especially the elderly.  At times, the life of a volunteer could be frustrating, but most of the time it was as they say in Spanish vale la pana, very worthwhile.  In many ways, for someone trained in psychology, a tour in the Peace Corps becomes a living laboratory.  You can see the results of schedules of reinforcement and what modeling and role play can accomplish.  You learn a lot about group dynamics and cross-cultural communications.  And you learn a lot more about others and yourself and what you value.

"This January's Monitor had an excellent article about retirement.  The Peace Corps could be a great experience for any psychologist during retirement.  Also for a young man or woman who just finished their undergraduate work, the Peace Corps could provide the opportunity to serve others and to mature.  One of the best things that happened to me during my tour was that many of the younger volunteers asked me for assistance in planning their future.  Every volunteer, who wanted to return to school for an advanced degree, got accepted into a program.  Most universities are very Peace Corps friendly.  We had an electrical engineer who was in the environmental protection program and who is now a physician.  Another volunteer from the Healthy Schools program went back to law school and specialized in international law.   She is now assisting indigenous people world-wide.  The young volunteers I had the privilege of working with were just what John F. Kennedy had in mind, when he founded the Peace Corps.  My advice about the Peace Corps – if you are thinking about doing it, just do it" [Ernie Lenz].

Retired VA psychologist and now psychology historian and sage fiction writer, Rod Baker: "When you mentioned the person in retirement who said that he thought he still had something to pass on, I remembered one of my favorite stories an elderly gentleman passed on to me was his lament: 'Now that I know all the answers, no one asks me the question.'  Looking forward to seeing you at APA."  It is all right.  Aloha,

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

 

CHALLENGING TIMES – THE IMPACT OF TECHNOLOGY

Psychology, along with the other health professions, is beginning to appreciate the extent to which the unprecedented advances occurring within the communications and technology fields are having an extraordinarily impact upon our nation's health care environment.  It was not that long ago when President G.W. Bush noted: "The health care industry is missing an opportunity….  IT, information technology, hasn't shown up in health care yet.  But it has in one place, in one department… that's the Veterans Department.  Tommy Thompson is the Secretary of the Department of Health and Human Services – a strong advocate about the spread of IT throughout the health care industry….  By introducing information technology, health care will be better, the cost will go down, the quality will go up, and there's no telling whether other benefits will inure to our society….  When we get this implemented, America will remain on the leading edge of technological change.  This is the kind of innovation that's practical and makes sense, that will keep us the leader in the world."  The VA reports that in Fiscal Year 2013, more than 600,000 Veterans received health care utilizing telehealth – accounting for more than 1.7 million episodes of care.  The issue of licensure mobility/portability is critical to this evolution – and it is an area in which theNational Register has demonstrated proactive leadership.

            State Leadership Conference (SLC):  For practitioners, the annual APA Practice Directorate State Leadership Conference (SLC) is one of, if not the, highlights of the year.  At last year's conference, Katherine Nordal described the beginning stages of the implementation of President Obama's Patient Protection and Affordable Care Act (ACA) as: "Really just a mile marker in this marathon we call health reform.  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us."  This year, Katherine noted: "Our country still doesn't pay nearly enough attention to mental health and substance use treatment.  Health care reform implementation is a work in progress.  And there are hopeful signs, especially related to the goal of increasing the ranks of Americans with health insurance coverage.  As we confront serious problems and the uncertainty of a health care system in flux, psychology continues to demonstrate that we're poised to face those challenges.  The 2014 Medicare fee schedule marked the first time since 2007 that the payment pool allocated for Medicare psychological services increased – psychologists gained the second highest increase in payment allocation among all Medicare provider groups.  The demand for evidence-based practices and use of quality measures related to process and outcome, including behavioral health measures, will grow.  And the increasing use of technology for electronic health record keeping and telepsychology service delivery will continue to evolve.  In a survey last fall, we asked what specific changes members were likely to make in their practice over the next three to five years.  Nearly half indicated they will increase their use of technology….  We achieve good results when psychologists get energized and commit themselves to making positive things happen."

            One of the most intriguing workshops at SLC, chaired by Deborah Baker, was "Developing a Roadmap for Telepsychological Practice."  Already 21 states have affirmatively addressed the issue of insurance reimbursement for telehealth services, with an additional 19 state legislatures currently considering legislation.  The underlying issue of licensure mobility/portability is complex.  For example, does the locus of the patient or provider or both provide the legal authority for licensure board jurisdiction?  Thoughtful views from the APA Insurance Trust (Jana Martin) and the Association of State and Provincial Psychology Licensing Boards (ASPPB) (Fred Millan) were shared – all clearly seeking ways to ensure that psychology will be responsive to the dramatically evolving health care environment.  Will, for example, a special licensure category be established for providing Telepsychology care?  It was refreshing to hear how proactive the joint APA-ASPPB-Insurance Trust taskforce, co-chaired by presenter Linda Campbell, is during its deliberations.  Steve DeMers pointed out that ABPPB has received a special grant from the Health Resources and Services Administration (HRSA) to address the underlying issues.  The National RegisterMobility Program is becoming increasingly timely – now approved or in the process of being approved in 46 jurisdictions in the U.S. and Canada.

            FY 2015 HRSA Budget Request:  The Administration has requested $124.5 million this coming year for the Office of Rural Health Policy.  Established in 1987, this is the focal point for rural health activities within HHS.  Historically, rural communities have struggled with issues related to access to care, recruitment and retention of health care providers, not to mention maintaining the economic viability of hospitals and health care providers in isolated communities.  Today there are nearly 50 million people living in rural America who face challenges in accessing health care.  Rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than their urban counterparts.  The potential for telehealth providing quality specialty care, professional continuing education activities (addressing provider isolation); and innovative, evidence-based behavioral programmatic activities should be evident.  Interestingly, the Office has historically worked collaboratively with the VA and the Departments of Agriculture, Education, Labor, and Transportation given its holistic approach to ensuring comprehensive care.

            The Office of Rural Health's Telehealth Grants initiative proposes to expand the effective use of telecommunications technologies within rural areas that can link rural health providers with specialists in urban areas, thereby increasing access and the quality of healthcare provided to rural populations.  Telehealth technology also offers important opportunities to improve the coordination of care in rural communities (a priority of the President's AAC) by linking rural health care providers with experts not available locally.  These grants are expected to strengthen the rural health care infrastructure.  This year's budget proposes specific evaluations of the program's impact on the health status of rural residents with chronic conditions, including obesity, and the return on investment for rural grantees and communities.  $13.9 million has been proposed in the coming fiscal year for telehealth activities supporting: 1.) Telehealth network Grant Program grantees (up to 26 grants); 2.) Telehealth Resource Center Grant Program grantees (up to 14 grants); and, 3.) The Licensure Portability Grant Program (2 grants).

            The Federal Trade Commission (FTC):  In March of this year, the FTC issued a policy paper suggesting that state legislators should be "cautious when evaluating proposals to limit the scope of practice of Advanced Practice Registered Nurses (APRNs).  By limiting the range of services APRNs may provide and the extent to which they can practice independently, such proposals may reduce competition that benefits consumers.  Even well-intentioned laws and regulations may impose unnecessary, unintended, or overbroad restrictions on competition, thereby depriving health care consumers of the benefits of vigorous competition."  In the view of the FTC, consumer health and safety are paramount concerns in the regulation of the health professions, and competition is an important mechanism to promote high quality health care.  It is also a means of controlling costs and allocating resources.  When restrictions restrain competition and are not closely tied to legitimate policy goals, they may do more harm than good.  As psychology seeks to expand its clinical influence under the provisions of the ACA, both in its scope of practice (e.g., obtaining prescriptive authority) and actively engaging in the treatment of those with chronic conditions, for example, the recommendations proffered by the FTC become highly relevant.

Recognizing Two Colleagues Whose Leadership Has Made a Real Difference:  On June 13, 2013 Colonel Rebecca Porter became the first clinical psychologist in the U.S. Army to command a Medical Treatment Facility (MTF).  She assumed command of Dunham U.S. Army Health Clinic at Carlisle Barracks, Pennsylvania.  Durham provides primary care to students, faculty, and families at the U.S. Army War College through its Patient Centered Medical Home.  Dunham and its outlying clinics, including the Army Wellness Center, serve a beneficiary population of more than 9,000 active duty military members, retirees, and their families.  Commanding a MFT is not the only "first" for Becky.  She was also the first clinical psychologist to serve as the Army's Director of Psychological Health and Chief of Behavioral Health for the Army Surgeon General (2010-2013), and the first clinical psychologist to serve as a Special Assistant to the Chief of Staff of the Army (2001-2003).  She is a member of the APA and Past-President of Division 19, the Society of Military Psychology.

            "Each and every day of an extraordinary 23 accomplished years, Judy Hall lived and breathed the NationalRegister.  We could not have asked for a more dedicated, intelligent, and caring leader.  Judy kept the Register healthy and on a steady track through two+ decades of profound changes in the health care landscape.  A passionate and tireless advocate for us and professional psychology, she represented the organization in over 300 invited program presentations and 60 interviews on radio, TV, and in print.  For years, Judy has had a central role in formulating national standards for education and training in professional psychology and I sincerely doubt that anyone else in the nation has anywhere near the intimate knowledge that she has of every training program in psychology.  While she has retired from the role of Executive Officer, we have asked Judy to continue with us in a consulting role and are extremely pleased that she has agreed to do so.  Speaking for the Board of Directors – and I believe the 11,000 members of the National Register as well – Judy has our profound thanks for a job well done" [Ray Folen, President/Chair].  Aloha,

Pat DeLeon, former APA President – National Register – March, 2014

 

 

A REAL DIFFERENCE

Having served for nearly four decades on Capitol Hill, I remain impressed by the astute observation of former APA Congressional Science Fellow Neil Kirschner, more than a decade ago, at our annual convention in Toronto: "More often than not, research findings in the legislative arena are only valued if consistent with conclusions based upon the more salient political decision factors.  Thus, within the legislative setting, research data are not used to drive decision-making decisions, but more frequently are used to support decisions made based upon other factors.  As psychologists, we need to be aware of this basic difference between the role of research in science settings and the legislative world.  It makes the role of the researcher who wants to put 'into play' available research results into a public policy deliberation more complex.  Data needs to be introduced, explained, or framed in a manner cognizant of the political exigencies.  Furthermore, it emphasizes the importance of efforts to educate our legislators on the importance and long-term effectiveness of basing decisions on quality research data….  If I've learned anything on the Hill, it is the importance of political advocacy if you desire a change in public policy."

Katherine Nordal, Executive Director of the APA Practice Directorate, issued a similar challenge at last year's State Leadership Conference, reflecting upon President Obama's landmark legislative accomplishment: "The Affordable Care Act [ACA] has survived, and implementation of the largest expansion of the health care safety net will proceed.  But January 1^st is really just a mile marker in this marathon we call health care reform.  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us.  One of the first steps in positioning for reform is for practitioners to recognize that they bring numerous professional skills and strengths to integrated care setting.  Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  No one else is fighting the battles for psychology… and don't expect them to.  Health care is a marathon – we're in it for the long haul.  We can't hope to finish the marathon called health care reform if we're not at the starting line."

Those of you who are working in Long-Term Care are to be truly commended.  Many years ago, the late Powell Lawton of the Philadelphia Geriatric Center, who was a visionary in the field of healthy aging, shared his excitement about the potential contributions of the behavioral sciences to the future of our elderly.  Even then, it was clear that our nation was rapidly aging and further, with the advances beginning to occur within the communications and technology fields, that it would be increasingly possible to bring unprecedented social-environmental changes (e.g., stimulation modules) to the lives of our most senior citizens, regardless of where they were residing.  Today, there is considerable discussion at the national level regarding the ever-escalating costs of health care.  The United States spends more on health care than any other industrialized nation, if not twice as much; and yet, our health outcomes are not comparably favorable.  Further, the Institute of Medicine (IOM) reports: "Regions that deliver more services do not appear to achieve better health outcomes than those that deliver less."  "In fact, underuse, misuse, and overuse of various services often put patients in danger."  It is estimated that 50+% of all resource expenditures in hospitals is quality-associated waste (i.e., recovering from preventable foul-ups, building unusable products, providing unnecessary treatments, and simple inefficiency).  Health care systems need to be focused and accountable.

A number of the underlying provisions of the ACA are envisioned as building coordinated, patient-centered systems of care where psychology can contribute significantly to integrated care teams – regardless of the age or disability of the patient.   Historical procedure-oriented reimbursement mechanisms are to be steadily replaced with outcome-oriented metrics.  Cross-provider and cross-diagnostic comparisons are increasingly being called for.  We are optimistic that the critical psychosocial-economic-cultural gradient of "quality" health care will finally be appreciated by other disciplines and most importantly, by those who ultimately make financial decisions.  As Katherine continues to emphasize, the ACA is merely a stage in the evolution of our nation's health care environment.

Unfortunately for psychology, however, our profession is not expressly included in the underlying statute or implementing regulations of either the critical Accountable Care Organization or Patient-Center Medical Home provisions of the law.  Further, although historically Medicaid has been the major source of financial support for long term care services, the profession of psychology has been significantly remiss in not being actively involved.  Accordingly psychology is not recognized in many state Medicaid programs.  If one appreciates that law and business have long been the major professional backgrounds of those elected to Congress and reflect upon Neil's observations, substituting "health care" for "research," one can appreciate that we have a long way to go.  And yet, there can be no question that our clinical expertise can make a real difference in the quality of life of our nation's senior citizens.

Visiting Professor Ann Burgess at the Daniel K. Inouye Graduate School of Nursing, USUHS: "Sexual assault has no barriers to the victim's age or gender.  For example, in the Albert Lea case in Minnesota five teenage nursing assistants were found guilty of sexual harassment and sexual assault of over a dozen male and female Alzheimer residents over a six month period.  Court papers revealed that the nursing assistants were laughing as they talked of poking the breasts and genitalia of elders and taking pictures for online posting.  Family members, after learning of the assaults, said they had noticed changes in behaviors but attributed it to advancing dementia or medication.  This case emphasizes that therapy has no barriers as to age, gender, or mental capacity.  There is the need for caregivers as well as family members to take seriously any patient complaint or behavior that has an oblique or direct sexual content.  In addition, studies show that elder demented patients respond positively to expressive therapies, especially music therapy."  Will those who are working with Long-Term Care families take the next step to ensure that psychology's expertise is appropriately recognized?  Aloha,

Pat DeLeon, former APA President – Psychologists in Long-Term Care – March, 2014

 

EXTRAORDINARY COLLEAGUES

During the final days of my APA Presidency in 2000, I traveled to Washington State to present a Presidential Citation to Colleen Hacker for her outstanding contribution as a role model for our nation's female youth -- inspiring them to excel beyond their wildest dreams.  That evening, Barry Anton's daughter caught him by surprise by agreeing to come to the dinner and sat next to Colleen.  Subsequently, Colleen and I participated at several APA conventions where her message remains very clear: active involvement in sports will make all the difference in a girl's life -- physically, emotionally, and socially.  This past month was Colleen's fifth Olympics as a mental skills coach and her first time at the winter games, working with the U.S. Women's Hockey team.  "Every day it's making new friends and new connections.  It's totally peace and harmony and the world's entire population in support of one another.  The entire world has so much more in common, even with our differences.  We're striving for excellence, we love our families.  We cheer for one another.  All of us say every day, why can't our countries get along the way our athletes and coaches get along?"

            Now it is Barry Anton's turn to serve as APA's 123^rd President.  "APA is home to a diverse and talented group of psychologists who understand that, 'Together we stand.'  APA's effective advocacy efforts ensuring our place in health care delivery in a changing environment, obtaining our fair share of research funding, providing quality education and training for our students, and supporting our ongoing efforts in social justice are some of the issues that I will be working on during my Presidential cycle.  My proposed international summit on psychology and integrated care will help ensure that we bring our best science, our best practices, our best educators and our best trainers together to address the psychological and health needs of an increasing diverse, rapidly changing population."  For me personally, Barry's long time commitment to our nation's children and ensuring that they have ready access to quality psychological care is particularly meaningful.  Children are more than merely "little adults."

            As the nation steadily implements President Obama's Patient Protection and Affordable Care Act (ACA), it is critical that psychology appreciates that the health care environment of tomorrow will be extraordinarily different than what many were trained for.  Integrated and interdisciplinary care is the future.  The unprecedented advances occurring with the communications and technology fields will allow cross-patient and cross-provider comparisons.  Translational science (i.e., bringing new scientific knowledge to clinical practice) has become a high priority for the Administration.  No longer will it be acceptable for new knowledge to take 15-20 years to reach practitioners.

            I had the distinct pleasure of serving with Ruth Paige on the APA Board of Directors during my Presidency.  She was the "behind the scenes" advocate for a number of major policy issues such as ensuring that every state association would have a vote on the Council of Representatives.  Most recently, we have been collaborating on "giving a voice" to the experiences of our senior colleagues who have decided to retire and embark upon new journeys.  Always exciting times.  Aloha,

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

PERSERVERANCE AND SPIRIT HAVE DONE WONDERS IN ALL AGES

The Importance of "The Bigger Picture":  Over lunch in the Uniformed Services University of the Health Sciences (USUHS) cafeteria, Kevin McGuinness recently discussed with several nursing doctoral students the importance of appreciating the "bigger picture" for those wishing to become actively involved in health policy.  A former military Service Member and now an officer in the USPHS (and a national leader in the federal RxP movement), Kevin's personal goal is to see mental health addressed with the same urgency as physical health within the federal system and for psychology to be understood as a primary weapon in the armamentarium of public health, capitalizing upon its cost-effectiveness when integrated within primary health.  Kevin consistently emphasized the necessity of taking a broad holistic view of "health care," including the context in which one works.  Looking around the room, it became evident that the historical emotionally charged battles over the possible "purple suit" identity of uniformed Defense health care providers really represented concerns of the past.  Here were nurses and other health care disciplines, selected from each of the Services, learning and socializing together.  That afternoon he would address our health policy class, attended by nursing and psychology students – reminding us that integrated, interprofessional training is one of the hallmarks of President Obama's Patient Protection and Affordable Care Act (ACA).

Moving Away From Isolated Silos:  During its deliberations on the Fiscal Year 2014 Appropriations bill for the Department of Defense (DoD), the Senate Appropriations Committee addressed the importance of DoD working collaboratively with the Department of Veterans Affairs (VA) on behalf of their beneficiaries.  "While the DoD and VA may have different missions, they are bound together in a mutual mission to support those who have served in the defense of the country.  Over the past several years, collaboration between the Departments has significantly increased and the number of joint projects and services has expanded.  The Committee applauds these efforts and believes that future information sharing between DoD and VA must strengthen in order to ensure a seamless transition from active duty and timely access to VA benefits.  Nowhere is this more evident than in the transmission of service treatment records from DoD to VA.  These records are essential in the VA's process of making accurate and timely determinations of benefits to which a veteran may be entitled….  In October 2010, DoD and VA established a first-of-its-kind partnership with the opening of the Captain James A. Lovell Federal Health Care Center [FHCC].  This is a fully integrated Federal healthcare facility that serves Active Duty military, their family members, military retirees, and veterans.  The Committee continues to support the pilot program at FHCC and believes it will produce valuable lessons that can be used to expand future collaboration between DoD and VA hospitals as well as produce substantial savings to the taxpayer by combining the two healthcare systems where practical."

            Earlier this year, VA announced its partnership with Kaiser Permanente to pool resources and ideas to solve some of the largest and most complex challenges in VA health care.  The Secretary: "VA is always on the lookout for opportunities for partnerships with the private sector and other federal agencies to enhance care for Veterans.  We are proud to partner with Kaiser Permanente for the health and wellbeing of our Nation's Veterans."  It is expected that this joint effort will enable more effective research and sharing of best practices, focusing initially on four areas: Telehealth and virtual care; Genomics; Care of Veterans who are members of Kaiser Permanente; and Advanced analytics to use large data sets and population management with appropriate patient privacy protections.  The two systems expect to develop recommendations for how to design care using advanced analytics and technologies, as well as research.  This is building upon a 2010 agreement in which the two organizations launched a pilot program to exchange medical data using the Nationwide Health Information Network.  That project allowed clinicians from both organizations to obtain a more comprehensive view of a patient's health record using electronic health record information, including information about health issues, medications and allergies; while ensuring privacy and confidentiality.  An expressed goal is to increase ease of access and quality of services.  With over 8 million enrollees, VA operates the largest integrated health care delivery system in the nation.  We would be interested in learning whether VA is negotiating similar agreements with Federally Qualified Community Health Centers, which are the true "safety net" for many Americans, particularly in rural America where a number of veterans reside.

            The Importance of Investing in Prevention:  Several of the lessons which Kevin shared are: * Change takes time, often far longer than one would initially expect.  And, * Those establishing policy often focus upon the immediate crisis, rather than investing in prevention in order to avoid future crises.  A graphic example: Today, the nationwide epidemic of obesity is a high priority for the Obama White House.  However, in 2007 the RAND Corporation proclaimed: "America appears to be in the midst of an obesity epidemic.  Should we care?"  Obesity in the U.S. had been increasing steadily over the past two decades – with severe obesity increasing the fastest.  Obesity translates into higher health care costs (more than smoking or drinking) and contributes to disability at all ages.  It was apparent that traditional clinical approaches, in particular bariatric surgery, could not slow the trend.  Medicare and Medicaid savings stemming from increasingly good health among the elderly could be swamped by the cost consequences of disability among the young.  More than one in five U.S. adults were then classified as obese based on self-reported weight, and almost one in three based on objectively measured weight.  Compared with their normal-weight counterparts, the obese spend 36% more on health care services and 77% more on medications; the comparable numbers for current smokers are 21% and 28% respectively, and less for problem drinkers.  Severely obese people are more than twice as likely to be in fair or poor health and have about twice as many chronic medical conditions.  For men, severe obesity is associated with a 300% increased probability of having limitations on basic activities of daily living; for women, the effects are even larger.

Another RAND study that year found: "When it comes to getting the right care at the right time, children in this country fare even worse than adults."  They are not receiving recommended preventive care and screening services, such as regular weight and measurement checks to ensure they are growing properly and not at risk for obesity.  Foreshadowing another one of Kevin's policy messages: * Neighborhoods exert a powerful effect on residents' physical activity and thus neighborhood design should be considered a public health issue.  Girls pose a particular concern because their physical activity is known to decrease as they progress through adolescence.  "Obesity is the most serious public health problem confronting America today."  Testifying before the Senate Appropriations Committee in 2012, U.S. Army Major General Jimmie Keenan noted: "In America, we in DoD spend an average of 100 minutes each year with our health care team.  The other 525.500 minutes of the year our patients are not with us – the same amount of time our environment influences the behaviors that determine our health occur."  The psychosocial-cultural-economic gradient of health care is absolutely critical.  Public service psychology and advanced practice nursing must embrace their professional responsibility of addressing broad public policy/public health issues in order to be effective in the long run, including focusing upon and advancing wellness, patient responsibility, and environmental risk factors.

            The National Institute on Minority Health and Health Disparities (NIMHD) (NIH):  The Fiscal Year 2014 budget request for NIMHD was $283.3 million.  Its fundamental mission is to lead scientific research to improve minority health and eliminate health disparities.  Cognizant of the potential of science and the multiple factors and related issues that underlie health disparities, NIMHD's approach to achieving this mission is embodied in building a broad-based coalition of partners across multiple disciplines and sectors.  Although the U.S. has seen recent improvements in the overall quality of care, stark disparities in health quality and access to care persist in many communities, as well as pervasive differences in health between groups around the country.  Increasing evidence-based research findings continue to underscore the complex interplay of factors such as race, ethnicity, social, economic, geographic, environmental, genetic, and behavioral influences across the life-course that contribute to the early onset of disease, the aggressive progression of a disease, and to premature death.  In particular, Translational Science and Recruiting and Retaining Diverse Scientific Talent and Creativity are foundational aspects of the Institute's efforts to eliminate health disparities.

The approach of the NIMHD health disparities programs is to examine the causes of health disparities; integrate science, practice, and policy approaches to address health disparities; provide a platform for academic institutions to conduct research and support the training of a diverse workforce; offer a vehicle to build community research capacity, study national and global patterns of health disparities; and advance the translation and dissemination of research results.  The elimination of health disparities requires a transdisciplinary evidence-based approach, which incorporates efforts to promote translational science to ensure that the benefits of scientific discoveries reach those most affected by health disparities.

            A series of community health reports resulting from NIMHD-funded research reveal that social, economic and environmental conditions of low-income and non-white neighborhoods in some U.S. counties can project who is sick, healthy, and will live longer.  The results of these reports have policy and practice implications as it relates to the systems and structures that contribute to health disparities.  In another study utilizing quantitative and qualitative methods to study racial/ethnic disparities in early life risk factors for childhood obesity, researchers will study several factors.  Including, for example, the extent to which maternal experiences of two chronic stressors, racism and interpersonal violence - before and during pregnancy – are of significance.  It is felt that there is a unique and compelling need to promote diversity in the biomedical, behavioral, clinical and social sciences research workforce.  Thus, enhancing workforce diversity is a priority.  We would suggest that many of those who receive care from the Division's membership could benefit from NIMHD's vision.

            He Never Drank Water.  He Always Drank Wine:  It has been fascinating to hear from colleagues of different disciplines describing their post-retirement experiences.  Some wistful; some exhilarating.  "I still feel that I have something to share and pass on.  The desire to teach and educate this upcoming generation of health care professionals is strong.  I am applying for another opening at…."  "I decided to end my job search.  I am getting older, and there is age discrimination.  I accept it.  So I am cobbling together consultancies and subsidizing the payers.  I am frugal; so far I am making it.  Not to worry, I am doing fine!  It is what it is."  Two other colleagues with extraordinary professional backgrounds described trying unsuccessfully to join the Peace Corps, even though both were in excellent physical and mental health.

And at the same time, "I am retired from all things psychological thus not doing reviews anymore.  Priscilla and I are enjoying retired life in central Virginia, especially the increased family time.  Lunch in C'ville yesterday with an old friend.  Lang Lang concert last night in C'ville (incredible performance!!).  Breakfast at our house this morning with our daughter and son-in-law who live here.  They brought the homemade muffins, we fixed the rest.  UVa women's basketball game this afternoon with friends (we have season tickets).  Strategic planning committee meeting for me tomorrow for our neighborhood association (750 homes), and couples bridge on Tuesday night at our country club.  Staying busy.  It's a good life [Ludy Benjamin]."  Times are changing as today's generation of senior colleagues steadily departs from their prior, in retrospect predictable professional lives.  Former Division 18 President Jacqueline Wall recently sensed what is perhaps a fundamental shift in perspective: "Just so you know, I have received 20 nominations for President-elect.  Most people say that they are too busy to assume the responsibility.  It makes me wonder if the nature of our work has changed so much that people are beginning to protect their time to the point of decreasing involvement in anything that isn't obligated by an employer or for which compensation is given.  I mentioned the other day that when I started, the standard organizational practice was 50% patient contact time.  I'm hearing now that my colleagues are in direct patient care 80-90% of the day; leaving little time for things like writing reports, making phone calls, answering e-mails, etc.  Gives one pause and makes me think we'd best rethink how we do things."  If I'd bet on ol' Stewball, I'd be a free man today.  Aloha,

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

 

ADDRESSING SOCIETY’S NEEDS

Former APA Practice Directorate State Association Guru Mike Sullivan truly appreciated the importance of our state associations providing creative leadership in bringing psychology's expertise to focus upon society's most pressing needs.  As educated professionals, this is our societal responsibility.  "Heads Up Kentucky" was an enjoyable, highly visual effort to promote healthy lifestyles on the local level.  It effectively asked if residents knew that: "Stress is linked to the six leading causes of death: heart disease, cancer, lung ailments, accidents, cirrhosis of the liver, and suicide."  The Hawaii Psychological Association recently highlighted Gaby Toloza's collaborative efforts with the Hawai'i Autism Foundation and local YMCA to provide family centered support that focused upon the concept of Self-Care for the Caregivers of children on the autism spectrum.  For eight Saturdays, these families participated in two hour workshops with their children, including siblings.  A number of HPA members donated their time and expertise.  The second hour was targeted towards engaging the participants in physical exercise.  The goal being to behaviorally embed the need and benefits of physical exercise for parents with special needs children.  It was a very successful event with the parents gaining a greater awareness of their own need for self-care.

            As a nation, we are entering a new era of transformative health care reform.  The unprecedented advances occurring within the communications and technology fields, as well as the priorities of the Obama Administration reflected in the Patient Protection and Affordable Care Act (ACA), indicate a future of patient-centered care with a priority on prevention, wellness, and data-driven clinical decisions.  The advances occurring within telehealth (i.e., Telepsychology) will eliminate historical geographical and hopefully cultural barriers.  The VA and DoD have been leading the way.  In FY 2013 more than 600,000 Veterans received care utilizing telehealth – more than 1.7 million episodes of care.  Former Division 31 and Georgia Psychological Association President Linda Campbell and ASPPB CEO Steve DeMers have been proactively guiding psychology through these unchartered waters.  We suggest that this would be an excellent topic for our state associations to focus upon.  What are the laws, regulations, ethical issues, and supervision possibilities? -- while providing "hands-on" demonstrations, perhaps utilizing federal or state technology.  This could be in conjunction with other professions – another key element of the ACA.  And, of course, developing legislative agendas to provide critical reimbursement support.  There is a particular need for these services at Federally Qualified Community Health Centers, which are society's "safety net."

From our public policy perspective, nursing has historically been particularly responsive to addressing society's needs, especially throughout rural America.  Accordingly, we were pleased to participate in two conference calls during the past year in which the Administration requested their help in educating society about the benefits of ACA – Vice President Biden hosted the first; Secretary Sebelius the second.  Will psychology earn similar respect?  Aloha,

Pat DeLeon, former APA President – Division 31 – March, 2014

 

AN INTRIGUING GLOBAL PERSPECTIVE

APA Past President Don Bersoff recently took the wintery Amtrak Acela from Philadelphia in order to address my health policy class at the Uniformed Services University of the Health Sciences (USUHS), continuing his personal commitment to those who "place themselves in harm's way."  Our next generation of military psychologists and advanced practice nurses learned of his ROTC and Children Defense Fund experiences, as well as his service as an Air Force psychologist during the Vietnam War.  Reflecting upon his international travels during his Presidential year, Don described how the training models for psychology in the United States and around the world are of different lengths, and that this has led to collaborative efforts to tease out commonalities and essential competencies.  APA is very well respected internationally – as one quickly appreciates during our annual convention Opening Ceremonies.

            Earlier this year, the Institute of Medicine (IOM) released its report "U.S. Health in International Perspective: Shorter Lives, Poorer Health."  Our nation is among the wealthiest nations in the world, but it is far from the healthiest.  Although Americans' life expectancy and health have improved over the past century, these gains have lagged behind those in other high-income countries.  This health disadvantage prevails even though we spend far more per person on health care than any other nation.  The IOM panel which developed this report was struck by the gravity of its findings in reviewing data from 16 "peer" countries – other high-income democracies in Western Europe, Canada, Australia, and Japan.  For many years, Americans have been dying at younger ages than people in almost all other high-income countries.  This disadvantage has been getting worse for three decades, especially among women.  Not only are our lives shorter, but Americans also have a longstanding pattern of poorer health that is strikingly consistent and pervasive over the life course – at birth, during childhood and adolescence, for young and middle-aged adults, and for older adults.  This includes faring worse for injuries and homicides, obesity and diabetes, and disability.  Many of these conditions have a particularly profound effect on young people, reducing the odds that Americans will live to age 50.  For those who reach age 50, these conditions contribute to poorer health and greater illness later in life.

            The U.S. health disadvantage cannot be fully explained by the health disparities that exist among people who are uninsured or poor.  Several studies are now suggesting that even advantaged Americans – those who are white, insured, college-educated, or upper income – are in worse health than similar individuals in other countries.  No single factor can fully explain the U.S. health disadvantage.  For example, although individual behaviors are clearly important, they do not explain why Americans who do not smoke or are not overweight also appear to have higher rates of disease than similar groups in peer countries.  Without action to reverse current trends, the health of Americans will probably continue to fall behind that of people in other high-income countries.  Americans are dying and suffering from illnesses and injury at rates that are demonstrably unnecessary.  From a public policy and public health perspective, as a nation we can and must learn from other countries.  Over the years that I served on the U.S. Senate staff, I came to appreciate that two agencies in particular within the Department of Health and Human Services (HHS) have a significant international presence: The John E. Fogarty International Center (FIC) at the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC).  The Health Resources and Services Administration (HRSA) plays a smaller, but still significant role.

            The Fogarty International Center:  The Fiscal Year 2014 budget request of $72.864 million for the Fogarty Center provides an intriguing glimpse of potential opportunities for early career colleagues, as well as the ongoing HHS efforts to develop a comprehensive strategic approach for world-wide health care.  Director's Overview: From leading the call for an AIDS-free generation to developing vaccines and therapeutics for diseases that affect populations worldwide, the United States is a global leader in health research and scientific advances that improve the lives of Americans and people across the globe.  These discoveries are often made by U.S. and foreign scientists working in close collaborations that enable the best and brightest minds to tackle complex health challenges together.  The FIC therefore supports innovative training and research programs for U.S. and low- and middle-income country (LMIC) scientists that strengthen the research capabilities and catalyze the international scientific partnerships that lead to research discovery and improved health.  By investing in current and future leaders in global health research and strengthening the long-term capacity of research institutions to provide robust and sustainable platforms for cutting-edge science, FIC advances the goals and extends the leadership of the NIH and the U.S. government in science and research, while playing a vital role in building the capacity needed to successfully tackle critical health challenges.

*  Recruiting and Retaining Diverse Scientific Talent and Creativity.  FIC programs have supported long-term research training for over 4,500 scientists worldwide, in collaboration with over 230 U.S. and LMIC research institutions.  These investments provide unique training opportunities for early-career global health researchers, and aid in the retention of this diverse scientific talent in the research enterprise.  The Framework Programs for Global Health Innovation brings together teams of postdoctoral trainees from many disciplines to produce fresh insights into global health problems, and innovations for implementation in low-resource settings.  For example, a medical, engineering, and architecture team from Boston, South Africa, and Peru is receiving the training needed to design and validate effective, affordable prototypes for air disinfection that can help prevent airborne infections, such as tuberculosis and influenza, from spreading in low-resource settings.  The Medical Education Partnership Initiative, co-administered by HRSA, is transforming medical education and research training for medical students in 12 African countries utilizing e-Learning and resource-sharing to train the next generation of scientific leaders to solve their country's most pressing health problems – from HIV/AIDS to maternal and child health, and to non-communicable conditions, such as mental health and cardiovascular disease.

*  Translational Science FIC programs support researchers who are generating critical scientific evidence and applying this research to specific interventions, policies, and programs.  Infectious disease outbreaks from human and animal hosts post significant potential health and economic threats in the U.S. and other countries.  The Research and Policy in Infectious Disease Dynamics program – cofunded by the Department of Homeland Security – brings together senior infectious disease modelers and postdoctoral fellows to conduct the research and develop infectious disease modeling approaches that can help the U.S. and other policymakers plan for and respond to potential infectious disease threats.  These models have explored, for example, how the Avian Influenza can develop into outbreaks from an initial case and how these outbreaks can be controlled effectively.

*  Today's Basic Science for Tomorrow's Breakthroughs initiative supports catalytic basic biomedical and behavioral research that can lead to tomorrow's breakthroughs.  The FIC Brain Disorders program supports cutting-edge research in LMICs on nervous system development, function, and impairment throughout life – research that could lead to new diagnostic, prevention, and treatment strategies.  In India, grantees are exploring why Alzheimer's affects Indian populations less than populations in developed countries.  In Uganda, research is creating a base of knowledge on dementia in those with long-term HIV infection.

Future Challenges -- the need for sustainability poses a significant challenge for investments in global health research and research training.  FIC investments continue to evolve with increasing research capabilities in LMICs in order to build on successes and support the training of individual scientists and strengthen research institutions.  In addition, FIC will increase support for institutional networks and hubs for data collection and sharing.  When such sharing platforms are built around a core of trained individuals and strengthened institutions, they can effectively harness the different strengths of these institutions, and promote enhanced efficiencies and more robust, collaborative science.  FIC envisions that its U.S.-LMIC GEOHealth hubs will become global leaders in the collection, management, synthesis, and interpretation of data on environmental and occupational health, serving the larger multi-national regions in which they reside, as well as supporting research of great relevance to both these LMIC regions and the U.S.  In sub-Saharan Africa, universities supported are emerging as regional training centers and upgrading the technology to enable distance learning and resource-sharing among institutions.  This model is revolutionizing African medical education and research training by enabling partner institutions across Africa to pool their areas of expertise, sharing teaching tools, and ensure that all students receive the highest-quality instruction from the continent's best qualified faculty and researchers.  These efforts will ensure that the U.S. will continue to compete and lead in science.  The behavioral sciences have much to contribute to the underlying FIC mission.  The key question is whether psychology and nursing faculty appreciate their potential contributions and are they appropriately engaged?

Change Always Takes Time:  In March, 2005 then-HHS Secretary Michael Leavitt testified before the Senate Appropriations Committee:  "Influenza.  Since the H5N1 strain of Avian Influenza first appeared in 1997, public health officials have grown increasingly concerned about the possibility that a pandemic strain will emerge that could cause an additional 90,000 to 300,000+ deaths in the United States.  Avian Influenza has reappeared in Southeast Asia again this year, indicating that the virus has become endemic.  The FY 2006 budget continues to expand HHS's efforts to be prepared in the event this or another deadly influenza strain changes in a way that makes it easily communicable from person to person.  Since FY 2001, HHS has increased its direct expenditure related to influenza vaccine from $42 million to $439 million in FY 2006, in addition to insurance reimbursement payments through Medicare….  Increasing the use of annual influenza vaccinations will both reduce annual morbidity/mortality, and make the Nation better prepared in the event of a pandemic.  CDC estimates that 185 million people should receive annual immunizations – but fewer than half of that number have ever been immunized in a given year."  The vision of FIC's leadership continues to be most timely.  Secretary Leavitt also noted: "This year, for the first time ever, States spent more on Medicaid than they spent on education."

            Reflections For The Future:  ACA-- Coral Andrews served as the first Executive Director of the Hawaii Health Connector, the State of Hawaii's online health-insurance exchange that was established by the Hawaii legislature to implement President Obama's Patient Protection and Affordable Care Act (ACA).  A former Navy nurse, she reports her two years building the Connector has been among the most challenging and rewarding chapters of her health-care career – even providing the opportunity to speak directly with President Obama on a conference call.  She is currently a Regent for the American College of Health Care Executives (ACHE).  "Healthcare executive competencies in the era of healthcare reform reflect the confluence of shared industry expertise.  In this wake of social change, psychologists and advanced practice mental health nurses are positioned as core contributors in evolving organizational dynamics and multi-stakeholder policy formulation.  To establish a competency baseline, ACHE has published a tool entitled 'ACHE Healthcare Executive Competencies Assessment Tool, 2013.'  The tool serves as a resource for executives to use in assessing their expertise in core areas of healthcare management.  The application of the assessment allows it to be applied in diverse disciplines and settings.

There is a central role that psychologists and advance practice nurses may play in assisting organizations, leaders, diverse stakeholder groups and human resources professionals in the successful application of these competencies in an operational environment.  Human resources, for example, has historically been the primary industry responsible for human capital management in organizations.  However, the lines between human capital management and psychology/nursing as applied are blurred when discussing organizational psychology principles.  Human capital management within the human resources domain can include the administrative activities of payroll and benefits administration, but it also includes applied organizational dynamics.  Similarly, psychology and nursing span many different applications: clinical, behavioral, organizational, etc.  As I reflect on the preparatory implementation of the ACA and engaging in its post-implementation, I would suggest that psychologists and advanced practice nurses can be innovative in the contributory roles that they can play in the following: organizational readiness for change, integration with other disciplines, public-private partnership business models, and beyond that the innovation of tools that organizations can leverage for assistance beyond the in-person consultative services.  Is there a role that psychology and psychiatric nursing can play in developing online software for organizations that provides resources at varying price points?  We are working with the University of Hawaii to explore a healthcare executive graduate program.  The competency tool is a 'universal' resource regardless of discipline.  I suggest our next generation should be imaginative as they contemplate clinical acumen transported into this new era of reform.  They may be on to something….  "

"As I reflect on the ACA implementation in Hawaii, there are wonderful learnings that can be carried forward as implementation continues through the 'phase in' of ACA.  The learnings are only possible if the environment allows for an opportunity to comfortably mine for insights and to openly discuss them.  When implementing new policy, there is risk.  Risk should not be viewed as a negative but as an opportunity.  Managing risk is simply a part of achieving change and creatively pursuing innovation.  Hawaii has a rich culture that provides for a solid value base which serves as a beacon for consensus.  Given the policy debate in a multi-stakeholder environment, the host culture's values serve as the framework by which consensus can be guided… a baseline to go back to when policy discussions become spirited.  Passion for policy is a good thing provided the motivation behind it always leads back to purpose.  The purpose is to achieve long term value in the health of the population.  It requires a consumer oriented design as contrasted to an organizational, top-down design.  This methodology requires adjustments by leaders and policy makers as the human tendency is to design toward one's organizational advantage.  In a multi-stakeholder environment, everyone needs to put a 'marble in the circle' to achieve success.  It minimizes dominance and leans toward sharing wins and losses in order to achieve collective success.  A risk adverse culture can constrain the openness to reflect, evaluate, and learn especially if there are strong political influencers which can occur in an election year.  To leapfrog through change, an important starting point necessitates that individuals and organizational cultures evolve to embrace success as defined in a new way.  Implementing change is not indifferent to space exploration.  We need leaders who are willing to navigate through and be alert to the cognitive and behavioral responses to change.  Often, evolving to the future state is enabled when the people and organizations involved are supported with educational insights about how to change.  It does not come naturally for all but is an important skill and capability that is required to successfully achieve the optimal implementation of the ACA for long term value.  Implementing systems is the easy part.  Bringing the people, organizations and cultures along in support of, is where organizational psychologists and clinical nurse specialists can facilitate the process."

            VA -- Heather O'Beirne Kelly, who was born at Tripler Army Medical Center and whose grandfather was stationed at Pearl Harbor on that fateful September 7, 1941 morning, recently assumed APA's lead for military and Veterans policy, including coordination of APA-wide clinical and training activities related to DoD and VA, in addition to their research portfolios, as well as that of the National Science Foundation (NSF).  She sits on the Executive Committee of the Friends of VA Medical Care and Health Research Coalition (FOVA); represents APA on the VA Office of Mental Health Services Stakeholders Group; has testified before Congress regarding funding for VA research and mental health services; and has coordinated numerous Capitol Hill briefings on topics of interest to the Veteran population, including suicide prevention, PTSD, and traumatic brain injury.  She also directs APA's Executive Branch Science Policy Fellowship Program.

            Most recently, Heather has been advancing APA's Veteran-focused priorities on Capitol Hill through hearing testimony, meetings with Congressional staff, and intensive behind-the-scenes collaboration with several key offices particularly interested in Veterans' mental health care and research.  She worked to successfully include APA's language providing for psychologists' system-wide prescribing authority within the VA, increased collaboration between VA medical centers and local enforcement crisis intervention teams, and expansion of VA lethal means reduction for suicidal Veterans which are included in draft legislation proposed by Senator Patty Murray (D-WA).

            A graduate of Smith College, Heather has worked in non-profit development for clients including the Children's Defense Fund, UNICEF, and the March of Dimes before becoming director of corporate relations for Wolf Trap Foundation for the Performing Arts.  Her clinical internship was at Children's National Medical Center in Washington, DC.  Her interest in military and Veteran issues is longstanding; her father and both grandfathers were career military officers and her mother has worked for many years in military family policy.  Aloha,

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