ALL THE LEAVES ARE BROWN AND THE SKY IS GRAY

Change Is Forever Upon Us:  One of the advantages of working on Capitol Hill for an extended period of time is developing an appreciation for evolving national trends.  It would seem, for example, that there are increasing signs of bipartisan Congressional collaboration which will eventually allow state delegations to once again effectively address the unique needs of their constituents (perhaps even through the "ear-mark" process).  It is also clear that our nation's health care environment is undergoing unprecedented and fundamental change as a result of the enactment of President Obama's Patient Protection and Affordable Care Act (ACA), as well as the increasing application of computer technology to health care delivery, including research and educational endeavors.  At this year's exciting APA State Leadership Conference (SLC), visionary Practice Directorate Executive Director Katherine Nordal provided an optimistic view: "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.  A combination of professional, marketplace, legislative and regulatory developments encourages more collaborative, multi-disciplinary practice models.  As the landscape shifts towards more integrated care, new reimbursement mechanisms will emerge.  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.  Many of our members -- especially our early career colleagues -- seem attuned to this evolution.  We achieve good results when psychologists get energized and commit themselves to making positive things happen."

            Unchartered Waters:  One of the most valued bipartisan (i.e., nonpartisan) health care resources for those serving on Capitol Hill is the Alliance for Health Reform, led by Ed Howard, a former staffer for then-Congressman Sparky Matsunaga.  This past month the Alliance addressed "Patient-Centered Medical Homes (PCMH): The Promise and The Reality" -- a critical element of the ACA in which psychology is not mentioned.  While the PCMH model has increasingly been embraced by providers and payers as a way to improve health care and lower costs, many questions remain about its effectiveness.  Definitions of medical homes vary, but they are generally known as a model that aims to transform primary care through increased coordination and communication among a team of providers.  Recent medical home initiatives have encouraged primary care practices to invest in capabilities such as patient registries and electronic health records (EHRs), and to achieve medical home recognition.  Health plans offer to pay more to the practices that achieve recognition.  What do these models look like under different payers?  Given variation in how PCMHs are set up and reimbursed, how scalable are these models?  How long does it take for practices to make the PCMH transformation?  What are some of the challenges practices face when making the transition?  Do these models have an effect on costs?  Do they improve quality of care?

Another Alliance briefing focused upon "Health Centers at the Launch of the Coverage Expansion."  Eighty-four percent of health center patients earn under 200% of the federal poverty level.  Implementation of health information technology (HIT) by health centers has more than doubled since 2009; however, many health center leaders report provider shortages, especially with the anticipated influx of new patients and focusing upon integrating behavioral health.  Health centers may face a funding cliff after the $11 billion mandatory trust fund created by the ACA expires in 2015.  This calls into question whether or not there is adequate continued support for health centers and whether or not they have the stability to continue to meet the needs of new patients.  Funding for health centers is not only about grants, but payment models.  Total grant income is only 9% of the budget of one highlighted center, while Medicaid accounts for 60%.  The evidence suggests that health centers save money by providing good quality primary care to people who otherwise would have difficulty getting it.  There are 1.1 million people currently utilizing health centers who would be eligible for insurance coverage if their state expands Medicaid to the 133% of poverty level.  In those 24 states that have chosen not to expand Medicaid, these individuals remain uninsured and yet must still be served.  The Commonwealth Fund reports that spurred by federal investments and financial incentives to more fully embrace HIT, 85% of centers report they had achieved advanced HIT capacities in 2013 – meaning they could perform at least nine of 13 key functions, such as electronically prescribing medications.  The 2009 rate was just 30%.  Pursuant to Senator Inouye's vision, there is now a federally qualified community health center on every island in Hawaii, including Molokai and Lana'i.  Robert Hirokawa is the Executive Director of the Hawai'i Primary Care Association (HPCA).

            Integrated Care:  The movement towards integrated care, interdisciplinary collaboration, and effective utilization of computer technology (i.e., HIT, Telepsychology, and Comparative Effectiveness Research exploring cross population and cross provider outcomes) was also highlighted at the 17^th annual VA Psychology Leadership (AVAPL) Conference – "Serving Veterans through Interprofessional Care and Expanding Partnerships."  APA President Nadine Kaslow and former VA Chief Consultant for Mental Health Toni Zeiss provided a visionary global perspective.  Kathy McNamara, Theodora Stratis, and Henry Beck represented Hawaii.  The VA has been the national leader in these areas, especially under the leadership of Toni and her husband Robert Zeiss who has made post-doctoral training a high VA priority, which is expected to support 400 positions in 2014-15.  It was fascinating to listen to early career colleagues talking about their work on cancer units, organ transplant units, and with local police departments.  Half of the highly enthusiastic attendees were early career psychologists or interns/post-doctoral fellows.  The poster sessions emphasized transformational change, burnout among veterans, weight loss predictions, and the importance of active community involvement.  The leadership of AVAPL announced that henceforth their scholarships will be named in honor of APA's Randy Phelps for all that he has done for public service psychology over the decades.  From a public policy perspective, the one missing element was representation from Division 19, the Society for Military Psychology – they are the Veterans of tomorrow.

            USUHS:  Having the opportunity to teach at the Uniformed Services University of the Health Sciences (USUHS) provides a unique perspective on the contributions psychology and advanced practice nursing can make to our nation's military and their families.  I have been especially pleased with the extent to which APA and APS, as well as national nursing organizations, have been willing to provide USUHS students with special training experiences.  APA's Donna Beavers, for example, invited LT. Chantal Meloscia, a Navy officer studying clinical psychology, to attend the recent conference titled "Confronting Family and Community Violence: The Intersection of Law and Psychology."  "The conference was hosted by both APA and the American Bar Association (ABA) with a focus on the effects of violence on communities and families, as well as exploring ways to integrate law and psychology services in response to community and family violence.  The conference participants included psychologists, attorneys, other clinicians, educators, child advocates, judges, and many more professionals involved in both the law and psychology fields.  The keynote speaker addressed how the intersection of psychology and law can help to reduce the exposure of children in the United States to trauma and violence.  Another important theme that emerged from a series of the sessions was the role of the collaboration between law and psychology to support military members and Veterans.  Across these various talks, the message portrayed was that stress, trauma, and exposure to violence can influence the way military members and Veterans behave, leading to increased interaction with the criminal justice system.  The creation of specialized Mental Health, Substance Abuse, and Veterans Treatment courts has shifted the focus of courts for these populations to rehabilitation.  Particularly important in focusing on rehabilitation is the increased benefit not just for the individual, but for the family of the individual, especially if children are involved.  As legal and psychology professionals continue to work together to develop informed policy and rehabilitative court systems, military members and Veterans affected by stress, trauma, and violence will obtain the support they need to heal.  The APA and ABA conference provided an inspiring forum for those professionals to continue this incredibly important collaboration."  Interdisciplinary collaboration is the future.  Accordingly, we would be very pleased to learn of plans for a similar HPA-HBA conference in the near future.

            At USUHS, we strive to facilitate health policy experiences, which are a required competency within nursing – but not psychology.  Following up from SLC -- "Thanks for sharing this.  I have recently had some conversations with students and colleagues about the lack of training that we as psychologists receive in policy.  I often speak about how it was difficult for me to forge a path into the policy arena with no psychology mentors who were doing work in policy and no models for how to get into the policy arena.  As the healthcare system and models of care become more and more integrated, it is incumbent that psychologists be prepared to work in inter/multidisciplinary settings and also learn about how to interact with and impact the policy arena" (Le Ondra Clark, consultant California Senate Committee on Business, Professions and Economic Development).  California Dreamin'.  Aloha,

Pat DeLeon, former APA President – HPA – June, 2014

 

IT ALWAYS SEEMS IMPOSSIBLE UNTIL ITS DONE

State Leadership Conference (SLC):  At this year's exciting Practice Directorate State Leadership Conference (SLC) titled "Creating Roadmaps for Practice," visionary Executive Director Katherine Nordal emphasized: "The way the Affordable Care Act [ACA] is unfolding reminds us that no single advocacy strategy for psychology can address the diverse legislative, regulatory and marketplace environments we see from one state to another.  Meanwhile, our country still doesn't pay nearly enough attention to mental health and substance use treatment.  We've carved out this treatment from medical care and made people jump through hoops to get the psychological services they need.  And mental health is chronically underfunded.  About 20% of our population experiences a mental health disorder in any given year, compared to a lifetime incidence of 6% for adults with cancer.  Yet, in 2012, the federal government invested more than 5 billion dollars in the National Cancer Institute but less than 1.5 billion dollars in NIMH.  Health care reform implementation is a work in progress.  There are hopeful signs, especially related to the goal of increasing the ranks of Americans with health insurance coverage.  A combination of professional, marketplace, legislative and regulatory developments encourages more collaborative, multi-disciplinary practice models.  As the landscape shifts towards more integrated care, new reimbursement mechanisms will emerge.  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.  Many of our members seem attuned to this evolution."  As Katherine also indicated at last year's SLC conference: "Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  If we are not valued as a health profession, it will detract from our value in other practice arenas as well.  Health care reform is a marathon – we're in it for the long haul.  New models of care and changes in health care financing won't take shape overnight."

            Integrated Care:  Katherine's description of the "changing winds" of health care reform is extraordinarily accurate.  The Alliance for Health Reform recently sponsored a Hill briefing – "Is the Mind Part of the Body?  The Challenge of Integrating Behavioral Health and Primary Care in a Reform Era."  "As more people gain coverage that includes behavioral health benefits, and given a limited supply of mental health professionals, analysts and advocates are raising concerns over how and whether new laws and regulations will be able to change that situation.  One option being explored in many settings is the integration of behavioral health services with primary care.  There is early evidence that coordinating care in this manner may deliver high-quality care more efficiently.  For almost 20 years, bipartisan majorities in Congress have been legislating ways of bringing behavioral health services to the 62 million Americans in need of them.  Beginning with the 1996 Mental Health Parity Act, Congress has steadily broadened access to these services.

            "All state Medicaid programs and plans sold on the health insurance marketplaces cover behavioral health services.  Yet 60% of adults and 70% of children with a mental health disorder do not receive treatment.  In children, the average time between onset and treatment of mental illness is nine years.  And one in six adults has co-morbid mental health and medical conditions.  More commonly their medical condition is being treated while their mental health condition goes undiagnosed and untreated.  Do current models of integrating behavioral and physical health hold promise?  Are there enough providers to meet the demand of the newly insured?  What is needed to help primary care fill the gap?  How are the states meeting the budgetary challenge in Medicaid programs?  Is parity a reality?"

            Our colleagues in the American Psychiatric Association (ApA) would appear to agree with Katherine, recently calling for much tighter integration of primary care and mental health care, thereby providing better services with a reduction in costs.  "Studies have shown that concurrently treating behavioral and physical conditions leads to better control of the illness itself, but also better patient satisfaction, quality of life, and reduced costs [ApA President]."  The ApA commissioned report shows that effective integration could save $26 billion to $48 billion a year in general medical care.  Almost half of people with a mental disorder first consult with a primary care physician and approximately 50% of the 38,000 individuals who commit suicide each year have seen a primary care physician within a month of the completed attempt.  Their report, which drew on claims data for 20 million enrollees, found that only 14% of those who had a mental disorder were receiving treatment but that they accounted for 30% of the spending reviewed.  "Even though they are insured and are being treated for their mental illnesses, the lack of coordinated care represents lost opportunities….  The higher costs were mostly attributable to patients falling through the cracks or not getting proper care – which showed up in more emergency room visits, more hospitalizations, and hospital readmissions [ApA President-Elect]."

            In our judgment, critical to the success of Katherine's vision of psychology being recognized as a bona fide "health care profession" is affirmatively embracing our societal responsibility to provide proactive leadership in addressing society's most pressing needs.  Psychology is one of the "learned professions" and with that come a fundamental obligation to effectively utilize our clinical skills, beyond the confines of traditional practice.  Last year we were very pleased to learn of Gaby Toloza's efforts on behalf of the Hawaii Psychological Association (HPA) to address the needs of families with an autistic child.  Her "call to action" this year: "We are in need of about 6-7 psychologists to volunteer ONE hour of their time on Saturday at the Windward YMCA to give an interactive psycho-educational talk about an aspect of Self Care to a group of 15-20 parents of autistic children.  Some previous topics related to mind body connection, achieving balance, how to change behavior, role of nutrition, stress management, financial stress management and relationship health.  This is a wonderful way to give back to the community and promote psychology as a profession, but more importantly the necessity of self-care and a wellness model.  This supports HPA and APA initiatives for public education and it's just a fun, simple and meaningful experience for both the families and providers.  It is a collaborative project with HPA, YMCA, Hawaii Autism Foundation and Creative Connections Foundation, so it also represents yet another way that the work of psychologists can be integrated and effectively used to support a given population.  Thank you for your time and hope I hear back from many of you wonderful helping professionals (Yes, shameless positive feedback in hopes of soliciting your time)."

            Interdisciplinary Training For The Next Generation:  The Robert Wood Johnson Foundation (RWJ) Nursing and Health Policy Collaborative at the University of New Mexico reports that over 100 doctoral level nursing programs have stand-alone, required courses in health policy, with numerous other programs incorporating health policy content into related courses.  In sharp contrast, we have been able to find very few related courses within psychology' training programs.  An appreciation of the legislative and administrative process is essential for all health professions.  For example, the Institute of Medicine (IOM) found that although the primary purpose of a state licensing board is specifically to protect the interests of the public, 52% of dentists thought that the primary purpose of their state dental board was to protect the interests of dentists and 32% thought they protected the interests of both dentists and the general public.  The IOM report also concluded that publicly funded health programs should not separate oral health from overall health.  The IOM President: "Can you imagine a time when we fully incorporate mental and dental health into our thinking about health?  What is it about problems above the neck that seems to exclude them so often from policy about health care?"

            At the Uniformed Services University of the Health Sciences (USUHS), the next generation of psychologists and doctors of nursing practice (DNP) train together in a number of venues, including health policy.  "My colleague, CPT Kathleen Young and I had the pleasure of attending the American Association of Colleges of Nursing (AACN) Student Policy Summit held in Washington, DC.  The Summit provided a panoply of distinguished nursing professionals and activists committed to the advancement of nursing and nursing practice that bestowed upon us the importance of uniting as a profession to influence changes that affect our profession and the care that we provide to our patients.  Astonishingly we have approximately 3.1 million nurses of which only approximately 100,000 belong to the American Nurses Association (ANA).  While this statistic does not include the many other nursing organizations that nurses may be members of, it is nonetheless an astonishing fact that nurses make up the majority of the healthcare industry, yet we have the least amount of members participating in organizations that influence the very policies that impact our profession.

            "The AACN Summit provided an opportunity to show the ease with which nurses can become politically involved to improve health status and the delivery of healthcare.  Mindful of relevant DoD Directives, my colleague and I were graciously allowed to accompany Dr. Jane Kirschling, President of the AACN and Dean of the University of Maryland School of Nursing, as well as several bright undergraduate and graduate nursing students from the State of Maryland as they were welcomed by the offices and staff of the Maryland Senators and Congresspersons.  The well-spoken students impressed upon their Representatives the importance for continued support for Title VIII funding for nursing education, increased funding for nursing research, and support for nursing practice bills designed to promote the role of Advanced Practice Nurses in the healthcare delivery system.

            "The AACN Student Summit Policy Summit was an extraordinary opportunity to network with nursing leaders, advocates for the advancement of nursing practice, and colleagues with the common goal of imparting change.  In an era of unprecedented health care reform nurses, one of the most trusted health professions in the nation, have a unique opportunity and dare I say obligation, to provide our expertise in matters that affect the profession of nursing and the delivery of care that we provide [Capt. Kellie Webb-Casero, USAF]."  Aloha,

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

 

LEAVING ON A JET PLANE

 This Spring's Practice Directorate State Leadership Conference (SLC) was appropriately titled "Creating Roadmaps for Practice."  Last year Executive Director Katherine Nordal reminded those attending that: "The clock is ticking towards full implementation of the law [President Obama's Patient Protection and Affordable Care Act (ACA)] and January 1, 2014 is coming quickly.  But January 1^st is really just a mile maker 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.  What many of our practitioners increasingly will need to promote: the value and quality they can contribute to emerging models of care.  I believe that if we are not valued as a health profession, it will detract from our value in other practice arenas as well.  So regardless of how we feel about the current state of our health care system, psychology must take its seat at the table and contribute to the solutions needed to fix our ailing system."  SLC continues to be, in my judgment, one of the highlights of APA's year.  The leaders of our profession from around the country get a first-hand glimpse of the policy/political forces that are impacting their daily professional lives.  Perhaps most importantly, our next generation of colleagues is actively encouraged to become involved in shaping the future of theirprofession.

The 500+ colleagues in attendance this year – including President Nadine Kaslow and President-elect Barry Anton -- heard an inspiring vision from Katherine: "The way the [ACA] is unfolding reminds us that no single advocacy strategy for psychology can address the diverse legislative, regulatory and marketplace environments we see from one state to another.  The landscape continues to take shape.  Speaking of landscapes, you know as well as I that the professional terrain for psychologists – and other health care providers – has been somewhat rocky in recent years.  Disruption and demands on practitioners have raised anxiety levels.  Meanwhile, our country still doesn't pay nearly enough attention to mental health and substance use treatment.  We've carved out this treatment from medical care and made people jump through hoops to get the psychological services they need.  Mental health care is chronically underfunded.  About 20 percent of our population experiences a mental health disorder in any given year, compared to a lifetime incidence of six percent for adults with cancer.  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.  Keep in mind that all enrollees in the new health insurance exchange plans benefit from federal requirements for mental health parity.  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.

"Many psychologists know that we scored a major win regarding Medicare payment in 2014.  In essence, we reversed the downward payment trajectory for psychological services.  The 2014 Medicare fee schedule marked the first time since 2007 that the payment pool allocated for Medicare psychological services increased.  The eight percent jump meant that psychologists gained the second highest increase in payment allocation among all Medicare provider groups for 2014.  A combination of professional, marketplace, legislative and regulatory developments encourages more collaborative, multi-disciplinary practice models.  The demand for evidence-based practices and the 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.

"Many of our members seem attuned to this evolution.  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 of respondents indicated they will increase their use of technology for professional purposes.  And one-third of all respondents said they 'will further diversify practice activities and skills.'  That was particularly true for our early-career respondents.  Again, there is no single optimal path forward for practitioners.  We need lean, mean advocacy machines to protect our seat at the table and move psychology forward as the health care marketplace evolves.  Psychology is a learned profession filled with smart, creative people.  We achieve good results when psychologists get energized and commit themselves to making positive things happen.  These experiences fill me with optimism as I look down the road toward our practice future.  Let's all continue putting to good use our collective energy and enthusiasm for the profession we love.  Our patients, our profession and our future are depending on leaders like you!"

A Special Vision For The U.S. Army:  This April, the Senate Appropriations Committee invited the three military Surgeons General to testify on their budget priorities for the coming fiscal year.  Interestingly, the DoD announcement regarding the hearing highlighted the critical nature of their mental health and psychological providers for the achievement of the services' underlying mission.  The U.S. Navy Surgeon General noted: "Psychological Health is an important component of overall force health protection.  We recognize that prolonged operational stress can have potentially debilitating consequences."  This institutional appreciation of the value of mental health care represents a fundamental change in the historical DoD posture and, as the nation steadily implements the ACA with its emphasis upon encouraging comprehensive and holistic systems of care, speaks well for the potential future of all behavioral and mental health disciplines.

The U.S. Army Surgeon General Patricia Horoho consistently reminds her colleagues that the Army health care system only sees its beneficiaries 100 hours a year.  And, that what the Soldiers and their Family Members do during the rest of the time has a significant impact upon their overall health status.  "Since 1775, America's medical personnel have stood shoulder to shoulder with our fighting troops, received them at home when they returned, and been ready when called upon to put their lives on the line.  While the wounds of war have been ours to mend and heal during a period of persistent conflict, our extraordinarily talented medical force also cared for the non-combat injuries and illnesses of our Soldiers and their Families.  It is an honor to serve as the commander of this outstanding healthcare organization, caring honorably and compassionately for our 3.9 million beneficiaries….

"Our medical teams have achieved the highest combat survival rates in history.  Multiple improvements in battlefield medical care… have contributed to the all-time high survivability rate of 91% during Operations Enduring Freedom and Operations Iraqi Freedom despite more severe and complex wounds.  Moreover, our unwavering support of wounded, ill, or injured Soldiers has allowed necessary healing and recovery, and enabled a 47% return to duty rate for the Force.  This translates to a cost-avoidance to recruiting and training of $2.2 billion.  We also have considered the long-term impacts of war, recognizing that not all combat injuries are visible.  The rapid coordination of traumatic brain injury screening and clinical practice guidelines allowed for our in-theater concussive care centers to provide a 98% Return-to-Duty rate.  In addition, by embedding capabilities such as behavioral health and physical therapy with deployed units, we provide early intervention and treatment, keeping the Soldier with the unit and decreasing the requirements to evacuate Soldiers from theater.  Through a combination of efforts, suicides in Active Duty Soldier ranks fell from 165 to 126 in 2013….  To maintain a ready and deployable Force, our Nation's Total Army requires a comprehensive System for Health designed to maximize the fighting strength, prevent disease and injury, build resiliency and promote healthy behaviors….  Our readiness platforms include… programs and initiatives designed to improve healthy behaviors, such as the Performance Triad of healthy sleep, activity, and nutrition, increase the health and resilience of our Soldiers to better prepare them for challenges unseen."

Lt. General Horoho pointed out that since September 11, 2001, more than 1.5 million Soldiers have deployed and many have deployed multiple times.  Our nation has never endured two simultaneous conflicts for this length of time.  The Army is charged with being prepared to face tomorrow's challenges.  As Katherine emphasized, there will be an increased reliance upon evidence-based guidelines and the Army is a good example.  "Wartime medical lessons learned have led to over 36 evidence-based, battlefield-relevant Clinical Practice Guidelines that have decreased combat morbidity and mortality….  While research in civilian medicine can take 16 years to integrate findings into clinical practice, through collaboration with organizations such as the Defense Centers of Excellence and the Defense and Veterans Brain Injury Center, we are able to more rapidly translate research findings into the latest guidelines, products, and technologies.  Improved data sharing between agency, academic and industry researchers accelerate progress and reduce redundant efforts without compromising privacy.  This rapid coordination is what led to a 98% RTD [return-to-duty] rate in theater for those Service Members treated at our Coordinated Care Centers in Afghanistan.  In August, 2013, the White House released the National Research Action Plan (NRAP) mandating interagency collaboration to better coordinate and accelerate TBI and psychological health (including suicide) research.  MRMC [Army Medical Research and Materiel Command] is working closely with other federal agencies such as National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS), National Institute on Disabilities and Rehabilitation Research (NIDRR) and the Department of Veterans Affairs (VA) to execute the President's National Research Action Plan.

"A key element of our Warrior Ethos is that we never leave a Soldier behind on the battlefield.  This commitment extends beyond the battlefield to the unwavering commitment of Army Medicine….  As an Army, as a military, and as a Nation, we have a global influence on medicine and health….  Women have been a part of America's military efforts since the Revolutionary War.  As their roles continue to evolve, Army Medicine recognizes the unique health concerns of women in the military.  Females make up 15.8% of the Force today – including Active Duty and RC [reserve components] – and the percentage of women continues to grow, up from about 4% from 20 years ago….  The Army is the first military service to focus specifically on women's health issues, particularly related to deployed environments.

"We are aggressively moving from a healthcare system – a system that primarily focused on injuries and illness – to a System for Health that now incorporates and balances health, prevention and wellness as a part of the primary focus for readiness.  Through early identification of injury and illness, surveillance, education, and standardization of best practices, we are building and sustaining health and resiliency.  This also moves our health activities outside of the brick and mortar facility, brings it outside of the doctor's office visit, and into the Lifespace where more than 99% of time is spent and decisions are made each day that truly impact health.  We are investing on research focused on prevention….  We recruit Soldiers, but re-enlist families….  We have an enduring obligation to the men and women in uniform, to their families who serve with them, and to the retired personnel and families who have served in the past….  The Army Medicine Team is proudly Serving to Heal, and Honored to Serve."

Telehealth/Telepsychology:  One of the most intriguing workshops at SLC was chaired by Deborah Baker -- "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 Fred and Linda Campbell, has been 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.  In her testimony, SG Patricia Horoho noted that the Army currently offers care via telehealth in multiple medical disciplines across 18 time zones and in over 30 countries and territories.  In fiscal year 2013 the Army provided over 34,000 real-time patient encounters and consultations between providers in garrison and over 2,300 additional encounters in operational environments.  While the Army provides care via telehealth in 28 specialties, Tele-Behavioral Health accounts for 85% of the total volume in garrison and 57% in operational environments, with over 2,000 portable clinical video-teleconferencing systems having been deployed to support Behavioral Health providers across the globe.  The April APA Monitor reported that 44 percent of veterans returning from Iraq and Afghanistan come home to rural ZIP codes.  The shortage of health care providers of all specialties in rural America has been well documented.  Telehealth/Telepsychology is increasingly becoming a viable response to this critical national need.

The Substance Abuse and Mental Health Services Administration (SAMHSA):  In submitting her Fiscal Year 2015 budget justification, the Administrator of SAMHSA echoed many of the themes raised by Katherine at SLC.  "Our nation stands at a critical crossroad.  Recent tragic events and the Administration's call to action on the mental health and well-being of our citizens, have spurred critical public health investments.  At the same time, our health care system is preparing for the influx of individuals now eligible and enrolling for coverage.  The Mental Health Parity and Addiction Equity Act along with the Affordable Care Act also requires coverage for mental or substance use disorders to provide the same level of benefits as is provided for general medical/surgical treatment.  Yet, millions of Americans do not receive the help they need.  It is time for our country to address these issues, and SAMHSA must lead the way….  Behavioral health problems contribute to early death, disability, lost productivity, and high health care costs.  But if we intervene early, we can save lives and lower these costs.  Despite the existence of effective treatments, it typically takes more than six years for people to receive treatment after the onset of a mental illness or substance use disorder.  The FY 2015 Budget Request includes funding to help teachers and other individuals who interact with youth recognize early signs of mental illness, and to improve referrals and access to mental health services for young people ages 16-25."  The budget emphasizes SAMHSA's responsibility to help the nation act on the knowledge that: Behavioral health is essential for health; Prevention works; Treatment is effective; and, People recover from mental and substance use disorders.

Two of SAMHSA's proposed Strategic Initiatives are * Health Care and Health Systems Integration and * Health Information Technology.  The first Strategic Initiative focuses on health care and integration across systems including systems of particular importance for persons with behavioral health needs such as community health promotion, health care delivery, specialty behavioral health care, and community living needs.  Integration efforts will seek to increase access to appropriate high quality prevention, treatment, recovery and wellness services and supports; reduce disparities between the availability of services for mental illness (including serious mental illness) and substance use disorders compared with the availability of services for other medical conditions; and support coordinated care and services across systems.  The Health Information Technology Strategic Initiative will ensure that the behavioral health system – including states, community providers, patients, peers, and prevention specialists – fully participate with the general healthcare delivery system in the adoption of Health IT, including interoperable electronic health records (EHRs), and the use of other electronic training, assessment, treatment, monitoring, and recovery support tools, to ensure high-quality integrated health care, appropriate specialty care, improved patient/consumer engagement, and effective prevention and wellness strategies.

A Critical Agenda --The Elderly: As Katherine pointed out at SLC, psychology is one of the "learned professions."  As such, we have a societal responsibility to provide proactive leadership.  Former Hawaii Psychological Association (HPA) President Terri Needels:  "Thanks for the letter about long-term care.  I am increasingly concerned about the way that Medicare does not address the needs of patients with Alzheimer's or dementia if they are not incontinent.  I am seeing more and more caretakers who are utterly exhausted and besides themselves trying to care for a family member with Alzheimer's at home.  Their family members are wandering around during the day, getting lost, falling, and are at risk for exploitation and harm while the caretakers are at work.  The caretakers are reporting that they can't get their loved ones into nursing homes unless they are incontinent.  Does this sound correct?  I am not an expert on the admission rules but am really concerned and appalled that the system (if this is really true) would only allow admission into a high level of care if someone has a physical, rather than psychological, difficulty.  Medicare must cover memory care or we are going to be facing a huge social crisis in the near future.  Who is taking responsibility for changing this?  I would certainly be willing to work on supporting proposals for the necessary changes in coverage.  I have clients who would be willing to testify and I imagine there are many other providers treating clients with similar situations.  Seems to me that I worked on this a long time ago."  If psychology will not act on behalf of our patients and their families – who should we reasonably expect will?

            Wisdom From The Past:  This Spring I had the opportunity of returning to Purdue University where I obtained my psychology degree.  A fellow graduate, Angela McBride, was present and we were able to reflect upon our personal journeys.  She is a "living legend" within the nursing profession, having retired as Dean of the Indiana University-Purdue University (IUPUI) School of Nursing, which is the largest in the nation (if not in the world).  Visiting with my major professor, Clifford Swensen, was a definite highlight: "Having been involved in politics, and for a long time in university politics, there are some things I have observed.  1.) Any change hurts somebody.  Who is being hurt and how can you ameliorate that?  2.) The status quo has a lot of vested interests.  Where are they and how can you alleviate their concerns?  3.) Any change brings about unanticipated, undesirable side effects.  How can you anticipate them as much as possible, but more important have in place means of coping with and ameliorating them.  4.) Opponents are not evil enemies.  They are people who have a vested interest somewhere and have a different point of view.  And, 5.) In any fight, the objective and overall purpose often gets lost, and the goal is simply to win the fight.  The longer I observe, the more I am convinced that a lot of conflict is based on the last item [Cliff Swensen]."  Is it any wonder that at the federal level, and we expect with the implementation of the ACA, change often takes significantly longer than initially expected?  All my bags are packed, I'm ready to go.  Aloha,

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

 

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