“TO IMPROVE IS TO CHANGE”

    Those of our colleagues who have had the opportunity during their careers to serve in both the Administration and on the Hill have had the fascinating experience of developing a personal appreciation for how the different branches of government have unique aspirations, cultures, and challenges; as well as how government can truly "make a difference" in the lives of our nation's citizens.  From the Hill perspective, one develops an instinctive sense for when fundamental change is evolving.  Now retired, Hawaii's U.S. Army Colonels Debra Dunivin and Ernie Lenz have the distinction of having been selected as APA Congressional Science Fellows.  With the change in Administration, Mary Wakefield completed her tenure as Acting Deputy Secretary of the Department of Health and Human Services (HHS).  Previously, she had served as chief-of-staff for two of North Dakota's U.S. Senators.

            The Fiscal Year 2017 Appropriations Legislation [P.L. 115-31]:  Movement -- "Concerns remain with the progress being made by the Departments of Defense and Veterans Affairs to fully develop, procure, and deploy an interoperable electronic health record solution.  The two systems must be completely and meaningfully interoperable, and the Under Secretary of Defense (Acquisition, Technology, and Logistics) is encouraged to focus on the overall goal of seamless compatibility between the two Departments' electronic health record systems….  These [quarterly] reports should also include any changes to the deployment timeline, including benchmarks, for full operating capability; …the status of the effort to achieve interoperability between the electronic health record systems of the Departments of Defense and Veterans Affairs, including the scope, cost, schedule, mapping to health data standards, and performance benchmarks of the interoperable health record; and the progress toward developing, implementing, and fielding the interoperable electronic health record throughout the two Departments' medical facilities.

"The PEO DHMS is directed to continue briefing the House and Senate Appropriations Committees on a quarterly basis, coinciding with the report submission.  Given that full deployment of this new electronic health record is not scheduled until fiscal year 2022, the Department of Defense is expected to continue working on interim modifications and enhancements to the current system to improve interoperability in the near-term….  Additionally, the Director of the Interagency Program Office is directed to continue to provide quarterly briefings on standards development, how those standards are being incorporated by the two Departments, and the progress of interoperability….  In an effort to ensure government-wide accountability, the PEO DHMS, in coordination with the appropriate personnel of the Department of Veterans Affairs, is directed to provide the Federal Chief Information Officer of the United States with monthly updates on progress made by the two Departments to reach interoperability and modernize their respective electronic health records."

The Times They Are A-Changin':  At a recent Give an Hour event hosted by President Barbara Van Dahlen, USUHS psychology graduate student Elizabeth Belleau met VA Secretary David Shulkin and Harold Kudler, chief consultant for mental health service.  Among other issues, they discussed the exciting potential for active duty mental health graduate students to obtain supervised clinical experience within the VA – especially since these future colleagues personally appreciate the nuances of military culture and will themselves eventually become VA beneficiaries (i.e., breaking down historical silos).   Impressively, Give an Hour has already provided over 220,000 hours of free mental health care (valued at over $20 million) to our nation's active duty personnel, Veterans, and their families.  The Secretary, who is the first non-Veteran to be appointed, has entered into a partnership with HHS to allow the assignment of U.S. Public Health Commissioned Corps members to provide direct patient care to Veterans in VA hospitals and clinics in underserved communities.  Earlier this year, he was instrumental in providing full practice authority for VA advanced practice registered nurses (APRNs) (with the exception of nurse anesthetists) as long as they were working within the scope of their VA employment.

Prescriptive Authority (RxP):  The APA Board of Educational Affairs and CAPP will be establishing a Task Force to Review and Revise the APA Recommended Postdoctoral Education and Training Program in Psychopharmacology for RxP.  The federal system, and particularly DoD, was the critical catalyst for this evolution, affirmatively demonstrating that appropriately trained colleagues could provide safe and quality psychopharmacological care.  Floyd Jennings, USPHS; John Sexton and Morgan Sammons, U.S. Navy; and Debra Dunivin, U.S. Army were among the first prescribing psychologists.  At the time of the adoption of the 2009 APA model curriculum, the consensus was to require postdoctoral training.  Several of the underlying issues to be considered at this point, however, include: * At what level is it appropriate to begin such training and what components of the training can be taken at what level?  * The balance between enough specificity in the required elements of the curriculum to ensure consistent training vs. allowing program flexibility.  And, * The components of the supervised experience.  The Task Force will also explore the similarities and differences in the various enacted RxP state laws.

With the steady movement of psychology towards integrated, team-based care it is my personal view that APA's new standards should strive to reflect the views of the practicing clinician, actively engage graduate students, and provide training programs with the flexibility to educate interested students throughout their doctoral training.  APA's original task force on RxP concluded in 1993: "Practitioners with combined training in psychopharmacology and psychosocial treatments can reasonably be viewed as a new form of health care professional, expected to bring to health care delivery the best of both psychological and pharmacological knowledge."  (Michael Smyer, chair; current APA President Tony Puente, an active participant).  "To be perfect is to change often."  Aloha,

Pat DeLeon, former APA President – Division 19 – May, 2017

 

Sent from my iPhone

Division 19 May column

“TO IMPROVE IS TO CHANGE”

            Those of our colleagues who have had the opportunity during their careers to serve in both the Administration and on the Hill have had the fascinating experience of developing a personal appreciation for how the different branches of government have unique aspirations, cultures, and challenges; as well as how government can truly “make a difference” in the lives of our nation’s citizens.  From the Hill perspective, one develops an instinctive sense for when fundamental change is evolving.  Now retired, Hawaii’s U.S. Army Colonels Debra Dunivin and Ernie Lenz have the distinction of having been selected as APA Congressional Science Fellows.  With the change in Administration, Mary Wakefield completed her tenure as Acting Deputy Secretary of the Department of Health and Human Services (HHS).  Previously, she had served as chief-of-staff for two of North Dakota’s U.S. Senators.

            The Fiscal Year 2017 Appropriations Legislation [P.L. 115-31]:  Movement -- “Concerns remain with the progress being made by the Departments of Defense and Veterans Affairs to fully develop, procure, and deploy an interoperable electronic health record solution.  The two systems must be completely and meaningfully interoperable, and the Under Secretary of Defense (Acquisition, Technology, and Logistics) is encouraged to focus on the overall goal of seamless compatibility between the two Departments’ electronic health record systems….  These [quarterly] reports should also include any changes to the deployment timeline, including benchmarks, for full operating capability; …the status of the effort to achieve interoperability between the electronic health record systems of the Departments of Defense and Veterans Affairs, including the scope, cost, schedule, mapping to health data standards, and performance benchmarks of the interoperable health record; and the progress toward developing, implementing, and fielding the interoperable electronic health record throughout the two Departments’ medical facilities.

“The PEO DHMS is directed to continue briefing the House and Senate Appropriations Committees on a quarterly basis, coinciding with the report submission.  Given that full deployment of this new electronic health record is not scheduled until fiscal year 2022, the Department of Defense is expected to continue working on interim modifications and enhancements to the current system to improve interoperability in the near-term….  Additionally, the Director of the Interagency Program Office is directed to continue to provide quarterly briefings on standards development, how those standards are being incorporated by the two Departments, and the progress of interoperability….  In an effort to ensure government-wide accountability, the PEO DHMS, in coordination with the appropriate personnel of the Department of Veterans Affairs, is directed to provide the Federal Chief Information Officer of the United States with monthly updates on progress made by the two Departments to reach interoperability and modernize their respective electronic health records.”

The Times They Are A-Changin’:  At a recent Give an Hour event hosted by President Barbara Van Dahlen, USUHS psychology graduate student Elizabeth Belleau met VA Secretary David Shulkin and Harold Kudler, chief consultant for mental health service.  Among other issues, they discussed the exciting potential for active duty mental health graduate students to obtain supervised clinical experience within the VA – especially since these future colleagues personally appreciate the nuances of military culture and will themselves eventually become VA beneficiaries (i.e., breaking down historical silos).   Impressively, Give an Hour has already provided over 220,000 hours of free mental health care (valued at over $20 million) to our nation’s active duty personnel, Veterans, and their families.  The Secretary, who is the first non-Veteran to be appointed, has entered into a partnership with HHS to allow the assignment of U.S. Public Health Commissioned Corps members to provide direct patient care to Veterans in VA hospitals and clinics in underserved communities.  Earlier this year, he was instrumental in providing full practice authority for VA advanced practice registered nurses (APRNs) (with the exception of nurse anesthetists) as long as they were working within the scope of their VA employment.

Prescriptive Authority (RxP):  The APA Board of Educational Affairs and CAPP will be establishing a Task Force to Review and Revise the APA Recommended Postdoctoral Education and Training Program in Psychopharmacology for RxP.  The federal system, and particularly DoD, was the critical catalyst for this evolution, affirmatively demonstrating that appropriately trained colleagues could provide safe and quality psychopharmacological care.  Floyd Jennings, USPHS; John Sexton and Morgan Sammons, U.S. Navy; and Debra Dunivin, U.S. Army were among the first prescribing psychologists.  At the time of the adoption of the 2009 APA model curriculum, the consensus was to require postdoctoral training.  Several of the underlying issues to be considered at this point, however, include: * At what level is it appropriate to begin such training and what components of the training can be taken at what level?  * The balance between enough specificity in the required elements of the curriculum to ensure consistent training vs. allowing program flexibility.  And, * The components of the supervised experience.  The Task Force will also explore the similarities and differences in the various enacted RxP state laws.

With the steady movement of psychology towards integrated, team-based care it is my personal view that APA’s new standards should strive to reflect the views of the practicing clinician, actively engage graduate students, and provide training programs with the flexibility to educate interested students throughout their doctoral training.  APA’s original task force on RxP concluded in 1993: “Practitioners with combined training in psychopharmacology and psychosocial treatments can reasonably be viewed as a new form of health care professional, expected to bring to health care delivery the best of both psychological and pharmacological knowledge.”  (Michael Smyer, chair; current APA President Tony Puente, an active participant).  “To be perfect is to change often.”  Aloha,

Pat DeLeon, former APA President – Division 19 – May, 2017

 

 

CHANGE IS THE LAW OF LIFE

Continuing Progress at the State Level:  "On April 3, 2017, Idaho became the fifth state in the nation to allow prescriptive authority to psychologists.  After three years of work by the Idaho Psychological Association, the legislation passed both houses without opposition and with only two nay votes.  How did this happen?  Here are a few of the factors that may have contributed.  * Psychiatrists negotiated with us.  The shortage of prescribers in our state is the worst in the nation and physicians and legislators are aware that the situation is desperate in some rural areas.  The physician chair of the House Health and Welfare committee became convinced by repeated meetings with our soft-spoken lobbyist that the training was rigorous.  We learned that the rest of the medical association was leaning our way.  The main concern of our colleagues in psychiatry was that the training be at least equivalent to that of an advanced practice psychiatric nurse practitioner (NP).  They brought in an experienced NP to vet our training and the language of equivalence is written into the bill.

            "* One of our state universities agreed to put together a two year full-time masters in psychopharmacology program taught through the pharmacy program.  We know that the training offered elsewhere is excellent but we couldn't convince our MD colleagues that it was equivalent to a full-time program.  A full-time training where they could have input tipped the scales for them.

            "* We strongly believe collaboration is best for both patients and practitioners.  We have written it into the law and have an advisory committee of psychologists, physicians and a pharmacist to assist our Board of Psychology on RxP issues.  To move from a conditional certificate to a full certificate, two years of supervised prescribing past the masters is required.  To work with children or the elderly, one of those years must be in that specialty.

            "* Our state association was involved and we received unflagging backing from our members, our Executive Director Deb Katz, our association President Page Haviland, and our lobbyist.  "A link to our full bill is: https:legislature.idaho.gov/wp-content/uploads/sessioninfo/2017/legislation/H0212.pdf.

            "We also have been asked why the most conservative state in the union would pass such a bill.  Our answer is that the legislation is completely non-partisan.  It appeals to liberals, conservatives, even libertarians.  The core idea is that once we demonstrate need and can vouch for rigorous training, it comes down to free-market issues.  Since we can prove that psychologists can prescribe safely, we then ask only that the playing field be level and that we be allowed to prove our worth.  We request no money from the state nor do we ask for any guild protection.  If the market works as it should, in a few years we should be able to demonstrate more practitioners, more widespread service, a movement into rural areas and a better fee structure.

            "One unanticipated outcome:  Three years ago we continuously were asked to define the differences between a psychologist, a psychiatrist and a counselor.  We are not asked that so much anymore.  Psychology appears to have established itself as a group of highly trained professionals looked upon with favor by our legislators.  There are only a few hundred of us in this very rural state.  It is deeply satisfying to see the profession become known and appreciated [Susan Farber, former IPA President]."  An historical note – one of the initial RxP training programs involved the School of Pharmacy at the University of Georgia and Georgia State University faculty, pursuant to the vision of Linda Campbell, former member of the APA Board of Directors, and Cal VanderPlate.  More recently, Judi Steinman at the University of Hawaii at Hilo College of Pharmacy provided RxP training for those in Hawaii and the Pacific Basin.  In addition, Morgan Sammons and Robin Henderson report that the State of Oregon House of Representatives passed their RxP legislation unanimously this spring.  Interdisciplinary collaboration is the future for psychology and for our nation's overall health care system.

            Developments at the Federal Level:  During a recent Give an Hour event, hosted by President Barbara Van Dahlen, USUHS psychology graduate student Elizabeth Belleau met VA Secretary David Shulkin and Harold Kudler, chief consultant for mental health service.  Among other issues, they discussed the exciting potential for active duty mental health graduate students to obtain supervised clinical experience within the VA – especially since these future colleagues personally appreciate the nuances of military culture and will themselves eventually become VA beneficiaries.  HRSA reports that 30 percent of the new hires by Federally Qualified Community Health Centers (FQHCs) over the past two years have been Veterans.  Heather O'Beirne Kelly, APA's Director of Military and Veterans Health Policy – a position created earlier this year by Interim CEO Cynthia Belar and President Tony Puente – recently had the opportunity to present testimony before the U.S. House Appropriations subcommittee with jurisdiction over the VA.

            "The Department of Veterans Affairs (VA) is the largest single employer of psychologists, who work both as research scientists and clinicians committed to improving the lives of our nation's Veterans.  As the largest provider of training for psychologists, the VA also plays a vital role in ensuring that the mental health workforce is equipped to provide culturally competent and integrated mental health services to Veterans and their families."

            "VA psychologists play a dual role in providing care for Veterans and conducting research in all areas of health, including high-priority areas particularly relevant to Veterans, such as: mental health and suicide prevention, traumatic brain injury (TBI), substance abuse, aging-related disorders and physical and psychosocial rehabilitation.  VA psychologists are leaders in providing effective diagnosis and treatment for all mental health, substance use and behavioral health issues.  In addition, VA psychologists often receive specialty training in rehabilitation psychology and/or neuropsychology, which helps to improve assessment, treatment, and research on the many conditions affecting Veterans, including: post-traumatic stress disorder (PTSD), burns, amputation, blindness, spinal cord injuries and polytrauma.  Equally important are the profoundly positive impacts of psychological interventions on the care of Veterans suffering from chronic illnesses such as cancer, cardiovascular disease, HIV and chronic pain."

            Every day 20 Veterans commit suicide which is unquestionably a major public health tragedy that calls for innovative interventions.  Secretary Shulkin has entered into a partnership with the Department of Health and Human Services to allow the assignment of U.S. Public Health Commissioned Corps members to provide direct patient care to Veterans in VA hospitals and clinics in underserved communities.  During her testimony, Heather raised two related issues.  She discussed psychology's historical leadership role in developing and providing telepsychological care (within the VA and the Department of Defense) and she recommended as an innovative strategy for addressing suicides by Veterans through enhancing access, continuity, and integration of care: "Granting specially-trained psychologists prescriptive authority analogous to that granted by the Department of Defense for almost 20 years, which will alleviate mental healthcare access issues."  After her testimony, one of the subcommittee members followed her out of the hearing room and stated that "I want that pilot program."  Will an already prescribing USPHS psychologist be assigned?

            A Vision for the Future:  In his prior position as VA Under Secretary for Health, Secretary Shulkin was instrumental in providing full practice authority for VA advanced practice registered nurses (APRNs) (with the exception of nurse anesthetists) as long as they were working within the scope of their VA employment.  APRNs now can provide care, regardless of historical state or local legal restrictions, without the clinical oversight of a physician.  This includes taking comprehensive histories, providing physical examinations; and diagnosing, treating, and managing patients with acute and chronic illnesses and diseases.  It also allows APRNs to prescribe medications and make appropriate referrals.

            Under the Secretary's leadership, in April of this year the VA announced its top five priorities which included Suicide Prevention – Getting to Zero.  The number two priority was Improving Timeliness, highlighting the potential contributions of telehealth.  The Department reported having established 10 Tele-Mental health hubs and 8 Tele-Primary Care hubs.  Not surprisingly, 45 percent of telehealth services are for rural veterans.  Overall, there were 2.14 million episodes of telehealth care provided to 677,000 Veterans, of which 336,000 were TeleMental health visits.  Under the leadership of Robert Zeiss and now Ken Jones, the VA Office of Academic Affiliations has been providing significant support for psychology post-doctoral training initiatives.  The VA has long fostered internship level training in psychology, with over 675 positions nationally located in 49 states plus Puerto Rico and the District of Columbia.  Post-doctoral training did not truly take off until the 2000-2001 academic year, when the number of funded residency positions expanded from five to 38.  These numbers have grown steadily, with a particularly large increase in 2008-2009, when the positions increased from 117 to 204 in just one year.  Currently, that number stands at approximately 440 annually – covering a wide range of clinical areas, as Heather noted in her testimony.  Psychology is well positioned to capitalize upon, and provide leadership for, the exciting potential for innovation which the proponents of telehealth envision.

            Art Kellermann, Dean of the School of Medicine at USUHS and a member of the National Academy of Medicine (formerly the Institute of Medicine), has similarly called for Embracing Telehealth while Rethinking the U.S.'s Military Health System.  "In deployed settings, the military health system uses telehealth to support health care providers working in small forward operating bases and on ships at sea.  Global teleconferencing allows trauma experts across 12 time zones to regularly meet, discuss complex cases, and identify opportunities to improve.  Despite its success with telehealth overseas, the military health system was slow to adopt it at home due to stringent information security requirements and budgetary constraints.  Section 718 of the NDAA [National Defense Authorization Act] directs the military health system to rapidly expand the use of telehealth in its clinical operations."

            Licensure mobility is critical to the effective use of telehealth services and psychology has been well served by the vision of Steve DeMers, CEO of the Association of State and Provincial Psychology Boards (ASPPB) in establishing their Interjurisdictional Compact (PSYPACT).  Linda Campbell and Fred Millan served as co-chair of the joint APA/ASPPB/APAIT Task Force for Telepsychology Guidelines.  "And those who look only to the past or present are certain to miss the future."  Aloha,

Pat DeLeon, former APA President – Division 29 – May, 2017

 

Sent from my iPhone

Division 29 May column

“CHANGE IS THE LAW OF LIFE”

            Continuing Progress at the State Level:  “On April 3, 2017, Idaho became the fifth state in the nation to allow prescriptive authority to psychologists.  After three years of work by the Idaho Psychological Association, the legislation passed both houses without opposition and with only two nay votes.  How did this happen?  Here are a few of the factors that may have contributed.  * Psychiatrists negotiated with us.  The shortage of prescribers in our state is the worst in the nation and physicians and legislators are aware that the situation is desperate in some rural areas.  The physician chair of the House Health and Welfare committee became convinced by repeated meetings with our soft-spoken lobbyist that the training was rigorous.  We learned that the rest of the medical association was leaning our way.  The main concern of our colleagues in psychiatry was that the training be at least equivalent to that of an advanced practice psychiatric nurse practitioner (NP).  They brought in an experienced NP to vet our training and the language of equivalence is written into the bill.

            “* One of our state universities agreed to put together a two year full-time masters in psychopharmacology program taught through the pharmacy program.  We know that the training offered elsewhere is excellent but we couldn’t convince our MD colleagues that it was equivalent to a full-time program.  A full-time training where they could have input tipped the scales for them.

            “* We strongly believe collaboration is best for both patients and practitioners.  We have written it into the law and have an advisory committee of psychologists, physicians and a pharmacist to assist our Board of Psychology on RxP issues.  To move from a conditional certificate to a full certificate, two years of supervised prescribing past the masters is required.  To work with children or the elderly, one of those years must be in that specialty.

            “* Our state association was involved and we received unflagging backing from our members, our Executive Director Deb Katz, our association President Page Haviland, and our lobbyist.  “A link to our full bill is: https:legislature.idaho.gov/wp-content/uploads/session info/2017/legislation/H0212.pdf.

            “We also have been asked why the most conservative state in the union would pass such a bill.  Our answer is that the legislation is completely non-partisan.  It appeals to liberals, conservatives, even libertarians.  The core idea is that once we demonstrate need and can vouch for rigorous training, it comes down to free-market issues.  Since we can prove that psychologists can prescribe safely, we then ask only that the playing field be level and that we be allowed to prove our worth.  We request no money from the state nor do we ask for any guild protection.  If the market works as it should, in a few years we should be able to demonstrate more practitioners, more widespread service, a movement into rural areas and a better fee structure.

            “One unanticipated outcome:  Three years ago we continuously were asked to define the differences between a psychologist, a psychiatrist and a counselor.  We are not asked that so much anymore.  Psychology appears to have established itself as a group of highly trained professionals looked upon with favor by our legislators.  There are only a few hundred of us in this very rural state.  It is deeply satisfying to see the profession become known and appreciated [Susan Farber, former IPA President].”  An historical note – one of the initial RxP training programs involved the School of Pharmacy at the University of Georgia and Georgia State University faculty, pursuant to the vision of Linda Campbell, former member of the APA Board of Directors, and Cal VanderPlate.  More recently, Judi Steinman at the University of Hawaii at Hilo College of Pharmacy provided RxP training for those in Hawaii and the Pacific Basin.  In addition, Morgan Sammons and Robin Henderson report that the State of Oregon House of Representatives passed their RxP legislation unanimously this spring.  Interdisciplinary collaboration is the future for psychology and for our nation’s overall health care system.

            Developments at the Federal Level:  During a recent Give an Hour event, hosted by President Barbara Van Dahlen, USUHS psychology graduate student Elizabeth Belleau met VA Secretary David Shulkin and Harold Kudler, chief consultant for mental health service.  Among other issues, they discussed the exciting potential for active duty mental health graduate students to obtain supervised clinical experience within the VA – especially since these future colleagues personally appreciate the nuances of military culture and will themselves eventually become VA beneficiaries.  HRSA reports that 30 percent of the new hires by Federally Qualified Community Health Centers (FQHCs) over the past two years have been Veterans.  Heather O’Beirne Kelly, APA’s Director of Military and Veterans Health Policy – a position created earlier this year by Interim CEO Cynthia Belar and President Tony Puente – recently had the opportunity to present testimony before the U.S. House Appropriations subcommittee with jurisdiction over the VA.

            “The Department of Veterans Affairs (VA) is the largest single employer of psychologists, who work both as research scientists and clinicians committed to improving the lives of our nation’s Veterans.  As the largest provider of training for psychologists, the VA also plays a vital role in ensuring that the mental health workforce is equipped to provide culturally competent and integrated mental health services to Veterans and their families.”

            “VA psychologists play a dual role in providing care for Veterans and conducting research in all areas of health, including high-priority areas particularly relevant to Veterans, such as: mental health and suicide prevention, traumatic brain injury (TBI), substance abuse, aging-related disorders and physical and psychosocial rehabilitation.  VA psychologists are leaders in providing effective diagnosis and treatment for all mental health, substance use and behavioral health issues.  In addition, VA psychologists often receive specialty training in rehabilitation psychology and/or neuropsychology, which helps to improve assessment, treatment, and research on the many conditions affecting Veterans, including: post-traumatic stress disorder (PTSD), burns, amputation, blindness, spinal cord injuries and polytrauma.  Equally important are the profoundly positive impacts of psychological interventions on the care of Veterans suffering from chronic illnesses such as cancer, cardiovascular disease, HIV and chronic pain.”

            Every day 20 Veterans commit suicide which is unquestionably a major public health tragedy that calls for innovative interventions.  Secretary Shulkin has entered into a partnership with the Department of Health and Human Services to allow the assignment of U.S. Public Health Commissioned Corps members to provide direct patient care to Veterans in VA hospitals and clinics in underserved communities.  During her testimony, Heather raised two related issues.  She discussed psychology’s historical leadership role in developing and providing telepsychological care (within the VA and the Department of Defense) and she recommended as an innovative strategy for addressing suicides by Veterans through enhancing access, continuity, and integration of care: “Granting specially-trained psychologists prescriptive authority analogous to that granted by the Department of Defense for almost 20 years, which will alleviate mental healthcare access issues.”  After her testimony, one of the subcommittee members followed her out of the hearing room and stated that “I want that pilot program.”  Will an already prescribing USPHS psychologist be assigned?

            A Vision for the Future:  In his prior position as VA Under Secretary for Health, Secretary Shulkin was instrumental in providing full practice authority for VA advanced practice registered nurses (APRNs) (with the exception of nurse anesthetists) as long as they were working within the scope of their VA employment.  APRNs now can provide care, regardless of historical state or local legal restrictions, without the clinical oversight of a physician.  This includes taking comprehensive histories, providing physical examinations; and diagnosing, treating, and managing patients with acute and chronic illnesses and diseases.  It also allows APRNs to prescribe medications and make appropriate referrals.

            Under the Secretary’s leadership, in April of this year the VA announced its top five priorities which included Suicide Prevention – Getting to Zero.  The number two priority was Improving Timeliness, highlighting the potential contributions of telehealth.  The Department reported having established 10 Tele-Mental health hubs and 8 Tele-Primary Care hubs.  Not surprisingly, 45 percent of telehealth services are for rural veterans.  Overall, there were 2.14 million episodes of telehealth care provided to 677,000 Veterans, of which 336,000 were TeleMental health visits.  Under the leadership of Robert Zeiss and now Ken Jones, the VA Office of Academic Affiliations has been providing significant support for psychology post-doctoral training initiatives.  The VA has long fostered internship level training in psychology, with over 675 positions nationally located in 49 states plus Puerto Rico and the District of Columbia.  Post-doctoral training did not truly take off until the 2000-2001 academic year, when the number of funded residency positions expanded from five to 38.  These numbers have grown steadily, with a particularly large increase in 2008-2009, when the positions increased from 117 to 204 in just one year.  Currently, that number stands at approximately 440 annually – covering a wide range of clinical areas, as Heather noted in her testimony.  Psychology is well positioned to capitalize upon, and provide leadership for, the exciting potential for innovation which the proponents of telehealth envision.

            Art Kellermann, Dean of the School of Medicine at USUHS and a member of the National Academy of Medicine (formerly the Institute of Medicine), has similarly called for Embracing Telehealth while Rethinking the U.S.’s Military Health System.  “In deployed settings, the military health system uses telehealth to support health care providers working in small forward operating bases and on ships at sea.  Global teleconferencing allows trauma experts across 12 time zones to regularly meet, discuss complex cases, and identify opportunities to improve.  Despite its success with telehealth overseas, the military health system was slow to adopt it at home due to stringent information security requirements and budgetary constraints.  Section 718 of the NDAA [National Defense Authorization Act] directs the military health system to rapidly expand the use of telehealth in its clinical operations.”

            Licensure mobility is critical to the effective use of telehealth services and psychology has been well served by the vision of Steve DeMers, CEO of the Association of State and Provincial Psychology Boards (ASPPB) in establishing their Interjurisdictional Compact (PSYPACT).  Linda Campbell and Fred Millan served as co-chair of the joint APA/ASPPB/APAIT Task Force for Telepsychology Guidelines.  “And those who look only to the past or present are certain to miss the future.”  Aloha,

Pat DeLeon, former APA President – Division 29 – May, 2017

 

I AM A ROCK – I AM AN ISLAND

The APA and APA Practice Organization Practice Leadership Conference (PLC):  One knows that spring has arrived in our nation's Capital when the talk of the town becomes the annual cherry blossom festival, perhaps the last snow storm of the year, and the APAPO state leadership conference, which is always the highlight of my APA year.  Renamed this year as PLC, over 400 colleagues enthusiastically attended "Practice, Politics & Policy."  HPA President-Elect Tanya Gamby led the Hawaii delegation, with executive director Ray Folen actively attempting to herd the crew to their various scheduled venues.  Once again, Dan Abrahamson and Susie Lazaroff did an outstanding job and it was particularly nice to have Congressman Tim Murphy (R-PA), who is a psychologist, honored for his outstanding contributions to our nation's mental health and substance abuse programs.

            APA President Tony Puente and President-Elect Jessica Henderson Daniel were ever-present, as was former HPA President Kate Brown now serving as Chair of CAPP.  At PLC we learned that Kate's fellow CAPP member, June Ching, will soon join the National Register Board of Directors.  Personally, I particularly appreciated Tony Puente's efforts to actively engage those early career psychologists and graduate students who were present in shaping the future of their profession.  Sybil Mallonee (1^st Lt., USA) is a graduate student at USUHS: "As a student attending the APA's Practice Leadership Conference for the first time, it was an amazing and exciting experience.  It was amazing seeing so many clinicians from all stages in their career come together to advocate for our field.  It was exciting to have the opportunity to be mentored by so many incredible clinicians who were eager to pass on their knowledge to the upcoming generation of psychologists.  It was also exciting to see such an emphasis on the importance of diversity and on having the sometimes challenging conversations around issues related to diversity.  There were many great speakers throughout the conference, but the one that stands out the most was the diversity panel.  This panel was of psychologists sharing challenging conversations and experiences related to diversity.  In keeping with the theme of the conference as a whole, their stories were inspiring to this future psychologist.  They were honest and challenging, but they also emphasized the importance of not losing your voice and of standing up for what is right."

            Katherine Nordal was most impressive in crystalizing the notion of promoting psychologists by advancing the trade of professional psychology – truly a new message for a number of our colleagues – and by each of us contributing to our Political Action Committee (PAC).  Today, the national psychology PAC ranks 44^th among 129 health professional PACs with dentistry, medicine, optometry, nursing, physical therapy, podiatry, social work, and psychiatry significantly ahead of us.  I would rhetorically ask: What percent of the membership has contributed to HPA's PAC?

            Hawaii psychologists are very fortunate in that our state has long possessed a Congressional delegation which truly appreciates the value of psychological care.  Kathy McNamara describing one of her recent Hill visits: "While in Washington in September for Hill meetings, I had an opportunity to meet with our Senator Mazie Hirono.  She voiced her absolute support of efforts to improve access to quality mental health care.  While I appreciated the Senator's statement of support, I appreciated even more the time she then took to stay in a conversation with me, sharing about her childhood in Japan, with a fond memory of being with her mother and eating persimmons (a reference to our persimmons season in Hawaii!).  Among other personal aspects of her background, she proudly mentioned that her undergraduate major was Psychology, so her interest in psychological services has been long-standing.  What a gracious, competent, and compassionate side of Senator Hirono was evident in this visit."

The Prescribing Psychologist (RxP) Evolution:  At PLC there were a number of interesting informal discussions following up on the success of Bethe Lonning and her colleagues in Iowa in having their RxP legislation enacted into public law.  The Connecticut Psychological Association (CPA) RxP Task Force just completed a survey of 900 licensed psychologists in their state and found that 70 percent supported RxP for properly trained psychologists (Anne Klee and Barbara Bunk).  Robin Henderson noted that RxP is once again alive in Oregon – this time being advocated for by non-psychologists.  Recall that in 2010 their legislation was vetoed by the Governor.  Beth Rom-Rymer is pleased with the progress they are making in Illinois in implementing their law.

All the proposed RxP legislative bills have referenced graduates taking a nationally recognized exam.  The Psychopharmacology Examination for Psychologists (PEP) exam is in the process of being transferred from the APA Practice Organization to ASPPB, with the original PEP examination remaining available to candidates until March 30, 2017.  This January, ASPPB, which has been intimately involved from the very beginning, issued a broad call for volunteers to assist in developing the new version of the national exam.  "An exam of this nature requires periodic updates to ensure that it continues to assess current knowledge required for competent practice."  With change comes opportunity; perhaps the time has come for APA to embrace pre-doctoral training rather than exclusively focusing upon post-doctoral models.  Beth's vision of a vibrant state with undergraduates, graduate students, and practicing psychologists working towards becoming prescribing psychologists, working in concert with Illinois' largest social service organizations, NAMI, the prison system, Illinois's largest academic and research medical institutions, major medical centers, and smaller community hospitals is coming to fruition.

In reviewing some of the statements made on the floor of the Hawaii State Legislature in opposition to Hawaii's RxP legislation, I could not help but reflect that these are not uncommon views being said in other states.  They present an opportunity for psychologists to do more and particularly to personally meet with their own local elected officials to discuss how rigorous their doctoral training was.  The essence of several of the statements is that those licensed psychologists who are pursuing RxP are "public health hazards" who would affirmatively harm their patients.  "One of the basic concerns we had last year, when the bill was killed, was safety.  We have, I believe, inadequate basic education amongst some of these people who will be prescribing medication.  Many of the people do not have basic science education.  Some of these people come from private universities which have very low entrance requirements."  "I'll be voting no on this measure, because we are playing games with people's health….  And I believe that they are not qualified to do it, and because of that, and in the interest of being cautious, we should, I am voting no on this measure."  One can reasonably agree or disagree on the RxP agenda.  One could also argue that when non-physicians, such as Advanced Practice Registered Nurses (APRNs) and Clinical Pharmacists, are actively engaged in the prescriptive process, more appropriate and more judicious use of medications is the result; that is, an overall higher quality of health care is provided.  "As of today, Hawaii's SB 384 has made it through crossover and is being heard in the House Health Committee this Thursday.  We're still alive!" [Jill Oliveira Gray].

Earlier this year South Dakota became the 22^nd state in the nation, plus the District of Columbia, to have Full Practice Authority for Nurse Practitioners.  In January, the Department of Veterans Affairs (VA), utilizing its federal preemption authority, issued regulations granting Full Practice Authority for APRNs (other than nurse anesthetists) regardless of State or local law restrictions, when the APRN is working within the scope of their VA employment.  This authority includes providing diagnosis and treatment of health or illness states, disease management, health promotion; and prevention of illness and risk behaviors among individuals, families, groups, and communities.  It also expressly authorizes prescribing medication and durable medical equipment.  "And a rock feels no pain.  And an island never cries."  Aloha,

Pat DeLeon, former APA President – HPA – March, 2017

Sent from my iPhone

HPA - Spring column

“I AM A ROCK – I AM AN ISLAND”

            The APA and APA Practice Organization Practice Leadership Conference (PLC):  One knows that spring has arrived in our nation’s Capital when the talk of the town becomes the annual cherry blossom festival, perhaps the last snow storm of the year, and the APAPO state leadership conference, which is always the highlight of my APA year.  Renamed this year as PLC, over 400 colleagues enthusiastically attended “Practice, Politics & Policy.”  HPA President-Elect Tanya Gamby led the Hawaii delegation, with executive director Ray Folen actively attempting to herd the crew to their various scheduled venues.  Once again, Dan Abrahamson and Susie Lazaroff did an outstanding job and it was particularly nice to have Congressman Tim Murphy (R-PA), who is a psychologist, honored for his outstanding contributions to our nation’s mental health and substance abuse programs.

            APA President Tony Puente and President-Elect Jessica Henderson Daniel were ever-present, as was former HPA President Kate Brown now serving as Chair of CAPP.  At PLC we learned that Kate’s fellow CAPP member, June Ching, will soon join the National Register Board of Directors.  Personally, I particularly appreciated Tony Puente’s efforts to actively engage those early career psychologists and graduate students who were present in shaping the future of their profession.  Sybil Mallonee (1^st Lt., USA) is a graduate student at USUHS: “As a student attending the APA’s Practice Leadership Conference for the first time, it was an amazing and exciting experience.  It was amazing seeing so many clinicians from all stages in their career come together to advocate for our field.  It was exciting to have the opportunity to be mentored by so many incredible clinicians who were eager to pass on their knowledge to the upcoming generation of psychologists.  It was also exciting to see such an emphasis on the importance of diversity and on having the sometimes challenging conversations around issues related to diversity.  There were many great speakers throughout the conference, but the one that stands out the most was the diversity panel.  This panel was of psychologists sharing challenging conversations and experiences related to diversity.  In keeping with the theme of the conference as a whole, their stories were inspiring to this future psychologist.  They were honest and challenging, but they also emphasized the importance of not losing your voice and of standing up for what is right.”

            Katherine Nordal was most impressive in crystalizing the notion of promoting psychologists by advancing the trade of professional psychology – truly a new message for a number of our colleagues – and by each of us contributing to our Political Action Committee (PAC).  Today, the national psychology PAC ranks 44^th among 129 health professional PACs with dentistry, medicine, optometry, nursing, physical therapy, podiatry, social work, and psychiatry significantly ahead of us.  I would rhetorically ask: What percent of the membership has contributed to HPA’s PAC?

            Hawaii psychologists are very fortunate in that our state has long possessed a Congressional delegation which truly appreciates the value of psychological care.  Kathy McNamara describing one of her recent Hill visits: “While in Washington in September for Hill meetings, I had an opportunity to meet with our Senator Mazie Hirono.  She voiced her absolute support of efforts to improve access to quality mental health care.  While I appreciated the Senator’s statement of support, I appreciated even more the time she then took to stay in a conversation with me, sharing about her childhood in Japan, with a fond memory of being with her mother and eating persimmons (a reference to our persimmons season in Hawaii!).  Among other personal aspects of her background, she proudly mentioned that her undergraduate major was Psychology, so her interest in psychological services has been long-standing.  What a gracious, competent, and compassionate side of Senator Hirono was evident in this visit.”

The Prescribing Psychologist (RxP) Evolution:  At PLC there were a number of interesting informal discussions following up on the success of Bethe Lonning and her colleagues in Iowa in having their RxP legislation enacted into public law.  The Connecticut Psychological Association (CPA) RxP Task Force just completed a survey of 900 licensed psychologists in their state and found that 70 percent supported RxP for properly trained psychologists (Anne Klee and Barbara Bunk).  Robin Henderson noted that RxP is once again alive in Oregon – this time being advocated for by non-psychologists.  Recall that in 2010 their legislation was vetoed by the Governor.  Beth Rom-Rymer is pleased with the progress they are making in Illinois in implementing their law.

All the proposed RxP legislative bills have referenced graduates taking a nationally recognized exam.  The Psychopharmacology Examination for Psychologists (PEP) exam is in the process of being transferred from the APA Practice Organization to ASPPB, with the original PEP examination remaining available to candidates until March 30, 2017.  This January, ASPPB, which has been intimately involved from the very beginning, issued a broad call for volunteers to assist in developing the new version of the national exam.  “An exam of this nature requires periodic updates to ensure that it continues to assess current knowledge required for competent practice.”  With change comes opportunity; perhaps the time has come for APA to embrace pre-doctoral training rather than exclusively focusing upon post-doctoral models.  Beth’s vision of a vibrant state with undergraduates, graduate students, and practicing psychologists working towards becoming prescribing psychologists, working in concert with Illinois’ largest social service organizations, NAMI, the prison system, Illinois’s largest academic and research medical institutions, major medical centers, and smaller community hospitals is coming to fruition.

In reviewing some of the statements made on the floor of the Hawaii State Legislature in opposition to Hawaii’s RxP legislation, I could not help but reflect that these are not uncommon views being said in other states.  They present an opportunity for psychologists to do more and particularly to personally meet with their own local elected officials to discuss how rigorous their doctoral training was.  The essence of several of the statements is that those licensed psychologists who are pursuing RxP are “public health hazards” who would affirmatively harm their patients.  “One of the basic concerns we had last year, when the bill was killed, was safety.  We have, I believe, inadequate basic education amongst some of these people who will be prescribing medication.  Many of the people do not have basic science education.  Some of these people come from private universities which have very low entrance requirements.”  “I’ll be voting no on this measure, because we are playing games with people’s health….  And I believe that they are not qualified to do it, and because of that, and in the interest of being cautious, we should, I am voting no on this measure.”  One can reasonably agree or disagree on the RxP agenda.  One could also argue that when non-physicians, such as Advanced Practice Registered Nurses (APRNs) and Clinical Pharmacists, are actively engaged in the prescriptive process, more appropriate and more judicious use of medications is the result; that is, an overall higher quality of health care is provided.  “As of today, Hawaii’s SB 384 has made it through crossover and is being heard in the House Health Committee this Thursday.  We’re still alive!” [Jill Oliveira Gray].

Earlier this year South Dakota became the 22^nd state in the nation, plus the District of Columbia, to have Full Practice Authority for Nurse Practitioners.  In January, the Department of Veterans Affairs (VA), utilizing its federal preemption authority, issued regulations granting Full Practice Authority for APRNs (other than nurse anesthetists) regardless of State or local law restrictions, when the APRN is working within the scope of their VA employment.  This authority includes providing diagnosis and treatment of health or illness states, disease management, health promotion; and prevention of illness and risk behaviors among individuals, families, groups, and communities.  It also expressly authorizes prescribing medication and durable medical equipment.  “And a rock feels no pain.  And an island never cries.”  Aloha,

Pat DeLeon, former APA President – HPA – March, 2017

 

Division 55 spring column

“COME ON AND HEAR!  COME ON AND HEAR!”

            The 34^th Annual APA and Practice Leadership Conference (PLC):  As always, the APA and Practice Organization’s State Leadership Conference (SLC), this year renamed the Practice Leadership Conference (PLC), was an outstanding success.  Dan Abrahamson and Susie Lazaroff were truly visionary in crafting the agenda for “Practice, Politics & Policy.”  Former Administration and Hill operatives provided an insightful glimpse into the new Trump Administration and what psychology’s practitioners might well face over the next four years.  One could feel a growing sense of urgency among those present for getting personally involved in shaping the future of our nation’s health care environment and especially for ensuring that psychology remains recognized as a bona fide autonomous health care profession.  Having worked on the U.S. Senate staff for over 38 years, I particularly appreciated Katherine Nordal’s challenge to advance the trade of professional psychology – a conceptually different approach than many have heard before.  She also noted that the psychology PAC currently ranks 44^th among 129 health professional PACs with dentistry, medicine, optometry, nursing, physical therapy, podiatry, social work, and psychiatry significantly ahead of us.

            APA President Tony Puente and President-Elect Jessica Henderson Daniel were constantly mingling among the 400+ attendees at PLC, urging colleagues to appreciate that the future of their profession lies in their own hands.  Once again, the number of first-time attendees was most impressive.  Our national leadership was especially attentive to the early career psychologists and graduate students who were present.  Division 55 should be proud that under the leadership of Presidents Neal Morris and now Sean Evers, USUHS graduate students Joanna Sells and Omni Cassidy have been actively engaged in shaping our Division’s annual convention programming.  As Dan Abrahamson reflected afterwards: “If we can’t support the future of our profession, we are done for….”

Sybil Mallonee (1^st Lt., USA) is a graduate student at USUHS: “As a student attending the APA’s Practice Leadership Conference for the first time, it was an amazing and exciting experience.  It was amazing seeing so many clinicians from all stages in their career come together to advocate for our field.  It was exciting to have the opportunity to be mentored by so many incredible clinicians who were eager to pass on their knowledge to the upcoming generation of psychologists.  It was also exciting to see such an emphasis on the importance of diversity and on having the sometimes challenging conversations around issues related to diversity.  There were many great speakers throughout the conference, but the one that stands out the most was the diversity panel.  This panel was of psychologists sharing challenging conversations and experiences related to diversity.  In keeping with the theme of the conference as a whole, their stories were inspiring to this future psychologist.  They were honest and challenging, but they also emphasized the importance of not losing your voice and of standing up for what is right.”

            Psychology Proudly Serving the Nation:  Cynthia Belar, Interim APA CEO, recently reported to the Council of Representatives: “Dr. Heather O’Beirne Kelly is now APA’s first Director of Veterans and Military Health Policy.  Dr. Kelly has served as a Senior Legislative & Federal Affairs Officer for the past 19 years in APA’s Science Directorate, where she has led our association efforts to address military and veteran issues and to promote the role of psychology in tackling those issues.  In her new role Dr. Kelly will join Practice’s government relations office, headed by Doug Walter, J.D., and she will work across directorates to ensure that the range of military and veteran issues are addressed.  One out of every six Americans is either a military service member, veteran, or family member of someone serving or having served in the U.S. armed forces.  APA has a long history of attending to the health and well-being of these populations, and the VA is the largest single employer of psychologists.  We believe that in this new role, Dr. Kelly will enhance our advocacy and work to better serve our service members, veterans, and the psychologists who care for them.”  As many of us aware, Heather has been working closely with the Division to expand psychology’s RxP capabilities throughout the federal system, including within the VA.

            On Veterans’ Day 2016, a long-time friend, Kris Ludwigsen shared her reflections with her local congregation on her personal service in the USAF.  “Today I would like to focus on the women who’ve volunteered to serve in the military.  I am a veteran of Desert Storm and my father was torpedoed in the Navy in WWII.  A Scottish ancestor, Daniel McClure, fought in the American Revolution at the battle of Ft. Vincennes, and 200 years later I went on active duty in the USAF.  We all survived the dangers of our tours of duty in the Army, Navy, and Air Force.

“Women of verve formed a militia of ‘minutemen,’ or stepped up as spies for the American Revolution.  In the Civil War they disguised themselves as men to fight with their husbands.  While Rosie went to work building battleships and bombers to backfill positions vacated by men, in WWII the WASPs flew hundreds of missions over some 64,000 miles; yet they were only granted veterans’ status in 1977.  In the wake of the WACs (1943) and the WAVES (1944) came the Army nurses tending the wounded in Viet Nam and the women of the National Guard who were deployed to grunt work and combat in Iraq and Afghanistan.

            “Why would a woman choose to join the military?  Some volunteer out of a desire to serve their country or family tradition, the same as a man.  Some join for adventure or travel, to be exposed to a broader view of the world.  Some join for financial independence and a structure that makes it possible to leave home or support children on their own.  Some sign up for training and educational opportunities.  For me it was the professional experience.  Teaching in a university and rubbing elbows with part-time instructors who were active duty psychologists at Wright-Patterson AFB, I wanted the immersion clinical experience the Air Force provided.

            “The military is a microcosm of society that includes physicians and nurses, social workers and psychologists, dentists and dieticians, attorneys and chaplains – as well as missile launchers and those fighting on the front lines.  It is a milieu with valuable lessons to teach.  The military is about learning responsibility and reliability, resourcefulness, leadership and teamwork with pride in an esprit de corps.  It is about courage under fire, proving yourself as an adult without the support of family, and about submerging your ego to the mission, to the common objective.

            “As the first military psychologist at an 18-bed hospital, I had an advantage in that no one really knew what a psychologist did.  So I was able to create my own job description that included meeting with the squadron commander or first sergeant to explain the dynamics that had resulted in the member’s problem behavior, often the precursor to discharge.  After assessment and treatment my goal was to integrate the member back into the squadron to salvage his or her Air Force career.  When a stream of young women from Dugway Army Proving Ground was admitted, I decided to investigate the cause, and drove out to the desert once a month to run an enlisted women’s morale group.  In such isolated surroundings, these women were being harassed by their male counterparts, resulting in acute stress disorder symptoms that precluded functioning on the job; and I worked with the company commander who had them transferred out of a hostile work environment. 

            “The transition back to civilian life is not easy; war time separations foster family problems difficult to repair.  Many Vets have suffered the toxic effects of Agent Orange or symptoms of post-traumatic stress disorder as I found working with retirees who’d served in Viet Nam, and with a nurse-friend who endured SCUD missile attacks in Desert Storm.  We must do more to help support Vets whose special needs originate from having given their all, for Service Beyond Self.  I went in as a Captain and retired as a Lieutenant Colonel line officer some 25 years later.  The Air Force was the most creative and exciting period of my 35-year career as a psychologist.  As a ‘lone ranger’ I learned that if I didn’t do it, it wasn’t going to get done.  I had to establish priorities for treatment and I had to grasp what it was like to be in the shoes of the diverse members of this military community.  In my time I met a number of men and women who earned my respect as true public servants, dedicated to the highest aims.  Remembering our Vets and those who continue to serve us in the military is our duty and professional responsibility.”

            The Future of Advanced Practice Nursing:  The Robert Wood Johnson Foundation (RWJ) has released its report Charting Nursing’s Future highlighting the progress our 350,000 APRN colleagues have made in obtaining full practice authority.  Twenty-two states and the District of Columbia allow APRNs to practice to the full extent of their education and training.  Final VA regulations, citing federal preemption authority, authorize its 5,825 APRNs (excluding nurse anesthetists) to follow national practice guidelines covering basic prescriptive authority, admissions; and eliminate previous physician supervision requirements, notwithstanding more restrictive state or local laws.  “It’s the best band in the land!”  Aloha,

Pat DeLeon, former APA President – Division 55 – March, 2017