Psychotherapy Bulletin

Psychotherapy Bulletin

Author’s Note: Dr. Pat DeLeon is a former APA President who served in 2000.

A Gradually Maturing Foundation

When the Final Report of the APA Ad-Hoc Task Force on Psychopharmacology, chaired by Michael Smyer, was submitted to the Council of Representatives in November, 1992 it anticipated that: “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. The contributions of this new form of psychopharmacological intervention have the potential to improve dramatically patient care and make important new advances in treatment.” Interestingly, Anita Brown, who was one of the staff liaisons, eventually joined the U.S. Army in order to become one of the first 10 military prescribing psychologists.

Training/Policy

The Task Force developed its recommendations within a framework of three levels of training and practice in psychopharmacology: *Basic Psychopharmacology Education; *Collaborative Practice; and *Prescription Privileges (RxP). Collaborative Practice (Level 2) training requires a doctoral degree and reflects the knowledge base necessary to participate collaboratively with other health care professionals in managing medications prescribed for mental disorders and integrating these medications with psychosocial treatment. Training at this level includes more in-depth knowledge of psychoactive medications and drugs of abuse, as well as knowledge of psychodiagnosis, physical assessment, pathophysiology, therapeutics, emergency treatments, substance abuse treatments, developmental psychopharmacology, and psychopharmacology research. Training for collaborative practice competence includes coursework, practica, and internship experiences. From our policy frame of reference, this would provide the necessary training for a psychologist to “functionally prescribe” in conjunction with an appropriately licensed health care provider, such as a primary care provider, Advanced Practice Nurse, or psychiatrist, which would be similar to the role that clinical pharmacists are increasingly adopting today.

Administrative/Implementation

Bob McGrath, Director of the M.S. Program in Clinical Psychopharmacology and Certificate Program in Integrated Primary Care at Fairleigh Dickinson University, provided a listing of the 16 state psychology licensing boards which have formally addressed this evolution, focusing upon “the best interest of the client/patient.” California, for example, notes—“There are many psychological conditions which manifest themselves in physical symptoms. There are physical problems which have psychological symptoms as well. The best interests of the patient demand that psychologists work closely with primary care physicians and psychiatrists who are prescribing medications to the patient of the psychologist. While a psychologist’s responsibility may include involvement in limited aspects of a patient’s medications, the patient’s physician is the only person who may lawfully prescribe and dispense the medication for the patient [August, 1998].” District of Columbia – “A psychologist may offer a medication recommendation to the prescribing physician about a patient he or she has evaluated when such recommendation is within the boundaries of his or her competence based on his or her education, training, supervised experience, or appropriate professional experience. It is then incumbent on the physician, based upon all of the evidence before him or her, which may include the recommendations of the psychologist, to decide what, if any, medication or medical treatment to prescribe [May, 1998].” Florida – “A Florida licensed psychologist may make recommendations for medications to physicians, including psychiatrists, as well as to other health care professionals, who are granted the authority to prescribe medications [July, 1998].” Prior to the enactment of their RxP law in May, 2004, Louisiana – “It is within the scope of practice of psychology to gain competence in the field of psychopharmacology. Psychologists who gain competence in psychopharmacology may provide consultations to professionals regarding psychotropic medications [July, 1999].” The other states which Bob referenced are: Maine, Maryland, Massachusetts, Missouri, New Hampshire, New Jersey, New York, Ohio, Oklahoma, Tennessee, Texas, and Vermont. We would be interested in learning of similar developments in other states and public/semi-public systems such as Federally Qualified Community Health Centers and state mental health programs. This can be surprisingly controversial for some of our colleagues, as I learned in addressing the Pennsylvania Psychological Association. However, in case there is any question as to whether in-depth knowledge of medications is valued by our nation’s health care system, the U.S. Department of Labor reports that, among workers employed in health care occupations (not including doctors and dentists, many of whom are self-employed), the nation’s 266,410 pharmacists had the highest average wages—$104,260—in May 2008. And, with over 2.5 million people employed as registered nurses, that occupation is the largest among all health care occupations. Registered nurses’ wages are typically the highest of occupations with employment numbered in the millions (including occupations not related to health care).

Visionary Leadership Within the VA

“Since it began offering paid postdoctoral fellowship positions in 1994 (with eight positions across the nation), VA’s Office of Academic Affiliations has continued to emphasize the importance of postdoctoral education by continuing to increase the number of available positions. By the 2013-14 academic year, the number of postdoctoral fellowship positions increased to 348 located at 62 different VA facilities in the U.S. and Puerto Rico. In addition to the general clinical psychology fellowships, many of these positions now are in specialty areas such as neuropsychology and rehabilitation psychology, while others include emphasis areas that incorporate Geropsychology, HCV & HIV Treatment, Health Psychology with an emphasis on Primary Care-Mental Health Integration, PTSD & Trauma Treatment, Psychosocial Rehabilitation and Recovery, and Women Veteran’s Needs. The number of positions should be even larger for the 2014-15 year” [Bob Zeiss, VA Office of Academic Affiliations, retired].

The senior nursing leadership within the VA recently proposed a national scope of practice such that individual state nursing practice acts would not limit their ability to provide quality care. As might have been expected, there was “push back” from medicine alleging a “public health hazard,” specifically focusing upon whether nurse anesthetists (CRNAs) should be supervised by anesthesiologists (various state statutes differ on this requirement). Ken Pope reports that more than 60 physician groups have expressed “strong concerns” that this would effectively eliminate physician-led, team-based care within the VHA. Excerpts from Secretary Shinseki’s response to interested Members of Congress: “VHA is proposing the authorization of full practice by CRNAs across the Department of Veterans Affairs (VA) health care system. This policy change will enable all VA CRNAs, not just those for whom the states currently allow, to practice to the full scope of their academic preparation and training. The policy will increase access to care and ensure continuation of the highest quality of care for our Nation’s Veterans, and help meet the growing demands for health care services nationwide while standardizing the scope of practice for CRNAs across VA’s health care system.

“CRNAs safely administer more than 34 million anesthetics each year to patients in the United States… using all anesthetic techniques and practicing in every possible setting. Over time, CRNAs have compiled a strong record of safety. That safety record is unchanged whether the anesthesia is provided by a CRNA working independently or by a CRNA working under the supervision of a physician. The available evidence does not substantiate that independent CRNA practice presents a threat to health and safety or in any way lowers the quality of anesthesia care…. Taking into account differences in patient and procedure complexity, the study revealed that patient outcomes did not differ between the states that did not require physician supervision and states that did…. Both studies confirmed that there were no measureable differences in quality of care or patient outcomes when anesthesia services were provided by CRNAs, Anesthesiologists, or CRNAs supervised by physicians. Current VHA policy recommends that CRNAs and Anesthesiologists work together in a care team model but does not require physician supervision of CRNAs. The proposed policy supports this team-based model of care that will fully utilize the knowledge, skills, and abilities of CRNAs. As a member of the anesthesia team, CRNAs will be able to lead anesthesia teams, consult with their physician colleagues, and will receive the same professional practice review, evaluation, and monitoring as all other anesthesia providers…. The overarching goal of VHA is to provide safe, effective and timely health care. The Undersecretary for Health is aware there are differing views with regard to physician supervision of CRNAs. To that end, VHA will engage in a rulemaking process which will afford all interested parties the opportunity to comment on the proposed policy change.”

The Institute of Medicine (IOM)

The National Academy of Sciences (NAS) recently celebrated its 150th anniversary, having been chartered by President Abraham Lincoln in 1863 to “investigate, examine, experiment, and report upon any subject of science.” In 1970 the IOM was established by the NAS to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. APA’s CEO Norman Anderson was recently elected to this distinguished body. One of the hallmarks of President Obama’s landmark Patient Protection and Affordable Care Act (ACA) is an increasing emphasis on provider accountability and data-based decision making. Another is fostering interdisciplinary collaboration within integrated systems of care. Not surprisingly, members of the IOM, in their other capacities, have been instrumental in drafting and implementing the ACA.

This winter the IOM requested nominations for a forthcoming Consensus Study on “Psychological Testing including Symptom Validity Testing (SVT).” The committee will consist of 12 members with the three underlying objectives: *Perform a comprehensive review of psychological testing, including SVT (with emphasis on the MMPI-2, TOMM, Malingering Probability Scale, Structured Interview of reported Symptoms, Validity Indicator Profile, Structured Inventory of Malingered Symptomatology, the Rey’s 15-Item-Test (FIT), and Portland Digit Recognition Test. *Determine the relevance of psychological testing, including the SVT, to disability determinations in claims involving physical or mental disorders; and *Provide guidance to help adjudicators interpret the results of psychological testing, including SVT. The study is being sponsored by the Social Security Administration with the goal of addressing and improving the agency’s policies and processes related to disability claims. Experts in fields such as neuropsychology, psychiatry, psychology, cognitive rehabilitation, health care cost/benefit analysis, and health service systems are being sought. The committee will be exploring multiple questions under six subgroups: *Use of Psychological Testing, including SVT; *Testing Norms; *Qualifications for Administration of Psychological Testing, including SVT; *Administration of SVT Testing, including SVT; *Reporting Results; and *Use of Psychological Testing, including SVT, in the Disability Evaluation process.

Our Colleagues in Nursing and Pharmacy have long appreciated the importance of the IOM’s deliberations to the quality of health care provided in our nation and to their professions’ future. At the Uniformed Services University of the Health Sciences (DoD), I enjoy teaching a small health policy class for nursing and psychology graduate students. “Since the launch of the IOM in 1970, nurses have been members of the IOM with an even greater number having served on IOM boards, committees, forums, and roundtables. Since 1973, when the IOM began serving as the National Program Office for the Robert Wood Johnson Foundation (RWJ) Health Policy Fellows initiative, nurses have been part of this interdisciplinary program to participate in health policy formulation at the highest levels of government.

“Since 1992 the IOM has hosted the Distinguished Nurse Scholar-in-Residence program. Supported by the American Academy of Nursing, the American Nurses Foundation, and the American Nurses Association, this residential program has been supporting nurse leaders in playing a more prominent role in health policy development at the national level through a 1-year program of orientation (scholars join the RWJ Health Policy Fellows’ orientation in the Fall) and study at the IOM. The scholar produces a report as a result of working on a current IOM initiative related to his/her area of expertise. This year’s Distinguished Nurse Scholar-in-Residence for 2013-14 is Beatrice Kalisch, Director of Innovation and Evaluation and Titus Professor of Nursing at the University of Michigan. She brings extensive experience in quality of care and patient safety. She will also be working on the upcoming IOM study of diagnostic errors. The 2012-13 Distinguished Nurse Scholar-in-Residence, Marla Salmon—an IOM member and the immediate past Dean of the University of Washington School of Nursing—will continue her role as resident scholar. Her work is focusing on three areas of policy and scholarship: *Global nursing workforce capacity building; *Women’s development aimed at enhanced educational and economic wellbeing; and *Social impact investment and microfinance as mechanisms for reducing barriers to women’s education and subsequent sustained economic engagement” [Marie Michnich, former RWJ Fellow who served with Senator Bob Dole for three years]. The 2003 Scholar was Angelia McBride, a fellow Purdue University psychology graduate; the 2006 Scholar was Ada Sue Hinshaw, Dean of the Daniel K. Inouye USUHS School of Nursing, where I serve as a Distinguished Professor.

A frequent discussant for my class, Lucinda Maine, Executive Vice President of the American Association of Colleges of Pharmacy (AACP), shared her profession’s appreciation for the long term importance of public policy involvement and the IOM. “IOM member J. Lyle Bootman, Dean of the University of Arizona College of Pharmacy and 2012-13 President of the AACP, challenged his members to ‘Get to tables of influence’ to insure that pharmacists’ roles in improving health and health care could be maximized. He did not overlook the power of the IOM tables in implementing his own recommendation. With resources from AACP and other organizations, a fellowship was endowed in the IOM Anniversary Fellowship Program. Every other year in perpetuity a pharmacist from academia, practice or both will be selected to serve as the Pharmacy Fellow at IOM. Over two years they attend IOM meetings, work to support study committees, forums and other IOM groups. Dr. Sam Johnson, affiliated with the University of Colorado in Denver and a leader in pharmacogenomics at Kaiser’s Rocky Mountain Health System, assumed the position of inaugural fellow in October 2012 and will complete his experience in October 2014. He describes his experience as nothing short of ‘life changing.’ It is clear that he has made an important imprint on the work of the IOM as well.”

A Sea Change in Orientation

The conference agreement for the Fiscal Year 2014 Consolidated Omnibus Appropriations bill, which President Obama has now signed into public law, contains an intriguing directive for the Substance Abuse and Mental Health Services Administration. “The agreement provides for a new five percent set-aside for the Mental Health Block Grant. The set-aside is for evidence-based programs that address the needs of individuals with early serious mental illness, including psychotic disorders, as proposed in Senate Report 113-71. It is expected that in implementing this set-aside, SAMHSA will collaborate with NIMH to develop guidance to States so that funds are used for programs showing strong evidence of effectiveness. It is expected that SAMHSA and NIMH brief the House and Senate Appropriations Committees on implementation status of this set-aside no later than 90 days after enactment of this act.”

Those fortunate to attend the annual Practice Directorate State Leadership Conferences (SLC), which in my judgment are one of the highlights of the APA year, have recently been exposed to the vision of Art Evans, Commissioner of the Department of Behavioral Health and Intellectual disability Services for the City of Philadelphia. Art has been singularly focused on the transformation of the city’s large behavioral health system. This involves hundreds of millions of dollars, hundreds of employees, tens of thousands of service recipients and ensuring a safety net for a city of 1.5 million people. The transformation of the behavioral healthcare system is focused on recovery and resilience outcomes and has required working at multiple levels and domains simultaneously. For example, the department has invested heavily in empirically supported treatments and has formed partnerships with clinical researchers such as Aaron Beck, M.D., and Edna Foa, Ph.D., to do large-scale implementations of evidence based practices. Simultaneously, Art and his colleagues have used financial incentives to improve provider performance, developing performance metrics for 90% of their service system. In addition to improving clinical service delivery, much of their focus has been on nonclinical strategies that they believe are essential to helping people achieve the best possible outcomes. Philadelphia has one of the most robust peer programs in the nation, training and deploying hundreds of people in recovery from mental health and addiction problems throughout their system from acute inpatient settings to assertive community treatment teams. Community work also includes working with members of diverse faith backgrounds who can support recovering people within their congregations and working with indigenous community leaders from immigrant groups to develop alternative pathways into treatment, as well as culturally-responsive support services. Art firmly believes that the next frontier for behavioral health is the adoption of a public health framework and strategies to address the psychological health of people.

Enjoyable/Intriguing Journeys

Since retiring from the U.S. staff after 38+ years with Senator Inouye, I have become increasingly intrigued by the experiences of colleagues who have “retired” from their previous employments. “If your Oregon tour schedule allows time I would be pleased to share coffee or a meal. I live in The Dalles, which if you check your map, is in the Columbia River Gorge. We are about 85 miles from Portland going East on I-84. It is probably the most scenic Interstate route in the nation and includes Multnomah Falls, Angel Falls, Bonneville Dam, etc., etc., etc. It is an easy, wonderful drive. We spend about eight months in The Dalles and four months in Yuma. We travel frequently. In retirement I travel, hunt, fish, volunteer on Veterans Issues, 4-wheel the desert southwest, and write. I am rewriting a book entitled ‘20th Birthday’ which is a diary of my time in combat in Vietnam and its aftermath in my life. The first edition can be found on Amazon and Kindle. It is a good journey and lots of life continues after retirement when we are no longer defined by what we do but who we are” [Pat Stone, former APA Congressional Fellow]. Over the years we have also come to appreciate how personal the public policy world can be. Judith Glassgold, who is director of the APA Congressional Fellowship program and a former APA Congressional Fellow herself, reports that this year’s Fellows Irina Feygina will serve with Senator Bennet focusing on environment, energy, and disaster relief issues while Joshua Wolff will be in the Policy Health Office of the Senate HELP Committee, working with Jenelle Krishnamoorthy, a former Congressional Fellow. Aloha.

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Cite This Article

DeLeon, P. (2014) The evolution towards integrated care. Psychotherapy Bulletin, 49(1), 57-62.

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