Psychotherapy Bulletin

Psychotherapy Bulletin

This spring I had the wonderful opportunity, along with our colleagues Hortensia de los Angeles Amaro and Brian Smedley, to attend the National Academy of Medicine (NAM) Culture of Health stakeholder meeting Engaging Allies in the Culture of Health Movement. The expressed objectives of this particular meeting were to discuss why Anchor Institution (such as academic health centers, hospitals, health systems, and universities) Strategies are a key component to advancing health equity and a culture of health in neighboring underserved communities; explore how to shape and use an Anchor Institution mission to advance health equity and a culture of health in communities highlighting promising models; explore how to effectively shape and use an Anchor Institution mission for businesses, non-profit foundations, and municipalities; and share information and “lessons learned” to determine a way forward in taking purposeful action through an Anchor Institution approach. Several key participants included high level representatives from Healthcare, Microsoft; Kaiser Permanente; Associations of American Universities and Academic Health Centers; Nashville Chamber of Commerce; and naturally the all-important student voice.

The Culture of Health Program is a high personal priority of NAM President Victor Dzau. It represents a multiyear collaborative effort to identify strategies to create and sustain conditions that support equitable good health for all Americans. Its four aims: Lead—identify a set of consensus study topics that build upon one another, leading to a solid knowledge base that can inform a set of actions and partnerships to advance health equity. Translate—bridge science to action for impact on health equity and optimal health for all. Engage—strengthen capacity in communities to continue to advance progress in achieving optimal health for all and inform legal, policy, and system reform. And, Sustain— transform culture in the United States to sustain progress made and to accelerate progress in areas that still have significant health disparities.

“All too often in healthcare, we ask the wrong questions, deploy the wrong resources, and are focused on the wrong solutions – and then wonder why healthcare is broken. We ask patients if they have medications, but we don’t ask if they have food, heat, or a job. We provide education to patients, but we don’t ask if they can read. We encourage people to lose weight, but we don’t ask if they have the ability to secure healthy food…. We need to step outside our comfort zones…. We need to focus on how we can have truly significant impact on health outcomes and in our communities by addressing the root causes of health and well-being.” One might reasonably ask why are organizations such as Kaiser Permante investing significant funding in communities where not all of the residents are their members? Perhaps because:  “Creating a culture of health across all of its operations is not just the right thing to do, it’s a smart way to get ahead of the cost curve of providing effective care, by helping create and sustain healthier communities.”

Interestingly, during the discussion period several participants, including myself, “pushed back a bit” on the almost exclusive focus during the meeting of Anchoring Institutions. Federally Qualified Health Centers (FQHCs), for example, have long been stressing the importance of communities and holistic care, including the cultural-psychosocial-economic component of quality health care. Notwithstanding, “Anchor Institutions have tremendous potential to invest in communities in ways that improve social, economic, and environmental conditions that shape health. Our NAM panel highlighted innovative approaches that offer strong returns on institutional investment. I’m grateful that psychologists, such as Hortensia Amaro, are leading thinking and action in this space, for psychology offers critical insights that public health and health systems are increasingly embracing” (Brian Smedley). My personal sincerest appreciation to Co-Directors Ivory Clarke and Charlee Alexander for orchestrating a truly outstanding meeting.

An Increasingly Important Focus

As the years pass, I have become increasingly sensitive to the importance of each of the health professions learning from the wisdom of those they elected to be their national Presidents. That experience gives one a unique perspective – on the potential unique contributions of their own profession and equally important, the nation’s ever-evolving global environment. Former APA President Susan McDaniel stressed the importance of interprofessional collaboration, especially during the formative graduate school experiences. Alan Kazdin emphasized the importance of seeking to serve those that simply do not have access to any health care: “e.g., children, older individuals, single parents, individuals of ethnicity, victims of violence, and it goes on.” I vividly recall my discussions with Seymour Sarason during his final years in an extended care facility where many of his Yale colleagues would eventually retire. He wished that he had been aware of the way that our nation’s elderly were “treated” so that he could have addressed this during his nearly half a century on the Yale psychology faculty. On the island of Lana’i visionary colleagues are making a lasting difference.

“Lana’i Community Health Center’s (LCHC) Behavioral Health Program started with our involvement in a Federal Training grant in 2012. Being a small remote, rural federally qualified health center (FQCHC) we were thrilled to be a part of this grant – but mostly we were thrilled to offer Behavioral Health (BH) psychology services to our community. The island of Lana’i is one of the smallest of the inhabited Hawaiian islands – its population is 3,100, with mostly Filipino residents who originally relocated to work in the pineapple fields. Health care of any sort is limited: there is a small critical care access hospital with the ability to treat and release or send out to the other larger islands, our FQCHC, one small private practice medical provider, and a small private practice dental office. Our organization is the only location where BH services are provided to all in need and the only place on island to offer such services on a sliding fee scale. From the first LCHC training grant fellows, to Cori Takesue, the first FTE Post-doc fellow hired with non-grant funds, we now have 2.5 FTEs. All post-docs are in the process of securing their license, and at least 2 FTE will hopefully remain with us. LCHC and its providers have worked hard to remove the stigma of seeking BH services, to be accepted and trusted by our community members. Our success can be seen by the growth in our patient numbers… and the growth in our wait list.

“What is also clear is that in our community it is not the opioid crisis that is affecting many areas of nation; it is depression, anxiety, stress, alcohol, and smoking that are bringing people to our doorstep. It is the stress of trying to make ends meet on an island where cost of living clearly outpaces salary. It is the depression and stress associated with feeling as if you are failing your family. So we continue to see the need grow. LCHC has been recruiting for a third FTE… for over two years. We will accept post-docs or licensed providers – however, due to the severe shortage of candidates, combined with the rural, remote nature of our community, we have continually fallen short of our recruitment goal. Our most likely candidates – those who are willing to work and live on our island – are those who have ties in Hawaii. Even better, if they intern with us for a year. Our main feeder has been Argosy with its connections to I Ola Lahui (a Native Hawaiian initiative, established by psychology) and their training program.

“We have successfully integrated all our services (medical, dental, and vision) with behavioral health – knowing that the key to wellness is a holistic approach. We utilize telemedicine for psychiatry, as well as a number of our specialty medical programs; however, for the basic day-to-day support we find that it is best if we have individuals living and working on our island. It is better for our patients who create a sound base of trust, and it is better for our providers who interact with all disciplines to ensure the holistic approach is being utilized. But now what? Sadly, we have the funds to support additional hires but no candidates to hire. Isn’t one of the roles of government to step in and provide workable solutions and oversight to protect harm to the individual? Clearly, in my opinion, government has failed – at least to this point.

“But all is not lost. Some programs and efforts show signs of recognition of needs and response. Under the leadership of former USPHS chief nurse, Dean Carol Romano, the Daniel K. Inouye Graduate School of Nursing at the Uniformed Services University (USU) has placed DNP graduate students with us. U.S. Navy LCDR Kayla R. Horton and U.S. Army MAJ Margaret Martin interned last year, sharpening their skills as a future APRN in rural, remote, and diverse settings. This partnership with USU brings a shared opportunity for learning and new experiences. Their experiences provided them with access to a full range of family practice issues, home visits, participation in LCHC’s school-based education program, and the use of telemedicine – especially for services that are uncommon in the military – including surviving a hurricane on a small austere island. They were exposed to the cultural diversity of Lana’i’s community, which will add enhanced cultural sensitivity to their arsenal of health care tools. Overall, by allowing faculty and students to participate in LCHC’s activities and live within our community, this joint effort and our combined resources works to develop, improve, and sustain the delivery of outstanding medical, dental, nursing, and clinical care and preventive medicine.

“The relationship that LCHC has forged with USU and other teaching programs has proven to be critical both to future health care providers as well as to LCHC’s workforce development. One of our main goals is role model development. With the current nurse and health care provider shortage in the United States, and more notably in rural areas such as Lana’i, these select students are able to go into the community and educate school age children on a career in nursing and/or as a nurse practitioner. These intimate interactions may also attract young people into the military nursing and medicine fields. We saw the potential to inspire the next generation of Lanai’s citizens in seeking nursing as a career and coming back to serve in our community.

“Additionally, these rotations benefits students in numerous ways, such as teaching critical thinking skills needed to practice in remote austere settings, gaining a greater appreciation for cultural diversity, and exposure to systems thinking outside of the Military Treatment Facility. A similar nursing program for Behavioral Health is needed – one that will be beneficial to both participants and will result in a larger applicant pool with rural health experience. Courage is needed on the part of the government to take this next step… not just leaving health care organizations like LCHC without the ability to address these pressing behavioral needs” (Diana Shaw, LCHC Executive Director).

RxPThe Maturing Agenda

Under Morgan Sammons’ stewardship the National Register has done an outstanding job representing the interests of psychology’s practitioners and particularly in educating them regarding the unprecedented changes occurring within the nation’s health care environment. For example, the Register will be sponsoring an RxP Webinar providing an update on Training and Legislation, featuring APA Board Member Beth Rom-Rymer and her colleague Gerardo Rodriguez-Menendez from the Chicago School of Professional Psychology. 

“This land was made for you and me” (Woody Guthrie). 

Aloha.

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Cite This Article

DeLeon, P. (2019). “This land is your land”. Psychotherapy Bulletin, 54(2), 47-50.

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