In This Issue

Exciting times for the public sector

The change in focus from previously almost exclusively acute care and “medical” issues, to the recognition of the importance of systems, holistic approaches and patient-centered care represents a very nice evolution/maturation.

By Patrick H. DeLeon, PhD

During this year’s Senate Appropriations Committee hearings on the Fiscal Year 2013 budget, the three Department of Defense (DoD) Surgeon Generals and the Chiefs of the Service Nursing Corps noted the importance of quality mental health care, advances in technology (e.g., telehealth), and the critical psychosocial-cultural-economic gradient of care to the military and to its families. Having personally observed these hearings over the years, the change in focus from previously almost exclusively acute care and “medical” issues, to the recognition of the importance of systems, holistic approaches, and patient-centered care represents a very nice evolution/maturation for which psychology and nursing can be justifiably proud. Many of the underlying concepts, such as coordinated and integrated care, not to mention fundamental interdisciplinary respect, are at the foundation of President Obama’s landmark Patient Protection and Affordable Care Act. I have come to particularly appreciate how critical the public sector’s inherent emphasis upon systems of care —  in contrast to the private sector’s often isolated (or silo-oriented) care — is in fostering cost-effective, state-of-the-art, high quality care for beneficiaries. This is the future and fortunately our training programs are becoming increasing responsive. At lunch the other day, for example, I learned that Uniformed Services University of the Health Sciences (USUHS)  clinical psychology graduate student LT Chantal Meloscia, USN, is enrolled/embedded in a Graduate School of Nursing advanced physiology course. This core course for advanced nurse practitioners provides an in-depth understanding of the function and regulation of the body system to maintain homeostasis, with an emphasis on the integration of the structure and functional systems within the human body. The course content ranges from cellular mechanisms to the major body organ systems, providing the basis for understanding physiologic derangements. On average, nine USUHS psychology students will take this required course annually, serving as a foundation for a pharmacology class the following year taken through the medical school.

United States Air Force (USAF):  National health care costs continue to rise at rates above general inflation and the DoD is not insulated from this growth as we purchase over 60 percent of our care from the private sector. In times of war there are always significant advances in the field of medicine. Today we are applying these lessons to shape future readiness and care. Build patient-centered care. At home, we continue to advance the Patient-Centered Medical Home (PCMH) to improve the delivery of peacetime healthcare. The foundation of patient-centered care is trust, and we have enrolled 920,000 beneficiaries into team-based, patient-centered care. Continuity of care has more than doubled with patients now seeing their assigned physician 80 percent of the time and allowing patients to become more active participants in their health care. PCMH will be in place at all Air Force Medical Treatment Facilities (MTFs) by June of this year. The implementation of PCMH is decreasing emergency room visits and improving health indicators. We have also implemented pediatric PCMH, focusing on improving well child care, immunizations, reducing childhood obesity and better serving special needs patients.

Our personalized medicine project, Patient Centered Precision Care (PC2), which builds on technological and evidence-based genomic association, received final Institutional Review Board approval. We enrolled the first 80 patients this year with a goal of enrolling 2,000 patients in this research. It will allow us to deliver state-of-the-art, evidence-based, personalized health care incorporating all available patient information — the advancement of genome-informed personalized medicine. We are also testing incorporation of smart-phones into our clinics to link case managers directly to patients. Linking wireless and medical devices into smart phones allows the patient to transmit weight, blood pressure or glucometer readings that are in high risk parameters, directly to their health team for advice and consultation.

Safeguarding the well-being and mental health of our people while improving resilience is a critical Air Force priority. We remain vigilant with our mental health assessments and consistently have Post-Deployment Health Reassessment completion rates at 80 percent or higher for Active Duty, Guard, and Reserve personnel. We have implemented the Congressionally directed two-phased approach requiring members to complete an automated questionnaire, followed by a person-to-person dialogue with a trained privileged provider. Whenever possible, these are combined with other health assessments to maximize access and minimize inconvenience for deployers. Each deployer is screened for post-traumatic stress disorder (PTSD) four times per deployment including a person-to-person meeting with a provider. Although our PTSD rates are rising, the current rate remains low at 0.8 percent across the Service. Our mental health providers, including those in internships and residencies, are trained in evidence-based PTSD treatments to include Prolonged Exposure, Cognitive Processing Therapy, and Cognitive Behavioral Couples Therapy for PTSD. Virtual Iraq/Afghanistan uses computer-based virtual reality to supplement Prolonged Exposure Therapy at 10 Air Force sites. Diagnosis is still done through an interview, supported by screening tools and other psychological testing as clinically indicated.

We are working closely with Air Force leadership to inculcate healthy behaviors. Comprehensive Airmen Fitness focuses on building strength across physical, mental and social domains. While we experienced a drop in the active duty suicide rate in 2011, we remain concerned. Guard and Reserve suicide levels have remained steady and low. The major risk factors continue to be relationship, financial and legal problems. No deployment or history of deployment associations has been found. By summer of this year, we will embed behavioral health providers in primary care clinics at every MTF. The Behavioral Health Optimization Program reduces stigma by providing limited behavioral health interventions outside the context of the mental health clinic, offering a first stop for those who may need counseling or treatment. We are increasing our mental health provider manning over the next five years.

This past year, the Air Force field-tested a new Electronic Health Record (EHR) during Aeromedical Evacuation (AE) missions. Air Force nursing priority for 2011 was to further advanced research and evidence-based practice initiatives to improve patient safety and pain management during AE transport. Our Informatics Fellowship is critical to prepare nurses to participate in the development and fielding of computer based information systems, such as the EHR. Patient centered care is at the core of all we do; it is our highest priority. Care for our patients crosses into both inpatient and outpatient arenas, and has been redefined with a more focused emphasis on providing healthcare to promoting health. Embedded in our patient-centered care is an emphasis on resilience. The Air Force is committed to strengthening the physical, emotional, and mental health of our Airmen and their families. “You will know you’re a military nurse when you visit the National Mall in Washington  D.C., and the Vietnam Veterans visiting The Wall tell you their stories of how nurses saved their lives, and then they thank you for serving. Then you swallow the lump in your throat and blink back the tears in your eyes and continue doing what you were doing without missing a beat.… You will know you’re a military nurse when at the end of the day, at the end of the tour, or the career, you say, ‘I’d do it all over again.’”

U.S. Army Surgeon General Patricia Horoho noted: “Psychological health problems are the second leading cause of evacuation during prolonged or repeated deployments.” Division member Ray Folen and Becky Porter were with the Surgeon General at Tripler Army Medical Center when she addressed 5,000 Army behavioral health providers throughout the world, utilizing video-conferencing. “It was an impressive event, the first of its kind in my 28 years with the Army. She is a most impressive visionary.” SG Horoho is the first non-physician and first woman selected for this leadership position in the history of the U.S. Army, dating back to 1775.

A Wonderful Role Model: “When I turned 70, I retired officially, but since I like to teach, I taught one course a term for free until I had to have my hips and right shoulder replaced at age 85 (the penalty for 50 years of pitching softball). Now I come to my office every morning to do email and play MURDER at noon. Then I go home to have lunch with my wife and read the New York Times which is delivered to us, daily. I still subscribe to 50 journals, including the Chronicle of Higher Education and Science magazine which come weekly; so I always have plenty to read. We also go on Tuesday evenings to hear the Easy Street Jazz Band, which plays some of the same music I played when I played piano in bars weekends during my college years. We have sung in the First Baptist Church for 65 years and enjoy that. We have an excellent Korean woman organist and a fine choir director. Our daughters and their husbands live nearby; so we get together with them frequently. For Christmas, Karen gives us a scroll for one year of free computer consultation and Linda and Larry give us a scroll promising one year of free household maintenance. (I’m no good at practical things). One of my friends retired from Harvard and can only go in to hear lectures because he doesn’t have an office. So, at age 91, we feel lucky to be healthy and well cared for. Best wishes!” [Bill McKeachie, former APA President. Regularly attending APA conventions since 1947].