Feature Article

Interesting times: The need for interdisciplinary collaboration

Initiatives are taking hold in the national movement toward integrated care, interprofessional collaboration and patient-centered/data-driven best practices.

By Patrick H. DeLeon, PhD

I recently had the privilege of attending the 17th Annual VA Psychology Leadership (AVAPL) Conference, “Serving Veterans through Interprofessional Care and Expanding Partnerships.” APA President Nadine Kaslow and former Veterans Affairs (VA) chief consultant for mental health Toni Zeiss provided extremely exciting visionary perspectives, highlighting the national movement toward integrated care, interprofessional collaboration, and patient-centered/data-driven best practices. Bob Zeiss announced that next year the VA is expected to support 400 postdoctoral psychology residencies, providing a wide range of critical health care expertise.

Having been involved in urging both the Department of Veterans Affairs and the Department of Defense (DoD) to fund postdoctoral initiatives, we rhetorically wonder to what extent DoD psychology really understands that this is the future, including training for RxP. Every APA president since Norm Abeles has attended the AVAPL conferences, and President-Elect Barry Anton (a veteran himself) is expected to be present next year. With the Div. 19 membership constituting the Veterans of the Future, hopefully your leadership will participate. On a personal note, I was particularly pleased that AVAPL presented its advocacy award to APA's Heather O'Beirne Kelly, who has long been a champion of military psychology.

A Congressional Perspective

On May 22, the U.S. House of Representatives passed the National Defense Authorization Act for fiscal year 2015 by the overwhelming vote of 325–98. The accompanying House report:

The committee is resolute in ensuring that the Military Health System remains a top priority for the Department of Defense during the post-conflict shift to readiness training and force reduction. The committee recognizes Department efforts in preventative medicine, clinical and translational research, public health initiatives, and pioneering the health care team model. It is imperative that these critical areas continue progressing with the same level of commitment in this changing landscape in order to sustain the medical readiness of our service members. The committee encourages the Department to maintain this commitment to solving the complex physical and psychological implications of wartime service for the foreseeable future.

The committee remains focused on making certain that the Department cost-saving measures are centered on achieving the most efficient Military Health System possible before significant cost-sharing burdens are placed on TRICARE beneficiaries. . . . The committee notes the Department efforts toward reorganization of the Military Health System, but remains unconvinced that current implementation efforts will result in the projected cost savings. To that end, the committee includes requests for a report to further clarify Defense Health Agency implementation plans and a review of Defense Health Agency implementation progress by the Comptroller General of the United States. The committee is also concerned that the Department's plan to reduce or realign Military Treatment Facilities will further shift the health care burden to the purchased care sector and ultimately increase costs.

The committee seeks to ensure continued access to care and adoption of best practices during the Military Health System reorganization. . . . Moreover, the committee directs the execution of a pilot program focused on the improvement of patient medication use and outcomes through use of commercial best practices.

The committee is encouraged by the current downtrend in the suicide rate of the Armed Forces and commends the Department's diligence in addressing this tragic issue. However, although the overall trend is downward, there are certain communities of service members who remain at high risk. The committee strongly encourages the Department to continue training, research, and therapeutics to address psychological health and resilience.

Clinical Pharmacy

Unprecedented change is in the air—in both the private and public sectors. Provider and programmatic accountability and interprofessional collaboration are becoming increasingly salient. The congressionally requested pilot program on medication therapy management would be conducted under TRICARE and, from a public policy perspective, is particularly intriguing on several accounts. It would be an outcomes-oriented (best practices) initiative that will be carefully evaluated. Section 725 of the House proposal would direct the Secretary of Defense to carry out a pilot program for at least two years at not less than three locations in order to evaluate the feasibility and desirability of including medication therapy management as part of the TRICARE program. It would be focused on improving patient medication use and outcomes using best commercial practices in medication therapy management, and would quantify effectiveness by measuring patient medication use and outcomes as well as health care costs. Patients participating in the program will have more than one chronic condition and be prescribed more than one medication.

The committee further directed that one of the projects shall have a pharmacy at a military medical treatment facility where the participating patients will generally receive their primary care services. The second shall have a pharmacy at a military medical treatment facility where the participating patients will generally not receive their primary care. And the third shall have the pharmacy located at a location other than a military medical treatment facility. Under this proposal, the term medication therapy management means “professional services provided by qualified pharmacists to patients to improve the effective use and outcomes of prescription medications.”

In 1999, the Institute of Medicine (IOM) reported that including a clinical pharmacist during the clinical rounds of a large teaching hospital reduced the rate of preventable adverse drug events related to prescribing significantly—by 66 percent. Perhaps next year the Congress will request a similar nonphysician pilot program under which military nurse anesthetists will be authorized to utilize their considerable clinical expertise by establishing comprehensive pain clinics—another significant military need.

The IOM recently issued a call for nominations for its IOM Pharmacy Fellowship, which will support a pharmacist as an early career health policy or health science scholar. The purpose of the fellowship is to enable these talented scholars to participate actively in the work of the IOM and to further their careers as future leaders in the field. The fellowships are awarded for a two-year period during which time the selectee will be expected to continue working at his or her main academic post. Selectees will be assigned to a board of the IOM, attend its meetings, and actively participate in the work of an appropriate expert study committee or roundtable, including contributing to its report or other products. They will be invited to the IOM annual meeting and will take part in an intense one-week orientation to health policy in our nation's capital. This will introduce them to a variety of perspectives, including legislators, government officials, industry, patient interest groups, scientists, and health professionals. Each fellow will be assigned to an IOM member who will serve as a senior mentor for the duration of the fellowship. Each will also receive a flexible research stipend of $25,000. Fellowships require a commitment of 10 to 20 percent time for the successful candidate.

Unique Training Experiences at the Uniformed Services University of the Health Sciences

When the first announcement for Bushmaster was made, I was not originally interested. The thought of being in the middle of the woods for 24 hours with questionable plumbing and twin beds was not only undesirable, but seemed unnecessary. Yet, when our department chair explained the importance of the particular exercise—the real-time simulations preparing medical students for combat settings, and the way civilians would gain a once-in-a-lifetime perspective about deployment—I was intrigued. With the knowledge of how much it would add to my military cultural and clinical expertise, I decided to sign up. And am I glad I did!

We arrived at Fort Indiantown around 10 p.m. the night before our assigned volunteer day to be briefed on the assignments for the following day. After a meal ready-to-eat [MRE] and a good night's rest in the barracks with 15 other volunteers, I was ready for a 0500 a.m. meet-up. As I sat in the MTV [medium tactical vehicle] with my Teflon helmet watching daylight break, I was both excited and enthusiastic about the day to come.

While I role-played various mental and physical casualties, including bipolar disorder, I recognized the awesome opportunity I had been given to gain a perspective about everything service members experienced while on deployment: from coordinating roles in their platoon to caring for the physically and mentally ill, and gathering and organizing necessary supplies, all while managing conflicts and cultural differences with natives. While I respected my military friends and colleagues before, I developed a newfound respect for their service in meeting the health care needs of the nation, all while protecting our freedoms. Now, I approach my clinical work with a better understanding of the experiences and potential stresses of our military members—a perspective I owe completely to Bushmaster.

-Omni Cassidy, graduate student, medical and clinical psychology

Serving on the faculty at the Uniformed Services University of the Health Sciences (USUHS), I have come to particularly appreciate the U.S. Air Force Surgeon General's perspective that this university (from which he graduated) is an investment in the future of U.S. Air Force's health care, as it should be for all of military psychology. Is there life after DoD? We enthusiastically recommend reading In Movement There Is Peace: Stumbling 500 Miles Along the Way to the Spirit by Elaine Orabona Foster, one of the first 10 USUHS-trained prescribing psychologists. Aloha.

Patrick H. DeLeon is on the faculty of USUHS and the University of Hawai‘i.