VA tries quality improvement approach to medical ethics

Tools to evaluate how health care facilities perform ethically are in their infancy. The VA Health Care System hopes others can benefit from its experience.

By Tanya Albert Henry
amednews.com
Originally posted May 20, 2013

How often does a physician have enough time to discuss a treatment recommendation with a patient?

Would a doctor be reluctant to raise concerns if he or she believes a colleague's clinical abilities are impaired?

How often are notes or papers with identifiable patient information left in areas where other patients, relatives or staff members might view the sensitive material?

These are just a few of the questions the National Center for Ethics in Health Care at the U.S. Dept. of Veterans Affairs is using to query its staff at the VA Health Care System. The goal is to help facilities see what they are doing well in terms of ethics and point out areas where they could be doing more.

The concept is similar to the recent push to evaluate quality of care by asking about procedural issues such as how well physicians are helping patients control hypertension or whether hospitals are keeping infection rates low.

Ethics evaluations, though, are not so common, and surveys do not tie payment to how well facilities score. However, the idea of measuring ethics as a component of quality of care is gaining momentum, and leaders in the field say its time has come.

“This is about managing ethics the same way you manage health care quality,” said Ellen Fox, MD, chief ethics in health care officer for the Veterans Health Administration. “Ethics quality is an important area that can have a dramatic effect on health care, including life-and-death decisions. … An effective ethics program promotes better patient care, better patient satisfaction, better efficiency.”

The entire story is here.

VA report: 22 veterans commit suicide each day

The number of veterans who commit suicide each day is more than 20 percent higher than previously estimated
 

By Kevin Freking

Salon.com
Originally published February 1, 2013

The number of veterans who commit suicide each day is more than 20 percent higher than the Department of Veterans Affairs has previously estimated, but the problem doesn’t appear to be getting worse for veterans compared to the rest of the country, according to a VA study released Friday.

Indeed, the overall percentage of suicides by veterans has declined in recent years. VA researchers say the trend suggests that efforts to reduce suicide among veterans may be having an effect.

About 22 veterans committed suicide each day in 2010. Previous estimates from the VA put the number at 18.

While much attention has been paid to suicides by veterans of Iraq and Afghanistan, the report indicates the problem is worse among older veterans. About 70 percent of veterans who commit suicide are over age 50.

The latest projections from the VA incorporate data from about two dozen states that recorded the cause of death on death certificates. Previous estimates focused only on those getting care from the VA’s hospitals and clinics. The department described the study as the most comprehensive it has ever taken on the issue. 

“We have more work to do, and we will use this data to continue to strengthen our suicide prevention efforts and ensure all veterans receive the care they have earned and deserve,” said VA Secretary Eric K. Shinseki.

President Obama orders VA to expand suicide prevention services

By Rebecca Ruiz
MSNBC.com
Originally published September 1, 2012

President Obama issued an executive order Friday tasking the Department of Veterans Affairs to expand its suicide prevention and mental health services.

Under the order, VA is expected to increase its veteran crisis line by 50 percent by the end of the year; ensure that a veteran in distress is given access to a trained mental health worker in 24 hours or less; and launch a national 12-month suicide prevention campaign to educate veterans about available mental health services.

The order reinforces some initiatives that VA has already undertaken.


In April, VA announced that it would hire 1,600 mental health clinicians to meet surging demand, and the order instructs the agency to use loan repayment programs and scholarships, among other strategies, to recruit those professionals by June 2013.

The entire story is here.

War Wounds

By Nicholas D. Kristof
The New York Times - Sunday Review
Originally published on August 10, 2012

IT would be so much easier, Maj. Ben Richards says, if he had just lost a leg in Iraq.

Instead, he finds himself losing his mind, or at least a part of it. And if you want to understand how America is failing its soldiers and veterans, honoring them with lip service and ceremonies but breaking faith with them on all that matters most, listen to the story of Major Richards.

For starters, he’s brilliant. (Or at least he was.) He speaks Chinese and taught at West Point, and his medical evaluations suggest that until his recent problems he had an I.Q. of about 148. After he graduated from West Point, in 2000, he received glowing reviews.

(cut)

Military suicides are the starkest gauge of our nation’s failure to care adequately for those who served in uniform. With America’s wars winding down, the United States is now losing more soldiers to suicide than to the enemy. Include veterans, and the tragedy is even more sweeping. For every soldier killed in war this year, about 25 veterans now take their own lives.

President Obama said recently that it was an “outrage” that some service members and veterans sought help but couldn’t get it: “We’ve got to do better. This has to be all hands on deck.” Admirable words, but so far they’ve neither made much impact nor offered consolation to those who call the suicide prevention hot line and end up on hold.

The military’s problems with mental health services go far beyond suicide or the occasional murders committed by soldiers and veterans. Far more common are people like Richards, who does not contemplate violence of any kind but is still profoundly disabled.

The entire story is here.

Technological Imperative

By Pat DeLeon
Posted with permission

One direct consequence of the advent and steadily increasing presence of technology within the health care arena will be the need for psychology to finally seriously address the issue of licensure mobility. The Department of Veterans Affairs (VA) recently announced its plan to increase veterans’ access to mental health care by conducting more than 200,000 clinic-based, telemental health consultations by mental health specialties this fiscal year. Earlier the VA indicated that it would no longer charge a copayment when veterans receive care in their homes from VA health professionals using video conferencing. The Secretary: “Telemental health provides Veterans quicker and more efficient access to the types of care they seek. We are leveraging technology to reduce the distance they have to travel, increase the flexibility of the system they use, and improve their overall quality of life. We are expanding the reach of our mental health services beyond our major medical centers and treating Veterans closer to their homes.” Since the start of the VA Telemental Health Program, VA has conducted over 550,000 patient encounters.

The Fiscal Year 2013 budget request for the Office of Rural Health Policy, which is located within the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services, notes that there has been a significant Departmental focus on rural activities for over two decades. Historically, rural communities have struggled with issues related to access to care, recruitment and retention of health care providers, and maintaining the economic viability of hospitals and other health care providers in isolated rural communities. There are nearly 50 million people living in rural America who face ongoing challenges in accessing rural health care. Rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than their urban counterparts. Rural areas also continue to suffer from a shortage of diverse providers for their communities’ health care needs and face workforce shortages at a greater rate than their urban counterparts. Of the 2,052 rural counties in the nation, 77 percent are primary care health professional shortage areas (HPSAs), where APA’s Nina Levitt reports that psychologists are eligible for the National Health Service Corps Loan Repayment Program which places health professionals in underserved rural communities. 

HRSA’s Telehealth Grants initiative is designed to expand the use of telecommunications technologies within rural areas, seeking to link rural health practitioners with specialists in urban areas, thereby increasing access and the quality of healthcare provided. Telehealth offers important opportunities to improve the coordination of care in rural communities by linking its providers with specialists and other experts not available locally. The strengthening of a viable rural health infrastructure is viewed as critical for long-term success, including facilitating distance education experiences. The budget request for the office of rural health office once again proposed $11.5 million, which has subsequently been approved by the Senate Appropriation Committee, and thus allows the continuation of the Licensure Portability Grant initiative, in order to assist states in improving clinical licensure coordination across state lines. This particular initiative builds on HRSA’s 2011 Report to Congress indicating: “Licensure portability is seen as one element in the panoply of strategies needed to improve access to quality health care services through the deployment of telehealth and other electronic practice services (e-care or e-health services) in this country…. Overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals in order to address workforce needs and improve access to health care services, particularly in light of increasing shortages of health professionals. ” 

For some colleagues, and particularly for those who are not comfortable with fundamental change, the relationship between telemental health and licensure mobility might seem to be a tenuous one. And yet, we would suggest that they are intimately linked. The public policy rationale for professional licensure is to protect the public from untrained and/or unethical practitioners, not to enhance the status or economic well-being of the profession. Historically, and we would expect for the foreseeable future, licensure decisions and qualification criteria have been made at the individual state level, where each of the professions plays a major role in determining its requirements for membership and its scope of practice, albeit through the political process. Within the federal system the governing statutes and implementing regulations generally require licensure in at least one state (regardless of practitioner geographical location) and facility approval (i.e., being credentialed). As improvements in technology allow for increasingly higher quality utilization, the congressional committees with jurisdiction have been systematically “cleaning up” potential lingering statutory restrictions. And, at both the state and federal level, expanding reimbursement paradigms are evolving. APA estimates that 13 states now require private sector insurance companies to pay for telehealth services. Over the years, we have not been aware of any objective evidence which suggests that the quality of care being provided via telehealth is in any way compromised. To the contrary, as the VA, the Department of Defense (DoD), and the federal criminal justice system are demonstrating, access has been significantly enhanced and new state-of-the-art clinical protocols have been developed and implemented. 

A First Hand View -- From Tripler Army Medical Center: “I joined the Telebehavioral and Surge Support (TBHSS) Clinic in February, 2011 during its infancy. At that time, the program was fully staffed with providers and support staff, making us 24 strong. TBHSS provides healthcare access by connecting eligible beneficiaries to providers who are able to indentify and treat their clinical needs. These services are provided through secured video technology which allows accessibility from remote locations worldwide. I was very excited to have the opportunity to work in a clinic that has the ability to reach out to those off island, typically in areas where the demand for services is far greater than that of the availability. To date, the clinic has been able to support Alaska, Texas, Korea, Japan, Okinawa, and American Samoa, as well as various sites on the island of Oahu and in the Continental United States. As a provider, it was refreshing to be able to provide multiple services such as therapy, consultation, administrative evaluations, and both neuropsychological and psychological assessments. In addition, we provided surge support during different points within the ARFORGEN cycle whenever there was a need for augmented behavioral health resources. In February, 2012 I was fortunate to be commissioned in the USPHS as a Lieutenant (0-3) and detailed to Tripler. As a clinical psychologist, I was able to utilize all the skills within the Department of Psychology that I acquired from my time at TBHSS. Recently, I had the honor to be promoted to the position of Clinical Director of TBHSS. Returning back to my roots has been exciting as I get to work with individuals who have a passion and commitment to serve service members and their families. My journey as a clinical psychologist civilian contractor to active duty clinical director has just begun and I am looking forward to the ongoing relationships that the TBHSS team forges with the different regions” [Sherry Gracey, Lt. USPHS]. 

ASPPB: We were very pleased to learn from Steve DeMers that the Association of State and Provincial Psychology Boards (ASPPB) was successful in its application this year for one of the licensure portability grants issued by HRSA. ASPPB will receive approximately $1 million over the next three years to provide support for state psychology licensing boards addressing statutory and regulatory barriers to telehealth, focusing upon continuing the development and implementation of its Psychology Licensure Universal System (PLUS) initiative. As an integral means of addressing the present barriers associated with telepsychology, ASPPB has developed an on-line application system, the PLUS, that can be used by any applicant who is seeking licensure, certification, or registration in any state, province, or territory in the United States or Canada that participates in the PLUS program. This also enables concurrent application for the ASPPB Certificate of Professional Qualification in Psychology (CPQ) which is currently accepted by 44 jurisdictions and the ASPPB Interjurisdictional Practice Certificate (IPC). All information collected by the PLUS is deposited and saved in the ASPPB Credentials Bank, a Credentials Verification & Storage Program (The Bank). This information can then be subsequently shared with various licensure boards and other relevant organizations. Therefore, streamlining future licensing processes. 

ASPPB is an active participant in the APA/ASPPB/APAIT Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, established by former APA President Melba Vasquez and co-chaired by Linda Campbell (APA) and Fred Millan (ASPPB). The members have backgrounds, knowledge, and experience reflecting expertise in the broad issues that practitioners must address each day in the use of technology -- ethical considerations, mobility, and scope of practice. Several of the meta-issues discussed to date center on the need to reflect broadness of concepts when incorporating telecommunications technologies and to provide guidance on confidentiality and maintaining security of data and information. In addition, a number of meta-issues focus on the critical issue of interjurisdictional practice. The underlying intent behind the proposed guidelines is to offer the best guidance to psychologists when they incorporate telecommunication technologies in the provision of psychological services, rather than be prescriptive. The Task Force met twice in 2011, June of 2012, and plans to meet once more this Fall. Feedback on their recommendations will be sought at the Orlando convention, throughout the APA governance, and continuously from the membership at large. Their goal is to have the guidelines adopted by APA as policy and approved by ASPPB and APAIT sometime in 2013. 

The U.S. Supreme Court: As we all must be aware, this summer the U.S. Supreme Court upheld the underlying constitutionality of the President’s landmark Patient Protection and Affordable Care Act of 2010 (ACA), including it’s far reaching individual mandate provision, by a 5-4 vote. For legal scholars, the most critical issue was probably the Court’s deliberations regarding the federal government’s power to regulate Commerce vs. its power to raise Taxes, as a government of limited and enumerated powers. “We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation’s elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions. 

For health policy experts and practitioners, the Court’s musings on our nation’s health care system makes for particularly intriguing reading. * “Everyone will eventually need health care at a time and to an extent they cannot predict, but if they do not have insurance, they often will not be able to pay for it. Because state and federal laws nonetheless require hospitals to provide a certain degree of care to individuals without regard to their ability to pay, hospitals end up receiving compensation for only a portion of the services they provide. To recoup the losses, hospitals pass on the cost to insurers through higher rates, and insurers, in turn, pass on the cost to policy holders in the form of higher premiums. Congress estimated that the cost of uncompensated care raises family health insurance premiums, on average, by over $1,000 per year.” * “Indeed, the Government’s logic would justify a mandatory purchase to solve almost any problem…. (M)any Americans do not eat a balanced diet. That group makes up a larger percentage of the total population than those without health insurance. The failure of that group to have a healthy diet increases health care costs, to a greater extent than the failure of the uninsured to purchase insurance…. (T)he annual medical burden of obesity has risen to almost 10 percent of all medical spending and could amount to $147 billion per year in 2008. Those increased costs are born in part by other Americans who must pay more, just as the uninsured shift costs to the insured.” * “In enacting [ACA], Congress comprehensively reformed the national market for health-care products and services. By any measure, that market is immense. Collectively, Americans spent $2.5 trillion on health care in 2009, accounting for 17.6% of our Nation’s economy. Within the next decade, it is anticipated, spending on health care will nearly double. The health-care market’s size is not its only distinctive feature. Unlike the market for almost any other product or services, the market for medical care is one in which all individuals inevitably participate.” * “Not all U.S. residents, however, have health insurance. In 2009, approximately 50 million people were uninsured, either by choice or, more likely, because they could not afford private insurance and did not qualify for government aid.” 

Bringing Psychology To The Table – State Leadership In Health Care Reform: At this year’s impressive State Leadership conference, Katherine Nordal exhorted our state association leaders to appreciate that: “We’re facing uncharted territory with proposed new models of care delivery. New financing mechanisms that we’re going to have to understand and appreciate, and the ways that they are going to impact practice, whether it’s private practice or institutional practice. We know that the states are in the drivers’ seat, and most of what happens about health care reform is going to happen back home. We know that we can’t do it alone. Our advocacy depends on effective collaborations and effective partnerships. We have to be ready to claim our place at the table. We need to be involved at the ground level. You’ve got to get involved in coalitions. If we don’t participate, then we abdicate our responsibility there and we let other people – physicians, nurses, social workers, MFTs, whoever – define what our future is going to be as a profession. And that’s just not an option for us. If we’re not at the table, it’s because we’re on the menu…. When you get home and you turn your focus to health care reform, I want you to remember that other groups don’t automatically think about psychology and invite us to the table when they’re having these discussions. We have to identify health care reform initiatives that impact psychological practice and our patients and get involved in those in a proactive way. If you wait….” Aloha,

Suicides Highlight Failures of Veterans' Support System

By Aaron Glanz
The New York Times
Originally published March 24, 2012

Francis Guilfoyle, a 55-year-old homeless veteran, drove his 1985 Toyota Camry to the Department of Veterans Affairs campus in Menlo Park early in the morning of Dec. 3, took a stepladder and a rope out of the car, threw the rope over a tree limb and hanged himself.

It was an hour before his body was cut down, according to the county coroner's report.

"When I saw him, my heart just sank," said Dennis Robinson, 51, a formerly homeless Army veteran who discovered Mr. Guilfoyle's body.

"This is supposed to be a safe place where a vet can get help. Something failed him."

Mr. Guilfoyle's death is one of a series of recent suicides by veterans who live in the jurisdiction of the Department of Veterans Affairs Palo Alto Health Care System.

The Palo Alto V.A. is one of the agency's elite campuses, home to the Congressionally chartered National Center for Post-Traumatic Stress Disorder.

The poor record of the Department of Veterans Affairs in decreasing the high suicide rate of veterans has already emerged as a major issue for policy makers and the judiciary.

On Wednesday, the V.A. Inspector General in Washington released the results of a nine-month investigation into the May 2010 death of another veteran, William Hamilton.

The report said social workers at the department in Palo Alto made "no attempt" to ensure that Hamilton, a mentally ill 26-year-old who served in Iraq, was hospitalized at a department facility in the days before he killed himself by stepping in front of a train in Modesto.

The story is here.

DOD, Services Work to Prevent Suicides

By Karen Parrish
American Forces Press Service

WASHINGTON, Sept. 9, 2011 – Officials know the facts about suicide in the military services, but the causes and best means of prevention are more elusive, a senior Defense Department official said today.

In testimony before the House Armed Services committee, Dr. Jonathan Woodson, the assistant secretary of defense for health affairs and director of the TRICARE Management Activity, said DOD has invested “tremendous resources” to better understand how to identify those at risk of suicide, treat at-risk people, and prevent suicide.

“We continue to seek the best minds from both within our ranks, from academia, other federal health partners, and the private sector to further our understanding of this complex set of issues,” Woodson said.

The overall rate of suicide among service members has risen steadily for a decade, he said, and DOD and the services are taking a multidisciplinary approach in their efforts to save lives.

The Defense and Veterans Affairs Departments are developing shared clinical practice guidelines that health care providers in both agencies will use to assess suicide risk and help prevent suicide attempts, Woodson said.

DOD also is working with the Department of Health and Human Services and the Substance Abuse and Mental Health Services Administration to offer critical mental health services to National Guard and Reserve members, who often don’t live close to military medical facilities, he added.

Woodson acknowledged much work remains.

“We have identified risk factors for suicide, and factors that appear to protect an individual from suicide,” he said. “As you well understand, the interplay of these factors is very complex. Our efforts are focused on addressing solutions in a comprehensive and holistic manner.”

Defense suicide prevention research includes Army ‘STARS,’ a study to assess risk and resilience in service members, Woodson said.

“This is the largest single epidemiologic research effort ever undertaken by the Army, and is designed to examine mental health, psychological resilience, suicide risk, suicide-related behaviors and suicide deaths,” the assistant secretary said.

The study, he said, involves experts from the Uniform Services University of the Health Sciences, University of California, University of Michigan, Harvard University, and the National Institute of Mental Health.

STARS is examining past data on about 90,000 active-duty soldiers, evaluating soldiers' characteristics and experiences as they relate to subsequent psychological health issues, suicidal behavior and other relevant outcomes, he said.

DOD has added more than 200 mental health professionals from the Public Health Service to medical facilities’ staffs, and is expanding access to services in civilian communities, Woodson said.

“Within the department, we have amended medical doctrine and embedded our mental health professionals far forward … to provide care in theaters of operation,” he added.

The department also has worked to collect, analyze and share data more effectively “so that the entire care team understands the diagnosis and treatment plan,” he said.

“As important as any step, we have also made great attempts to remove stigma from seeking mental health services, a stigma that is common throughout society, and not just in the military,” Woodson continued. “This is a long-term effort, but both senior officers and enlisted leaders are speaking out with a common message.”

Defense leaders are encouraged that service members increasingly now seek professional help when it is recommended, he said.

The entire article can be found here.

Vets face shortage of therapists

New program training clinicians in psychology of combat is an attempt to help fill the gap

By Peter Cameron, Special to the Tribune

When Daniel Brautigam tried to tell therapists how he felt having urine thrown in his face at Guantanamo Bay, he experienced the same frustration as thousands of other returning veterans who have sought counseling.

"They had no idea how to respond to that. It looked like to me that they were grossed out, and they're supposed to be helping me," said Brautigam, 31, who was diagnosed with post-traumatic stress disorder and depression following his return to Hoffman Estates from tours with the Navy in the Northern Arabian Gulf and Cuba.

The Department of Veterans Affairs estimates that 11 percent to 20 percent of veterans from the wars in Afghanistan and Iraq are suffering from PTSD. Others think the number is higher.
When vets seek therapy, they want a professional who can relate to soldiers in combat, and that usually means a therapist who has military experience. Without such empathy, therapy often is doomed, vets say.

Because most psychologists and mental health care professionals don't have a military background, there's a void in the safety net for vets. Some veterans' organizations have stepped up, training members to help their peers, and the Soldiers Project provides free counseling from licensed professionals and veterans by phone to newly returned vets.

A counselor to ex-soldiers for 35 years, Ray Parrish, 58, a self-described angry veteran, sees the problem on a daily basis. He is the benefits director for Vietnam Veterans Against the War in Chicago and helps those trying to navigate the bureaucracy of the Veterans Administration.

"There quite literally are not enough people that have knowledge of veterans' experiences and who have the professional expertise to provide them the health that they need," Parrish said. "That means that all of the veterans get inadequate care."

A new attempt to fill the gap is coming from the Adler School of Professional Psychology in Chicago, which this fall is launching a military specialization track for its doctorate of clinical psychology program. Joe Troiani, a faculty member and Navy veteran who created the track, said the school hopes to prepare students for the specific psychological problems that stem from military service. They will take such classes as the psychology of terrorism, and psychology of combat and conflict.

But some vets scoff at the idea of learning about the horrors of war in the classroom.

"You're dealing with a whole different mindset with a soldier," said Tim Miller, 30, of Chicago, a veteran of the Iraq war who is now studying to be a clinical psychologist at Argosy University. "You can't just wrap your head around that from reading a book."

Troiani called that criticism fair but said the school is training students how to treat the psychological effects of combat, rather than trying to re-create the experience of living in a war zone.

Read the story here.