Practice Keynote: A Report on National Practice and Advocacy issues

1. Practice Keynote:A Report on National Practice and Advocacy issues Carol D. Goodheart, Ed.D. Princeton, New Jersey Email: carol@drcarolgoodheart.com Website: http://www.drcarolgoodheart.com

2. What is Counseling Psychology Practice? • Generating & using knowledge for change • Psychology = Ultimate translational science • Practitioners translate, synthesize, select, combine, integrate, & tailor science for public good • Practitioners provide diverse services, in diverse settings, for diverse populations & organizations • Practice = ALL applications of psychology’s scientific foundation

3. Where is CP Practice • Health care and non-health care • Institutional settings • University & College counseling centers • Veterans Administration facilities • Community health & mental health centers • Independent settings • Solo and group practices, consulting firms • Policy and administration

4. Core CP Principles Infuse Practice • Health & adaptation, building upon strengths • Developmental perspective/life span approach • Social and cultural context • Brief interventions, as appropriate • Healthy work relationships, behavior &role fulfillment Gelso, C.J., & Fretz, B.F. (1986). Introduction to Counseling Psychology. New York: Wiley

5. A Bit of History • Advocated for mental health & health services • Advocated for Freedom of ‘Choice laws & reimbursement • Advocated for inclusion in Medicare • Flourished as mental health profession • Now enlarging frame: behavior experts, health profession, integration of mind/body, RxP, parity

6. Health Care Marketplace in U.S. • Costs • 5.9% GNP in 1965; 13.9% 1993; 16% 2007; 20% 2010 • Market Driven, Free-Enterprise Health Care • Competition For Cost and Quality • Accountability movement: managed care, restrictive EBT lists, outcomes review, CDHPs • Publicly-Funded Health Care Changes • Cuts in Funding • Privatization • P4P

7. Worrisome Turmoil • Impact on healthcare practitioners: stagnant incomes, reimbursement cuts, longer work hours • Gone in CMHCs; disappearing on panels (50% SWs, 25% psychiatrists, 25% psychologists • Leaving the VA • ECPs: where to turn with debt and prospects

8. The Good News • Practitioners have changed the way they practice, offer new services, & negotiate with panels for needed mh services • Plenty of room outside of health care • Successful ones are quiet • Organizational pushback: APA, APAPO, SPTPAs provide information, tools, strategies, & advocacy

9. Areas for Advocacy • Prescriptive authority • Restore Medicare MH reimbursement cuts • Acknowledge E & M services in Medicare • Enact strengthened Mental Health Parity bill • Health Information Technologylegislation (records privacy protection) • Fund the Mentally Ill Offenderlaw • EBPP • Pay for Performance

10. APA Policy: Evidence-Based Practice • IOM defines evidence based practice as: ‘the integration of the best research evidence with clinical expertise and patient values.’ • APA defines EBPP as: ‘the integration of the best available research evidence with clinical expertise in the context of patient characteristics, culture, and preferences.’ Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. APA policy statement: http://www.apa.org/practice/ebpstatement.pdf APA Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. American Psychologist, 61, 271-285

11. Words Matter • EBBP has profound implications for practice, training, and policy. • What is designated as “evidence-based” will determine, in large part, what treatment is conducted, what is taught, what is funded. • EBPs are ripe for misuse and abuse • Time to advocate, lest others unilaterally decide for us Norcross, J. EBPP: Implications for practice, training, and policy. APA Convention symposium, August, 2005.

12. Working Assumptions • Call for accountability is here to stay: Health professions will need to demonstrate the safety & efficacy of services • Solid position: Psychology has been a leader in demonstrating efficacy & in conducting outcome research • Demands for evidence will escalate: No amount of kvetching, howling, or resolutions will alter it • External demands arise from efforts to improve health AND to restrict services/decrease expenditures: It’s about effectiveness & money Norcross, J. EBPP: Implications for practice, training, and policy. APA Convention symposium, August, 2005.

13. “Evidence Based”: Often Used, Rarely Defined • Many uses of the term “evidence based” can be found in federal and state legislation • Frequently referenced in policy documents • The term is defined by referencing to other documents, resulting in circuitous definitions OR narrow definitions resulting in lists of treatments • Policy makers like it but don’t always seem to know what it means! Bufka, L. “Evidence Based” in legislation and policies. State Leadership Conf, 2007

14. APA’s Strategies for EBPP • Develop coalitions with other professional and consumer groups • Advocate that good clinical practice values clinical expertise and the individual patient and is not about the mere application of treatment protocols • Ensure that psychology is “at the table” Bufka, L. SLC, 2007

15. Pay for Performance Initiatives • Differential payments for similar services • Bonuses based on: • Outcomes • Following protocols • Meeting reporting benchmarks (HEDIS) • Data information systems • Focus on the aggregate Eisman, E.(2006). Pay for performance and outcomes.SLC, Washington, D.C.

16. Metrics to Assess Quality & Outcomes of Care • Feasibility • Relevance • Scientific quality • Reliable • Valid • Auditable • Actionable Doucette, A. By the numbers: Outcome metrics-pay for performance. SLC 2007

17. Targeting Performance Measurement – Outcome Efforts Potential factors to measure for outcomes: • Distress – symptoms and function • Common factors – e.g. alliance • Motivation- stage of change • Retention in care • Satisfaction • Adherence to treatment plan Doucette, A. By the numbers: Outcome metrics-pay for performance. SLC 2007

18. P4P Potential Problems • Care providers focus on doing what is needed to attain incentive • Potential negative effect on teamwork & collaboration • Incentive payout may be greater than anticipated & result in increasing the standards and benchmarks to merit incentives • As performance improves it may become more difficult to sustain P4P over time • Potential to select patients who will likely do well Doucette, A. By the numbers: Outcome metrics-pay for performance. SLC, 2007

19. What to Do? Be Alert • Attend to the motivation behind the legislation • Watch for “Evidence based” showing up in terms of treatment and measures • Examples are in Worker’s Compensation, rate setting, health administration • Be active • when proposed legislation directly relates to medical care & specifies physician involvement- psychology must advocate at outset that our practice approaches are sufficiently represented • Use the APA definition of EBPP and documents Bufka, L. “Evidence Based” in legislation and policies. SLC, 2007

20. New Initiatives for Psychology Practice • TF on the Future of Psychology Practice • Proposed new policies for APA on integrative care • Practice Summit 2009 • APA & APAPO • New Executive Director, Katherine Nordal • APAPO • New Center for Professional Development, coming soon