In his opening remarks, Richard V. Aghababian, M.D., MMS president, drew attention to recent violent events related to mental health, specifically the shooting at Newtown, Conn. and emphasized the importance of establishing a relationship between public health and mental health.

To illustrate Aghababian’s point, Jeffrey S. Wisch, M.D., clinical director, Vernon Cancer Center, acting chief of hematology/oncology and director of inpatient oncology at Newton-Wellesley Hospital, and associate clinical professor of medicine at Tufts University School of Medicine, offered a personal reflection on what he called a “broken system.” He related the story of sitting in an emergency room for hours with a 19-year old family member with severe depression; the youth was seeking admission but needed approval from the insurance company. Once this approval finally happened, no beds were available.

As a physician, Wisch expressed his frustration with the system. “I don’t need approval to admit or treat or discharge. Would a patient with chest pain be told they couldn’t be admitted because they were not yet having a heart attack?” he asks. “Mental health is where cancer was in the 1950s. The ER staff doesn’t know what to do with someone with emotional problems. There is no coordinated care going forward, no chronic rehab facility, no visiting nurse or case worker.”

To develop a more cohesive and collaborative system, the Substance Abuse and Mental Health Services Administration (SAMHSA) created a regional system that collaborates with local Health and Human Services departments to educate and engage the public and key stakeholders in the agency’s vision of public health reform. Kathryn Power, M.Ed., administrator for region one, which includes all of New England, points out that SAMHSA focuses on four key messages, specifically that behavioral health is essential to health; prevention works; treatment is effective; and people recover.

To achieve these goals, SAMHSA has devised a strategic initiative that includes block grants and the promotion of community-based services, focusing on coordinating primary care with specialty care and prioritizing prevention and quality rather than quantity of care.

Power expressed optimism regarding the Affordable Care Act (ACA), which has designated parity as its keystone. The creation of health homes, accountable care organizations (ACOs), patient safety initiatives in hospitals and quality measures for at-risk populations is a major step in the right direction toward equal treatment for those with mental illness, she says.

The economic side of parity came under discussion from Richard G. Frank, Ph.D., Margaret T. Morris Professor of Health Economics, Department of Health Care Policy at Harvard University Medical School. He notes that the government spends $329.28 billion every year on mental health-related care. “Most of the money has nothing to do with services,” he says. “How we are spending the money and how we can spend it more on services is the question.”

While Frank applauded the government’s efforts to achieve parity, he cited problems with the existing legislation. “This is regulation by analogy,” he says. “Does the service in mental health and substance abuse have comparable service on the medical surgical side?”

According to Frank, 40 percent of those under 65 have severe and persistent mental illness. Although studies on these individuals are not definitive, he does see “green shoots,” i.e., reasons for optimism. Specifically, he applauds the $100 million the government has earmarked for health care integration. “This is the biggest deal we’ve seen in mental health care ever. It’s of historical proportion and twice as important for substance abuse diagnoses. The infusion of new funds will be transformative,” Frank says. “We can’t get distracted by small stuff. We have to put the new money to work in a way to benefit the patient and not shortchange him.”

Mark Perlmutter, M.D., FACEP, chair and vice president of Emergency Network Services for Steward Health Care and associate professor of emergency medicine at Tufts University School of Medicine, addressed the on-going problem of overcrowded emergency departments where one in 21 patients presents with a mental health diagnosis. “The ED is not a locked unit, not a therapeutic milieu. The physicians don’t see these patients [immediately]. They become boarders without doctors,” he says.

Perlmutter decried the “bankers’ hours” that insurance carriers hold; patients should not have to await admission approval for hours, which is often the case, he says. He suggests rapid cycle interventions, higher reimbursement rates for certain patients and incentivizing insurers as partial solutions. “We need more transparency. We need more pilot programs to remove the silos,” says Perlmutter. “In Massachusetts, there is a lack of access and an increased demand, so the burden of care falls on the ED.”

Peter Metz, M.D., clinical professor of psychiatry and pediatrics at the University of Massachusetts Medical School, cites the System of Care, a federally supported framework for enhancing the behavioral health delivery system for children. This program is “family driven and youth guided, breaking down the silos and providing relevant services,” he says. “It’s  a family partnership at all levels of the system. It’s a community-based coordination of care, culturally and linguistically competent.” The goal of the program is to identify the strengths and weaknesses of the family, uncover what is unique and then measure the outcomes, Metz adds.

Metz believes in making “families feel they’re part of the solution.” One program that includes families is the Children’s Behavioral Health Initiative (CBHI), which serves eligible youth under 21 who have MassHealth. This program offers intensive care coordination of wraparound services; outpatient, in-home and behavior management therapy; therapeutic mentoring; family support and training; and mobile crisis intervention.

To wrap up the meeting, Ken Duckworth, M.D., medical director for the National Alliance on Mental Illness (NAMI), raised the issue of teens at risk. While preparing for his presentation, he asked his 16-year old twin daughters for advice on engaging teens in mental health advocacy. When they responded by showing him a YouTube video of “The Shake,” an international dance craze, he realized that belonging and developing an identity is crucial to teen development. “Kids have developing brains and life can be overwhelming. Kids with genetic vulnerability are at high risk for psychoses,” he says. Calling Massachusetts a “patchwork of care systems,” he notes a need to “find ways for young people to be part of a normal developmental flow.”

The Affordable Care Act (ACA), commonly referred to as ObamaCare, includes an expansion of Medicaid eligibility, a requirement for all individuals to secure coverage and health care exchanges, where individuals and smaller companies can purchase insurance at lower rates than they could on the open market.

While the ACA introduces many changes and updates to the current system, it falls short of the sweeping reform that some believe is needed.

Along with the creation of the mandated exchange and an overhaul of Vermont’s health care infrastructure, the state legislature approved a plan to create a single-payer, publicly financed, universal health care system.

“I think Vermonters were greatly concerned about the way that health care works today. It is not really a system. It’s an amalgam of a bunch of free agents and it results in a lot of inefficiency,” says Robin Lunge, Vermont’s director of health care reform. “We spend twice as much as every other country and our outcomes are far worse. It is hard to make an argument that our health care system is in any way better.”

The plan, labeled as Green Mountain Care, will eventually replace private insurance in the state tied to employment with a comprehensive system that provides basic care for all residents. It does not, according to the GMC’s Web site “require Vermonters to drop existing private coverage, nor does it prohibit Vermonters from purchasing supplemental coverage if desired.”

The drive for universal health care has been building in Vermont since the early 1990s, when individuals first collaborated to address what they felt was a broken system where small business owners, farmers and others without insurance paid exorbitant rates for care.

After many failures, they found a champion in now-Governor Peter Shumlin, who promised to work for a single-payer plan. Using a study by William Hsiao, Ph.D., a professor of economics at the Harvard School of Public Health and an internationally recognized expert on health care systems, to back up the push, advocates got the idea approved by the state legislature in 2011.

“We actually had three health care studies that looked at reform and they all found that the single payer plan was the best way to make sure all are covered, all contribute and reduce waste,” says Lunge.

What remains to be seen, of course, is exactly how it will work. If health care is no longer tied to employment, will it be funded by a replacement tax to individuals and corporations? Will larger employers leave the state rather than pay the increased tax even if it reduces their health care costs? How will private insurers be involved in the plan if they are allowed to bid for the right to deliver some of the administrative services? And, how will this affect health care professionals?

Before the plan’s implementation, hurdles must be overcome. The details and funding mechanism must be determined and the state will also require a waiver from the federal government because it will replace the mandated health insurance exchange.

The administration hopes to get the plan online in 2017.

Within psychology, there are many concerns about how this will affect private practice. One question brought up on the Vermont Psychological Association’s Listservice is whether professionals will no longer be allowed to work directly with insurance companies to negotiate deals.

“But I don’t think you’ll find many providers making their own deals with insurance companies now,” says Lunge. “Insurance companies dictate the rates for smaller providers.”

Another concern is that reimbursements are too low. According to Lunge, this concern is being taken very seriously because they know that the success of the system rests on keeping providers in Vermont to offer services.

“Right now, we are a fairly well paying Medicaid state,” she says. “We are paying at 80 percent of Medicare, which is better than most other states. We also recently voted to increase rates along with inflation rates. We are committed to working with our providers.”

The only way to combat this feeling of unease about the parts of the plan that have not been finalized or publicly announced, says Rick Barnett, Psy.D., LADC and president of the Vermont Psychological Association, is for professionals to participate in the process.

“As a global construct, single payer is a positive step forward. But with the finer details, it’s a lot less clear how positive this movement will be. We have to be active at the table and contribute to how it is shaped. To that end, the VPA are trying to be more and more involved as health care reform evolves.”

Gov. Deval Patrick’s comprehensive gun control bill would bring Massachusetts into compliance with the NICS Improvement Amendments Act of 2007, the federal law passed after the Virginia Tech shooting tragedy. One provision would require courts to transmit mental health adjudications and orders to the state’s criminal justice information system to forward to the federal government for use in firearms licensing. The courts would specify if a person’s commitment is based on a finding that they are “an alcoholic, a substance abuser or both.”

Another bill by Rep. David P. Linsky (D-Natick) would require all gun permit applicants to waive their right to privacy and disclose mental health treatment or services obtained for the previous 20 years.

Patrick’s bill proposes $5 million for Department of Mental Health programs, including training for teachers to recognize symptoms of mental illness in students, crisis intervention training for first responders and access to psychiatric consultations for pediatricians with concerns about young patients.

“We’re very grateful the governor recognizes that safe communities depend on having adequate access to mental health resources,” says DMH Commissioner Marcia Fowler, M.A., J.D.

Fowler says DMH receives 10,000 annual requests from local police chiefs conducting gun applicant background checks. Because Massachusetts has no statutory mechanism in place to send mental health information to NICS, out of state gun dealers can’t access Massachusetts records during background checks.

DMH provides information on people admitted to its inpatient facilities but has no authority to collect information on patients admitted to private psychiatric facilities. In 2012, DMH facilities admitted 1,700 patients, of whom 1,400 were involuntarily committed. But many more patients are treated at private hospitals: 74,000 private admissions were recorded in 2011 with 811 being involuntary.

Under Linksy’s bill, violators failing to report mental health treatment records could be charged with a felony and face up to five years in prison. Linsky says health information would be destroyed within 30 days following the issuing of a license or the outcome of any appeal.

“My intent here is not to deny a firearm license for someone who legitimately wants one and went through a minor issue some years ago, counseling for divorce or a job loss, something minor,” Linsky says.

In a state where the suicide rate is 2.7 times higher than homicides, both Fowler and Linksy acknowledge the two bills could keep firearms out of the hands of those who would harm themselves rather than others. Firearms were the state’s second most common suicide method (26 percent) after hanging (49 percent), according to 2011 Massachusetts Department of Public Health Injury Surveillance Program preliminary data.

“We want to tread carefully on taking measures that will have any type of chilling effect on people’s access to mental health services,” Fowler says. “The biggest thing we can do to make our communities safe is to ensure that people are aware that treatment is effective, people do recover from mental illness and that it’s okay to access mental health services.”

The National Alliance on Mental Illness of Massachusetts has “major problems” with requirements to share up to 20 years of mental health records, which would further stigmatize people with mental illness, Executive Director Laurie Martinelli, M.P.H., J.D. says.

“We think that a history of violence should be the deciding factor and not whether someone has mental illness. The vast majority of people with mental illness are not violent, have never committed a violent act and never will commit a violent act. They are mostly the victims of violence,” Martinelli says.

Three years ago, Russel A. Barkley, Ph.D., a clinical professor of psychiatry at Medical University of South Carolina, wrote about a lack of validity for the use of neuropsychological testing for the diagnosis of ADD and ADHD (“Impairment in occupational functioning and adult ADHD: the predictive utility of executive function (EF) ratings versus EF tests,” Clinical Neuropsychology, May 2010). He concluded that testing did not identify the disorder as reliably as self-reported scales.

“The controversy started in the literary journals with publications of mine that replicated and expanded earlier studies, but focused specifically on ADHD, and got the same results,” says Barkley.

Studies have shown, he says, that neuropsychological testing is not useful in diagnosing in part because it can often have false negative results.

“I was arguing that the use of these tests is no longer defensible and even borders on malpractice,” he adds.

The reaction to his article was immediate and fierce.

“The listservs across the country lit up over it,” he says. The issue, he adds was that for many, this discussion was about finances and was “not science-based. It was more emotionally charged.”

His comments began to work their way into legal cases and he found insurance companies asking for his opinion. In part because of his view, he says, private insurance companies have begun to change the way they cover neuropsychological assessments.

“It was no longer just an academic discussion,” he says. “It was now going into practice.”

Locally, the debate has begun to affect the way psychologists treat clients.

“It used to be far fewer insurance companies required prior authorization, which is really a cost management tool, for neuropsychological testing,” says Mitchell Clionsky, Ph.D., ABPP(CN), a neuropsychologist with a clinical practice in Springfield, Mass., “The insurance companies started insisting you know the answer [about the diagnosis] before you ask the question and they decided that ADD was not a diagnosis that required neuropsychological testing.”

In many cases, testing is covered as a medical benefit in a case where neurological impairment (head trauma, seizures, etc.) can also be proven.

While Clionsky agrees that testing should not be used as the primary tool to diagnose ADD/ADHD, because of the possibility of false negatives, the in-depth look at executive functioning should not be undervalued.

“I am in agreement that neuropsychological testing is not necessary to do a diagnosis,” says Clionsky. But, he adds, the testing can help tease out which executive functions are impaired and whether medication is helping. “To understand how the patient does with learning and memory, these things are not answered with a check list.”

Clionsky, who attended graduate school with Barkley, had a discussion with him recently about the debate. He felt that Barkley’s position on testing had been taken too far by insurers. The problem is that insurers do not want to pay for any claim that has ADD as the diagnosis, even if it is not used to actually make the diagnosis, but to support or to help with treatment.

“The statement that it is not needed for diagnosis (made by Barkley) was used by insurance companies to say that there is no place for it in ADHD at all. We do it more to see what else is impacted. It is important as a tool to rule out other issues, to make sure we are not missing something.”

With testing harder to get covered, practitioners often find they cannot provide services they feel would be helpful.

“It puts us in a difficult situation on how to provide adequate services of a growing part of our population,” Clionsky adds. “Why would we not bring to bear the important information that neuropsychological testing offers?”

Mary Schohn, director of mental health operations out of the VA Central Office, confirms that having one state license allows a psychologist to practice in any VA facility. “This applies to all VA facilities across the country,” she says, noting that the VA has always had this policy in place. Not only does the VA offer many opportunities for advancement, but the flexibility to move from one state to another also fosters professional growth, according to Schohn.

Providers who work in private or group practice and, for one reason or another, have an opportunity to move to another state must apply for a license in the new location. “This discourages movement,” says Schohn. “With the VA, you can readily relocate without getting a new license.”

Schohn points out that the psychologist must possess the right training and have a demonstrated expertise in a specific area when applying for a job at any VA facility in order to be hired.

The VA has been known to frequently hire newly licensed clinicians. “We hire people when they’ve finished their training when they don’t know where they want to be in 10 years,” Schohn says, noting that in most cases, these individuals remain in the VA system.

Michael Culpepper, chief officer for Workforce Management and Consulting for the VHA, adds, “[Having one state license] makes it easier to deploy trained clinical professionals and serves as a big draw in our marketing and recruiting campaign. Psychologists basically have a portable license.”

Since March 2012, a combined total of 48 psychologists and psychiatrists have shifted from one facility to another, according to Schohn. The VA is currently undergoing a recruiting campaign to hire more psychologists and psychiatrists and showcases the licensure benefit as part of its marketing strategy.

According to Deborah Baker in the legal and regulatory affairs department at the American Psychological Association, the general policy for health providers working in federal agencies/federal settings is that they must be licensed in good standing. “State health care licensure laws typically have an exemption for federally employed providers who work in federal settings. So a provider need not necessarily be licensed in the jurisdiction where the federal agency or facility is located so long as he/she maintains an active state license in good standing and is practicing only in the federal setting,” she says.

The Senate passed the bill in May and the House of Representatives was considering it at press time.

Currently in Connecticut, psychologists and physicians can have a joint location, but they cannot be partners. The legislation would redefine “professional corporation” to include corporations that are organized for the purpose of providing professional services by physicians and psychologists.

About half of the states currently have similar statutes, including Massachusetts, Rhode Island and New Hampshire.

Traci Cipriano, J.D., Ph.D., licensed clinical psychologist and director of professional affairs for the Connecticut Psychological Association (CPA), was among those offering testimony in support of the bill and says the ability for psychologists and physicians to incorporate as a multidisciplinary practice is becoming increasing relevant amidst healthcare reform and the formation of Accountable Care Organizations (ACOs), geared toward integrated, team-based care.

Cipriano says benefits of having a psychologist in the same office as a primary care physician include: patients can see both in one visit, records can be easily accessed for continuity of care and a bundled payment can cover both services.

“This is a really important step toward patient-centered care, and for providing integrated care,” Cipriano says.

It may also benefit psychologists who are in private practice or in smaller practices and considering joining larger practices, as this introduces another option to help them survive and thrive in the changing healthcare climate.

“I think a lot of psychologists are starting to think about what they need to do to survive in private practice,” she says. “Do they need to diversify in the type of work that they do or join a medical practice, or do something else? It’s at the forefront of people’s minds right now.”

Joint practices can help foster better communication with the primary care doctor and reduce redundancies, she says. Additionally, many primary care visits are rooted in a psychological cause, she says.

Research shows that when a physician refers a patient to a psychologist, approximately 50 percent do not make it to the first appointment, she says.

“Having a psychologist on site, they are there for brief interventions but also to enable that first handoff,” she says. “It would hopefully address more of the mental health needs of patients and thereby decrease costs, because if people keep going to primary care when their issue is really a psychological one and maybe coping strategies or other skills are warranted, that increases costs.”

According to Kahn, “Heroes put aside their emotions. They have to be clear thinking in the moment. Later, all the feelings come barreling in. There’s a cost to that.” The group and confidential, one-on-one sessions Kahn and the firefighters conducted aimed to alleviate post-trauma symptoms. “The New York firefighters had responded to the 9/11 attacks so served as role models, having gotten help themselves and are now functioning well,” Kahn says.

Critical incident stress management (CISM) training may account partly for the shift toward acceptance. Kahn indicates that first responders know to apply these techniques in situations like the marathon bombing. She points out that adding eye movement desensitization and reprocessing (EMDR) after CISM helps to fully integrate emotions.

In spite of the recent shift, some first responders are still reluctant to seek psychological help, fearful of the potential impact on their careers. All mental health visits require approval from insurance companies so if word gets to supervisors, the individuals may not get promotions or otherwise advance, says Kahn.

To overcome that barrier, the Boston area TRN is offering three to five pro bono sessions following this traumatic event. “It doesn’t go through insurance so it remains confidential,” Kahn says.

Also, at the request of the Massachusetts Departments of Mental Health (DMH) and Public Health (DPH), the Riverside Trauma Center in Dedham is providing psychological first aid to residents and businesses affected by the Boston Marathon bombings. Larry Berkowitz, Ed.D., director and co-founder of the center, reports that his staff has helped some first responders but notes that most go through their own EAP or peer networks for assistance.

Riverside staff has worked with Boston as it reintroduced owners to their businesses at the bombing site. “We also worked with the city of Cambridge, helping the schools, students and faculty cope with the assault on their community,” he says. One of the alleged bombers lived and attended school in Cambridge.

Currently, Riverside is assembling coping groups to facilitate healing, according to Berkowitz. He says that these groups will benefit some of the medically trained bystanders who unexpectedly had to leap into action on marathon day.

In addition to first responders, hospital personnel who treated the victims may suffer some post-traumatic issues, according to Andrea Stidsen, LICSW and Henrietta Menco, LICSW, certified EAP (Employee Assistance Program) professionals for Partners Healthcare. Hospital departments most directly involved with the aftermath of the bombing, i.e., the emergency room, operating rooms, intensive care and trauma units, have been the ones most seriously affected, says Stidsen.

Sleep difficulties, including nightmares, hyper vigilance and fatigue are the most prevalent presenting symptoms, says Stidsen. Menco adds, “Some people report having visual images they can’t get out of their minds.”

“People feel their reactions are abnormal, but it’s the situation that was abnormal,” says Stidsen. “We try to normalize their feelings.”

Menco says that since 9/11, seeking mental health counseling following a traumatic event has become more normative. “We’re seeing people who might not typically have sought services. People like physicians and security personnel are not ashamed.”

Stidsen attributes this shift in attitude to hospital leadership that encourages and sanctions efforts to get counseling. “Hospitals have done a great job of letting people know what resources are available and what symptoms to look for,” she says. “The media has also helped to reduce the stigma.”

Halaris, medical director of adult psychiatry and professor in the department of psychiatry and behavioral neurosciences at Loyola University Chicago Stritch School of Medicine, formally proposed creation of a new subspecialty called psychocardiology at the joint congress of the World Psychiatric Association and International Neuropsychiatric Association in Athens, Greece.

His proposal was offered in conjunction with study findings showing that an inflammatory biomarker, interleukin-6 was significantly higher in the blood of 48 patients diagnosed with major depression than it was in 20 healthy controls.

Research has shown that 30 to 50 percent of patients who suffer depression are at risk of developing cardio vascular disease and 40 to 60 percent of heart disease patients have clinical depression. Interleukin 6 has an effect on the formation of serotonin, which is an important transmitter of emotional stability.

Halaris acknowledges that the link between depression and heart disease has long been researched and recognized, but feels now is the time to take that information to the next level. “There have been numerous studies in North America and abroad for many years but they haven’t been translated into meaningful programs to address co morbidity,” he says. “I think intuitively it is the right time to bring this concept forward in a general manner.”

He says that while the idea is in its infancy, he would ultimately like to see psychocardiology evolve as a discipline with its own journal, conference and multidisciplinary teams of mental health and medical professionals collaborating productively in various settings.

“The biggest challenge will be to get hospital administrators to get excited about this concept and forge ahead and develop multidisciplinary programs. There’s a degree of inertia amongst all of us. We need to break down barriers of silo structures of departments. The tendency is to each do our own thing and only talk across the hall when there’s a dire emergency,” Halaris says.

Although bringing this concept to reality could take a decade or more, Halaris says the next step is creating teams comprised of psychiatrists, psychologists, social workers, cardiologists, nurses and others working jointly in academic and medical settings toward a common goal. “We need to do a better job at assessing, diagnosing and treating patients to help prevent cardiac problems with depression or depression that potentially leads to cardiac problems later in life. There has to be interaction beyond referrals after the condition is too far gone.”

Halaris will be presenting his concept to the Association of Psychosomatic Medicine later this year and emphasizes that psychologists should and must play a major role in the process. Psychologists can play a significant role in helping patients manage stress using interventions involving lifestyle, behavioral, cognitive and other changes, he notes, while psychiatrists handle the medical component. Continuing education to physicians in the safe and correct use of medications in cardiac patients with psychiatric co morbidity is another part of the plan.

While Halaris is excited about the possibilities of collaboration, others express skepticism.

Gregory Fricchione, M.D., director of the division of psychiatry and medicine and Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital says there are already psychiatrists, cardiologists and integrative medicine specialists who focus their careers on “points at the interface of heart disease and mood and anxiety disorders…I don’t see the need to establish a new cumbersome bureaucracy – new training schemas, education committees, expensive board exams – to establish this field of work and study.”

Fricchione notes that the Benson-Henry Institute focuses on health promotion and illness prevention including cardiac rehab and wellness through relaxation response training and resiliency enhancement including nutrition advice and exercise. He adds that cardiology and psychiatry meetings feature sections and journals routinely publish articles “at the interface of cardiology, psychiatry and psychology.”

Robert Allan, Ph.D., co-author/editor of “Heart and Mind: The Practice of Cardiac Psychology,” is a New York-based clinical psychologist with practice specialties in cardiac psychology, stress and anger management, a clinical assistant professor of psychology in medicine at Weill Cornell Medical College and a professional associate at New York Presbyterian Hospital.

He feels that focusing only on the link between depression and cardiovascular disease is “narrow, short-sighted and behind the curve,” because it excludes major risk factors like anger and social issues. Allan says that the field of cardiac psychology is arguably informed by the largest empirical database in behavioral medicine, therefore Halaris’ proposal appears to be “coming a little late to the table.” Still, he agrees that psychologists need additional training in this field and require more knowledge about cardiology in order to interact with physicians and “understand the lingo.” In addition, with a groundswell effort to cut down on hospital readmissions, there’s an opportunity for clinicians to make an impact by partnering with other personnel in hospital cardiac rehabilitation programs.

Ellen Dornelas, Ph.D., a health psychologist at Hartford Hospital and associate professor at the University of Connecticut Health Center, says that even with 40 years of research behind it, there’s still a lot to learn about the cardiology/psychology link.

The author of “Psychotherapy with Cardiac Patients: Behavioral Cardiology in Practice,” says that cancer care has been ahead of the curve with a specialty for psycho-oncology, a journal devoted to the topic, an annual meeting and a professional organization. “I would like to see the field continue to evolve with similar professional activities.”

Also the editor of “Stress Proof the Heart: Behavioral Interventions for Cardiac Patients,” Dornelas agrees that there is room for improved integration of psychological delivery of care into the delivery of cardiac medicine. “In this regard, he (Halaris) is doing a good thing. It’s nice to take the next step forward,” she says.

Peter Albert, senior vice president of Government Affairs at the Retreat says, “After an on-site survey in February by the Center for Medicare and Medicaid Services (CMS), the Brattleboro Retreat received a letter on March 13 citing deficiencies. The Retreat has submitted a Plan of Correction and CMS conducted a follow-up survey the week of April 15. We are awaiting the CMS report in response to the Plan of Correction and follow-up survey.”

Courtney Jenkins, Boston Regional Office press contact for the Centers for Medicare and Medicaid Services, provided a redacted version of the statement of deficiencies and plan of correction. The investigation was conducted over a seven-day period in response to 14 complaints spanning 10 months.

The statement notes the hospital’s “failure to respect patient’s right to refuse treatment, failure to promote and maintain a physically and emotionally safe environment, failure to implement appropriate use of restraints and/or seclusion in accordance with federal requirements and facility policy and failure to report allegations of mistreatment in accordance with state and federal requirements.”

The survey revealed improper documentation, including improperly filed and out of sequence Certificate of Need for Emergency Involuntary Procedures, physician orders, progress notes and other pertinent information. In late March 2013, the Retreat did implement new documentation flow sheets for neurological, respiratory, cardiovascular, musculoskeletal and integumentary systems.

According to the statement, the hospital must use data collected to “identify opportunities for improvement and changes that will lead to improvement.” Also the hospital must prioritize performance improvement activities that “focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence and severity of problems in those areas; and affect health outcomes, patient safety and quality of care.”

Once these actions have been implemented, the hospital must “measure its success, and track performance to ensure that improvements are sustained.”

The plan of correction indicates that the chief medical officer, in collaboration with the Brattleboro Retreat’s attorney and other staff, addressed the deficiencies, including revision of the policies for Emergency Involuntary Medication, Observation Levels/Safety Levels and other areas noted in the survey. All staff has been educated in the new protocols and will conduct regular audits in all units.

The Brattleboro Retreat’s Albert says, “Our recent growth as a hospital has been accompanied by a process of continuous learning, problem solving, creativity and innovation. We remain focused on excellence in our clinical practice at all levels of the organization to assure that we are providing exceptional and compassionate care to our patients. We are confident that we will correct all cited deficiencies and make all necessary improvements.”

The Retreat filed a plan of correction on April 24, 2013, which was accepted by the Vermont Department of Disabilities, Aging, and Independent Living.

Eighteen of the program’s 36 credits are courses and practicum experience required by the Behavior Analyst Certification Board (BACB) to sit for the national certification exam. Salve will also offer a certificate of advanced graduate studies (CAGS) in ABA for students with a master’s degree in a related field seeking national certification as an applied behavior analyst.

The program’s development started three years ago and received BACB approval last October, says Associate Professor and Department of Psychology Chairwoman Sheila Quinn, Ph.D., who serves as Salve’s graduate director in psychology.

“The mission of Salve has always been not only rigorous academics but there’s always been a service component,” Quinn says. “Applied behavioral analysis really teaches students to look at the environment and to manipulate or change that environment so that people are achieving their maximum potential.”

ABA is best known as a treatment for children with autism. Current estimates suggest 1 in 50 children are diagnosed with autism. In August, 2011, Rhode Island became the 27th state to pass an autism insurance reform bill requiring insurance coverage for ABA treatment. Less than a year later, in June, 2012, Gov. Lincoln Almond signed legislation to create a licensure board for behavior analysts in Rhode Island.

ABA also addresses a wide range of populations and settings such as law enforcement and corrections, business, hospitals and treatment centers.

“Although graduates in the field can apply their skills in a multitude of settings from schools to businesses, there is a significant need for more professionals to serve the increasing number of children being diagnosed with autism,” says Andrea Chait, Ph.D., BCBA-D, NCSP, an adjunct faculty member at Salve who worked closely with Quinn in developing Salve’s program.

Salve’s projected enrollment for fall 2013 is 15 students, Quinn says. Coursework will cover areas such as measurement and data analysis, behavior change techniques, assessment and systems management and ethics and professional conduct. Salve’s closest competitor offering a master’s degree in ABA is the University of Massachusetts Dartmouth.

“Our first graduates are probably going to receive most of their training in working with people with disabilities. However, we’re definitely going to be going in the direction of looking at the business environment,” Quinn says.

Salve also offers a post-baccalaureate certificate program for those with bachelor’s degrees who want to complete the assistant behavior analysis courses.