M.D. Update Issue #82

THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE PROFESSIONALS Issue #82

Special Section

Senior Health

E xpanding the Visual F ield Retina Associates of Kentucky enters the Louisville market and continues to be a leader in restoring vision in seniors

Also in this issue  A RURAL-URBAN Volume 4, Number 7

FAMILY MEDICINE PARTNERSHIP

 INSTITUTIONAL AND POST-ACUTE CARE FOR SENIORS  GUIDELINES FOR PARKINSON’S NONMOTOR SYMPTOMS  THE PERILS OF GRIEF  SEX & AGING

We’re improving access to quality health care because you live and work here.

Better care is here. And here to stay.

At KentuckyOne Health, we’re continuing to improve access to high quality health care. We believe that every Kentuckian from the hills of eastern Kentucky to the city of Louisville should receive the same level of care.

As we welcome the University of Louisville Hospital and the James Graham Brown Cancer Center into our system, our more than 200 health care locations from hospitals to home health agencies are more committed than ever to creating healthier communities across Kentucky.

Continuing Care Hospital Flaget Memorial Hospital Frazier Rehab Institute James Graham Brown Cancer Center

Jewish Hospital Jewish Hospital Medical Centers: East, South, Southwest, Northeast Jewish Hospital Shelbyville Jewish Physician Group

Our Lady of Peace Saint Joseph Berea Saint Joseph East Saint Joseph Hospital Saint Joseph Jessamine

KentuckyOneHealth.org

Saint Joseph London Saint Joseph Martin Saint Joseph Mount Sterling Saint Joseph Physicians Sts. Mary & Elizabeth Hospital

University of Louisville Hospital VNA Nazareth Home Care The Women’s Hospital at Saint Joseph East

from the publisher’s Desk

Physician-Led Health Care While attending the Lexington Medical Society’s meeting in October, I heard Dr. Ardis Hoven, president of the AMA emphatically state that the solution to providing care to the millions of new patients now included in the Affordable Care Act was “physician-led health care teams using practice extenders to their highest level of education, expertise and training.”

Hoven’s words echoed the same message spoken a month earlier by Fred A. Williams, MD, president of the Kentucky Medical Association in his interview with M.D. Update editorin-chief Jennifer Newton. (M.D. Update # 81, pg 4, Headlines) “In an attempt to get our arms around the access problem, we recognize that physicians by themselves are not going to be the sole answer.”

Enter Senior Health. Geriatric Medicine. Palliative Medicine. Hospice Care. Long-term Acute Care.

Home Health. Durable Medical Equipment. Mental Health of Aging.

You get the picture.

As Dr. Robert Taylor, Medical Director of Cardinal Hill Rehabilitation Hospital’s Home Health program told me, “Eventually, almost all of us will have a stay in a rehabilitation hospital, and if we’re fortunate, we’ll end our time in home health care.“ This issue of M.D. Update, our Senior Health issue, introduces some of the physicians and physician-led team members in Kentucky who work every day with patients who are called “elderly, senior, geriatric, or older.” I invite you to read their stories.

Contact me if you have a story to tell.

All the Best Gil Dunn Publisher, M.D. Update

Publisher note:

We regret a case of mistaken identity in last month’s cover story on members of the Markey Cancer Center. We incorrectly identified Daret St. Clair, PhD and Heidi Weiss, PhD. We apologize. Here are the correct photos and captions.

17

Daret St.Clair, PhD, associate director for Basic Research 19

Heidi Weiss, PhD, biostatistician and associate director of Shared Resources

Submit your Letter to the Editor to Jennifer S. Newton at jnewton@md-update.com 2 M.D. Update

Volume 4, Number 7 Issue #82 Publishers

Gil Dunn Print gdunn@md-update.com Megan Campbell Smith Digital mcsmith@md-update.com Editor in Chief

Jennifer S. Newton jnewton@md-update.com Graphic Designer

James Shambhu art@md-update.com

Contributors: Jan Anderson Valerie Areaux Scott Neal Kathryn Sandusky Sarah Schirmer Matt Smith Turner West Sarah Charles White

Contact us:

Advertising and Integrated Physician Marketing:

Gil Dunn gdunn@md-update.com

Mentelle Media, LLC

38 Mentelle Park Lexington KY 40502 (859) 309-0720 phone and fax Standard class mail paid in Lebanon Junction, Ky. Postmaster: Please send notices on Form 3579 to 38 Mentelle Park Lexington KY 40502 M.D. Update is peer reviewed for accuracy.

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Contents

Issue #82

cover story 4 HEADLINES 5 FINANCE 6 ACCOUNTING 7 LEGAL 9 COVER STORY 14 SPECIAL SECTION  SENIOR HEALTH

Expa n din g th e Vis ua l Fie l d

21 COMPLEMENTARY CARE 27 NEWS 31 EVENTS

Retina Associates of Kentucky enters the Louisville market and continues to be a leader in restoring vision in seniors page 9

Special Section  Senior Health 14 FORWARD THINKING: TJ SAMSON FAMILY MEDICINE & GLASGOW FAMILY MEDICINE RESIDENCY 

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16

18

20

16 IN THE BALANCE: KINDRED HEALTHCARE   18 A TEMPLATE FOR EXCELLENCE: LEXINGTON CLINIC NEUROLOGY   20 THE SALIENCY OF PALLIATIVE CARE: PALLIATIVE CARE CENTER OF THE BLUEGRASS 

Issue#82 3

Headlines

“Falls Summit” at Cardinal Hill Rehabilitation Hospital Aims to Reduce Risk, Injury, and Death In-patient hospitalizations for fall injuries skyrocket in less than 10 years “Falls are the leading cause of injury related deaths in older adults,” states Steve Sparrow, program coordinator of the Kentucky Safety & Prevention Alignment Network (KSPAN), part of the Kentucky Injury Prevention and Research Center (KIPRC), which is a joint venture of the Kentucky Department for Public Health and UK College of Public Health.

Fall prevention is such a public health issue that there is a standing committee within KSPAN, called the Kentucky Safe Aging Coalition, which began in 2008, and whose goal is to prevent and minimize fall related injuries among older adults.

“Falls in the older adult population can be caused by a number of factors, such as chronic diseases like osteoporosis, diabetes, stroke, dementia, and arthritis or multiple medicines prescribed for chronic diseases.

4 M.D. Update

Fall prevention encompasses all of these potential public health issues. Preventing falls enables older adults to stay in their home longer and decreases the burden on caregivers,” says Connie Gayle White, MD, MS, FACOG, deputy commissioner of Clinical Affairs, director, Division of Prevention and Quality Improvement Kentucky Department for Public Health.

White and other experts in fall safety and prevention participated in the 6th annual Falls Summit presented by KSPAN at Cardinal Hill Rehabilitation Hospital in Lexington on Wednesday October 16, 2013.

Both Sparrow and White say that one of the most effective treatments that primary care and geriatric specialists can employ for fall prevention for senior patients is utilizing the Stopping Elderly Accidents Deaths & Injuries (STEADI) program from the Centers

By Gil Dunn

for Disease Control and Prevention to assess whether their patients have fall risks and how to help prevent falls among older adults.

STEADI is an in-office procedure, which screens for fall risks with an 11 item checklist that includes fall history, medication review, strength and balance testing, hypotension, vision testing, and more.

The Costs of Falls is Personal and Financial

According to statistics gathered by KIPRC and published on the KSPAN website, www.safekentucky.org, hospital charges for fall-related in-patient treatment for adults 65 years and older in Kentucky has risen from $96M in 2003 to $267M in 2011, an increase of 275 percent. Female in-patient hospitalizations for fall related injuries outnumber male patients nearly three to one.

“The increase is most likely due to a large aging population and increasing health care costs,” says White. “To combat these increases, we need to utilize evidence-based fall prevention programs and partner with key stakeholders like the Kentucky Safe Aging Coalition to maximize and combine available resources to lower the elevated costs.

Prevention is the key to decreasing costs.”

“As a physician, I am aware of the time dedicated by providers to investigate, diagnose, and track down every detail of a patient’s progress while managing their chronic diseases. We must not lose sight of the fact that an individual’s quality of life can be significantly diminished if we do not also emphasize the importance of improving muscle strength, maintaining balance control, and falls prevention tactics. Many patients point to a fracture of the wrist, shoulder, serial vertebral fractures, and certainly, a hip fracture as the ‘beginning of the end’ of their independent high-quality life that is replaced with new limitations, restrictions, and chronic pain,” says White.

“We encourage physicians and all providers to use the STEADI program,” says Sparrow. “To be a part of a local fall prevention program, please contact Hannah Keeler at (859) 323-4747 or register on the KSPAN website at www.safekentucky.org.” ◆

Finance

Fine Wine and Estate Planning As financial planners, we routinely model estate plans to determine if they meet the goals and objectives of our client. Typically those goals fall into one of three areas: minimizing taxes, providing liquidity for survivors, and optimizing the disposition of one’s estate. Fair warning, my editor said that this topic is convoluted. But then the tax code is quite convoluted. Please persevere.

One of the big mistakes that we see being made regarding estate planning is the client’s assumption that because there is a $5 million plus exemption per person, there is no reason to do any estate planning. To refresh your memory, last December the big debate was whether Congress would leave the large exemption for estate and gift taxes in the law. They did, and they made it “permanent” in the American Taxpayer Relief Act of 2012. They also indexed it so that it would go up in the future. For 2013 the exemption is $5,250,000 and

future becomes reality, the welldrafted trust from yesteryear may no longer serve its intended purposes. We believe that trusts, especially irrevocable ones, should be reviewed each

BY Scott Neal year by qualified legal counsel to determine if changes are warranted. Wait a minute, you say. Aren’t irrevocable trusts just that, irrevocable, and therefore unchangeable? How then can an irrevocable trust be revised?

A court can certainly order that a trust be modified so long as certain state requirements are met. In addition, many trusts contain provisions for termination when the trust assets fall to a certain level. Kentucky

And you thought decanting only applied to your favorite libation. for 2014 it will be $5,340,000 due to indexing. Thus, a married couple can pass $10,500,000 in 2013 or $10,680,000 in 2014. Another important provision of the law made portability of the exemption permanent. Portability refers to the ability of a spouse to bequeath his or her unused exemption to the surviving spouse. To take advantage of the current situation, good estate planning is still essential. It may therefore be logical, but incorrect, for many to think that they don’t need to bother with estate planning.

Many people have trusts (either living trusts or trusts created in a will) that were developed years ago when the rules were different. Trusts may be created to serve purposes other than simply reducing or eliminating estate and gift taxes—i.e. they usually contain important control issues. At the time of drafting a trust it is difficult to anticipate all the changes that a family may undergo at some point in the future. As the

has enacted a statute to deal with trusts under $50,000; however, these too need court approval. Of course, another way to modify a trust is to distribute all the assets, but only if it’s in the Trustee’s power to do so. Beneficiaries probably need to consent; and such consent could be hard to come by. If you are a trustee, distributing assets could also carry substantial legal liability.

Even unborn potential beneficiaries should be considered when making distributions of trust assets.

For years, one of the key provisions of the tax code has been the step-up in tax basis of assets includable in a decedent’s estate. Step up refers to revaluing the asset for tax purposes to its date of death valuation. Ordinarily the tax basis for calculating capital gains is the purchase price paid for an asset. For assets that go up in value before they are sold, a capital gain tax is imposed on the gain at the time of the sale.

However, for assets that are included in your

estate, basis may be reset (i.e. stepped up) to the date of death valuation and the capital gains tax on the appreciation goes away.

For those years when estate taxes were high and capital gains tax low, estate planners often put in place credit shelter trusts or generation skipping trusts that kept the assets of those trusts out of the taxable estate of the beneficiaries upon their death.

Unfortunately, this also had the effect of eliminating the step up in basis. That saddles the receipt of those assets with a potential capital gains tax as well as the new Medicare Contribution Tax imposed by the Affordable Care Act. Taken together, the 2012 Act and the ACA have the effect of lowering, or even eliminating, estate taxes but potentially raise income taxes via higher capital gains tax and the Medicare Contribution tax. Once again, do not assume that there is nothing that can be done because granddad’s trust became irrevocable upon his death. Consult with legal counsel and ask him or her about decanting the trust.

Decanting, as applied to trusts, is the act of emptying the assets in a current trust and placing them in a different container, a new trust, with a new trustee. The new trust can have more flexibility than the old one. When handled correctly, decanting can even allow for inclusion of the trust assets in the estate of the beneficiary. Doing so may exempt those assets from estate taxes altogether due to the higher limits now in effect. At this writing, 20 states allow decanting. Kentucky’s provision took effect in 2012. And you thought that decanting only applied to your favorite libation. As you have probably surmised, this maneuver, or any other estate planning should only be undertaken with the help of qualified legal and tax counsel. The moral is: never say never, even when irrevocable is in the title.

Scott Neal, CPA, CFP is the President of D. Scott Neal, Inc., a fee-only financial planning and investment advisory firm with offices in Lexington and Louisville. Visit the website www.dsneal.com or email Scott at scott@ dsneal.com. ◆ Issue#82 5

Accounting

Keeping More of What You Earn As temperatures begin to fall, some of you will view this as the beginning of flu season.

For us, it signals the beginning of year-end tax planning season. Just like failing to get your flu shot, neglecting to plan for your taxes now can have severe consequences later.

The remainder of this article will discuss several tax saving tips for physicians.

Health Savings Accounts (H.S.A.)

An H.S.A. is a separate bank account that is used to pay for out-of-pocket medical expenses. It must be coupled with a highdeductible health plan (HDHP). When you contribute into the account, the contributions are pre-tax or tax-deductible up to certain limits. Funds can grow tax-free in the account and the disbursements are taxfree when used for medical expenses. For certain taxpayers, utilizing an H.S.A. can save around $3,500 per year in taxes.

Qualified Retirement Plans/401(k) Contributions

If you are employed and are not contributing the maximum annual amount to your particular employer’s retirement plan, we strongly encourage you to make that one of your primary goals. Not only does this go a long way towards meeting your retirement goals, but it can save you thousands in taxes every year as well.

If you own your business and the business does not have a plan in place, again, we strongly encourage you to get one in place and start utilizing it as soon as possible.

There are numerous employer based qualified retirement plans to choose from. Each have different limits, criteria, deadlines, and other aspects, but all have the common goal of sheltering income from current year taxes.

Small Employer Health Insurance Premium Credit

If you are a small business owner and your company has a health insurance plan to pay for your staff’s health insurance premiums, you need to be aware of this potential tax credit. For 2013, certain small businesses are eligible for a tax credit of up to 35 per6 M.D. Update

cent of the cost of health insurance premiums paid by the employer.

For example, if your private practice with four full-time staff members paid $300 per month per employee for

BY Matt Smith health insurance premiums, you could be entitled to a tax credit of over $5,000. This has been around since 2010, so check your prior year tax returns for this credit. You can amend prior year tax returns.

Dependent Care Assistance Programs

Many taxpayers are aware of the child and dependent care expense credit available and claimed by filing Form 2441. For higher income taxpayers, this credit’s benefit is limited to $600 for one child or $1,200 for two or more children. However, many taxpayers are unaware of the option to pay for these costs using pre-tax dollars if your employer offers this option. You can exclude up to the first $5,000 of wages by allocating them to this plan. The plan then pays your child/dependent’s care provider directly. For a taxpayer in an upper tax bracket with one child, the additional tax savings by using this plan instead of the tax credit is often over $1,000.

Section 179 and Bonus Depreciation

As of the date of this article, Section 179 expense limits are set to scale back to a maximum of $25,000 and bonus depreciation is set to disappear after 2013. For 2013, up to $500,000 of eligible property can be expensed in the year placed in service. Also, bonus depreciation of 50 percent of the eligible property’s cost allows for quicker expensing. For example, placing a new $800,000 MRI magnet in service in December 2013 can result in an overall maximum expense deduction of

$680,000 calculated as follows: $500,000 (Section 179 limit) + $150,000 (50 percent bonus depreciation on remaining $300,000 basis) + $30,000 (“normal” depreciation on remaining $150,000 basis. For 2014, the maximum first year expense deduction will be $160,000.

Self Employment Planning

Operating your business as a Schedule C for tax purposes allows you to take advantage of several tax breaks. Some of the more commonly utilized strategies and deductions used include the self-employed health insurance deduction, the home office deduction, employing family members, medical reimbursement plans, paying rent to related parties, and retirement plans.

Each of these options has specific rules and requirements that must be followed. When structured properly, they can each save you substantial tax dollars.

Capital Gains/Losses Planning

The tax rate on long term capital gains can be zero percent, 15 percent, or 20 percent, depending on your taxable income.

Because of this, proper tax planning becomes more valuable. In certain situations, harvesting losses by selling a security that has decreased in value, then purchasing the same security at least 31 days later can be beneficial.

These are just a few of the numerous ways to shelter some of your income from current year taxes. Most of these apply to all physicians in any situation. Some of these are more beneficial for employed physicians. Others only work for physicians in private practice. It is extremely important that you are aware of these and other tax saving measures as they can keep thousands more in your pocket each and every year.

L. Porter Roberts, Jr., CPA and Matthew S. Smith, CPA, CFE are with the Medical Services Group of Barr, Anderson & Roberts, PSC in Lexington, KY. If you would like more information, they can be reached via email at lproberts@barcpa.com and msmith@barcpa.com and via telephone at (859) 268-1040. ◆

Legal

Buying and Selling a Physician Practice Legal considerations for parties Dr. Smith has built a successful medical practice over the last 30 years, but is ready to retire and sell the practice to another physician. Dr. Jones practices with a group in the same specialty as Dr. Smith and thinks buying Dr. Smith’s practice presents a great opportunity for him to leave his medical group and open up his own office. Dr. Smith has the practice professionally appraised for fair market value. Based on the appraisal, he and Dr. Jones agree on a purchase price.

At least a month before the closing, Dr. Smith will send a letter to his active patients explaining his retirement, that Dr. Jones is taking over the practice, and recommending Dr. Jones’ services. At closing, Dr. Jones will make a down-payment and sign a two-year note for the balance of the purchase price.

Dr. Smith will turn over his active patient files, office equipment, etc., to Dr. Jones and sign a two year non-compete. Dr. Jones calls his lawyer, explains the deal, and asks the

lawyer to draw up an agreement.

Sounds fairly straight-forward, right? Dr. Jones’ lawyer says, “Not exactly.”

Compliance with HIPAA and the federal Antikickback statute

BY Sarah Charles White are just two of the legal concerns Drs. Smith and Jones should discuss with their attorney before finalizing the terms of the deal.

Transferring Medical Records Under HIPAA

Patients have the right to choose their physician. HIPAA takes both the patient’s choice and privacy into account. The physical records belong to Dr. Smith but the

protected health information in them is subject to the patient’s HIPAA privacy rights. HIPAA does not allow Dr. Smith to hand-over patient files to Dr. Jones without the patients’ written consent. Until he receives that signed consent, Dr. Smith will continue to be responsible under HIPAA and the AMA Code of Medical Ethics for maintaining the confidentiality and security of the PHI in his patient records and cannot disclose patients’ PHI to Dr. Jones.1 Dr. Jones’ best opportunity to acquire Dr. Smith’s active patients is to take custody of the records from Dr. Smith at closing. To facilitate this, Dr. Smith should enclose a patient consent form with his letter notifying patients of his retirement. The letter should ask patients to sign and return the form authorizing Dr. Smith to transfer their file to their new physician. At the closing, Dr. Smith should also have Dr. Jones sign a HIPAA business associate agreement to serve

Issue#82 7

Legal as custodian of Dr. Smith’s remaining active patient files until receipt of the patient’s signed consent to transfer.

The Anti-kickback Law and Selling a Medical Practice

The federal Anti-kickback law makes it illegal to knowingly and willfully solicit, offer, pay, or receive any “remuneration,” directly, indirectly, overtly, or covertly, in cash or in kind, for referral of business reimbursed

by Medicare or Medicaid.2 The compliance concern is that Dr. Jones’ payments to Dr. Smith over two years may be seen by the OIG3 as disguised illegal remuneration to Dr. Smith to make future referrals of Medicare and Medicaid patients to Dr. Jones.4 Federal regulations provide various safe harbors under the statute, including one for the sale of a practice by one practitioner to another.5 Strict compliance with the safe harbor is necessary, and Dr. Smith and Dr. Jones will need to modify the terms of their deal to satisfy both of the following requirements: (1) the period between the closing date and when Dr. Jones finishes paying Dr.

Smith for the purchase price cannot be longer than one year; and (2) Dr. Smith cannot be in a professional position to make referrals or otherwise generate business for Dr. Jones that is reimbursable under Medicare, Medicaid, or other federal health care programs after one year from the date of the first agreement pertaining to the sale.

If the date of the first agreement is the closing date, Dr. Jones must pay Dr. Smith for the practice within one year of the closing date, not two years. This also means that Dr. Smith needs to close his practice and truly retire within one year of the closing date. Any arrangement for Dr. Smith to provide consulting services or work at Dr. Jones’ office part-time during that year will require compliance with additional safe harbors under the Anti-kickback law.

Other Legal Considerations

If Dr. Jones’ pays Dr. Smith the purchase price over time, Dr. Smith will have a financial interest in Dr. Jones’ practice until paid in full. If the practice involves designated health services, the sale must be reviewed by

counsel for Stark implications.6 Other matters to consider include: (i) canceling ongoing contracts with payors; (ii) whether active equipment and space leases can be assigned to Dr. Jones; (iii) collecting patient receivables; (iv) obtaining advice on the tax consequences of the sale; (v) professional liability tail coverage, (vi) fair notice to Dr. Smith’s employees of the practice closing date; (vii) whether Dr. Jones wants to hire any of Dr. Smith’s staff; (vii) employee benefit plans sponsored by Dr. Smith and what is required to close and transfer plan funds; and (vii) arranging continuity of care for patients under active treatment; and (viii) compliance with DEA regulations on transfer and disposal of controlled drugs if Dr. Smith keeps any at his office.

Sarah Charles Wright is a partner with Sturgill, Turner, Barker & Moloney, PLLC. Wright advises health care entities and providers on corporate compliance with state and federal laws and regulations. She can be reached at swright@ sturgillturner.com or (859) 255-8581.

This article is intended as a summary of newly enacted state law and does not constitute legal advice. ◆

Would you rather be here?

Or HEAR?

Engineered for performance.

8 M.D. Update

Cover story

E x panding t he V i s ua l F ie ld Retina Associates of Kentucky enters the Louisville market and continues to be a leader in restoring vision in seniors Lee Thomas Liz Haeberlin

Dr. William J. Wood founded Retina Associates of Kentucky in 1975 in Lexington when there were no retina specialists in central and eastern Kentucky.

By Jennifer S. Newton A 2012 report by Prevent Blindness America estimates almost 30,000 Kentuckians over age 50 suffer from age-related macular degeneration (AMD) and nearly 103,000 Kentuckians over 40 are affected by diabetic retinopathy, one of the highest rates in the nation. Problems are compounded in more rural areas of the state such as eastern Kentucky, where obesity is endemic and health care access is a challenge.

Retina Associates of Kentucky (RAK), founded in 1975 in Lexington by William J. Wood, MD, has spent the last 37 years treating retina diseases in central and eastern Kentucky and has recently expanded its physician line-up Issue#82 9

Dr. Thomas W. Stone is the principal investigator of one of the largest diabetes trials in the world, the Diabetic Retinopathy Clinical Research Network (DRCR).

Liz Haeberlin

and its geographic reach. “From the very beginning, the guiding principle in the development of this practice was to provide nothing but the finest of care and the way to accomplish this is to be associated with the highest caliber and best trained physicians possible,” says Wood.

RAK is the largest retina-only practice in Kentucky with five physicians and offices in Lexington, Louisville, Ashland, Prestonsburg, Somerset, Richmond, Campbellsville, Danville, and London, Kentucky, and Huntington, West Virginia. “Referring physicians and patients appreciate the availability and support that having offices in so many locations can have for them,” says Maryanne Inman, MBA, practice administrator.

Rick D. Isernhagen, MD, was the first physician to join Wood in practice. “When I started 26 years ago, Dr. Wood and I were the only two retinal surgeons in Lexington, central Kentucky, and eastern Kentucky … I think our biggest asset is that as the need grew, so did our practice in terms of the training and skills our partners brought to the practice when they joined us,” says Isernhagen.

Those partners include Thomas W. Stone, MD, John W. Kitchens, MD, and Andrew A. Moshfeghi, MD, who joined the practice this summer.

The New Recruit

Regarded as a world-renowned retina surgeon, Moshfeghi interned at MetroWest Medical Center at Harvard Medical School and completed his residency at North Shore University Hospital at New York University School of Medicine. He completed medical retina and vitreoretinal surgery fellowships at Bascom Palmer Eye Institute in Miami, Dr. Andrew A. Moshfeghi was one Florida. Moshfeghi spent seven years of the first to describe the benefits at Bascom Palmer before coming of Avastin in AMD patients while at to RAK. His professional interests Bascom Palmer Eye Institute in 2005. include AMD, surgical interventions for detached retina and macular holes, diabetic retinopathy, and imaging of the eye.

At a point in his career where he was evaluating his next steps, Moshfeghi tried to keep an open mind about geography. “I really wanted to look for the right type of practice. Part of looking for the right type was identifying people I 10 M.D. Update

Lee Thomas

Cover story

could collaborate with,” he says. As it happens, Moshfeghi trained with Kitchens at Bascom Palmer and the two are close friends. Additionally, Moshfeghi had known Stone for about a decade through Moshfeghi’s brother, Darius Moshfeghi, MD, who is also a retina surgeon at Stanford University in Palo Alto, California.

Moshfeghi and his wife, Arlanna Moshfeghi, MD, a pediatric ophthalmologist who will begin practicing in the area in January, began to fall in love with Lexington on their visits there. “I was drawn to the people in the practice, drawn to the way they practiced, and drawn to the capabilities they had, as well as to Lexington,” says Moshfeghi.

New Frontiers

The practice recently expanded geographically, both to the east and the west, with the opening of a Huntington, West Virginia office in August 2013 and a Louisville office in October 2013.

“We’ve been asked each year, as years have gone by, to bring our services to patients where they live,” says Wood.

“While many physician practices are consolidating and either affiliating with, or becoming employees of hospitals and hospital groups, Retina Associates of Kentucky remains a private practice of dedicated physicians who provide specialized services for our patients,” says Inman. “Because this specialized care is not available in many areas of the state and surrounding states, RAK has multiple satellite offices where we care for patients in addition to our two main offices in Lexington and Louisville.” As a second “main office,” Louisville is equipped with the same technology and services as the Lexington office, capable of treating emergency, medical, and surgical needs of the retina, vitreous, and macula. Surgical services also are available in Lexington and Ashland.

The decision to expand into Louisville was a

simple one. Not only was it a new “western frontier” for RAK, but Stone lives in Louisville and is there full-time to meet the needs of patients.

“With the number of physicians we have and the number of treatments and research studies we offer, we felt it would be an attractive alternative to open the office in Louisville,” says Wood.

A Vision for Excellence

Time Takes its Toll

Age-related diseases are the number one cause of visual impairment and blindness in the US. Because of that, a large majority of RAK’s patient population is over the age of 60 and suffers from common conditions such as: age-related macular degeneration (AMD), diabetic retinopathy/diabetic macular edema, and retinal vein occlusion (RVO).

AMD is the leading cause of blindness and vision loss for people over 65 and makes up the largest portion of RAK’s patient base. To address

Lee Thomas

Wood’s philosophy to be the best and recruit the best has been a not-so-secret element of the practice’s success.

All five of the physicians were trained at top 10 ophthalmology programs, as ranked by US News & World Report, and all five have been chosen as Best Doctors in America, a designation voted on by their peers. Wood completed his residency at the prestigious Wilmer Ophthalmological Institute at Johns Hopkins University and was awarded the Heed Fellowship at the Massachusetts Eye and Ear Infirmary at Harvard University. Isernhagen was a fellow at the Wilmer Institute at Johns Hopkins and chief resident during his residency at Dean McGee Eye Institute in Oklahoma. Stone did his residency at Duke University Eye Center, including a year as chief resident, and pursued his fellowship in Retinal Diseases at Emory University in Atlanta. A native of Indiana, Kitchens performed his residency at the University of Iowa and completed a fellowship and chief residency at the Bascom Palmer Eye Institute.

RAK physicians are also invested in educating the next generation of retina specialists and surgeons. In conjunction with the University of Kentucky, RAK sponsors a two-year medical/ surgical fellowship and a one-year retina medical fellowship. The practice typically has three fellows at any given time who spend half their time with RAK and half with UK.

this large population of patients, Wood founded the Macular Degeneration Institute. “It’s the only facility of its kind in this region of the US serving all the needs of patients with macular degeneration in one location,” says Wood. Rehabilitation services are offered through RAK’s Low Vision Services, another arm of the practice, which provides magnification tools, electronic devices, services, and education to those who cannot be helped by surgery or glasses.

Diabetic retinopathy is a particular problem for the state of Kentucky because of the prevalence of obesity and diabetes. “ As we see the baby boomer generation moving into their sixth and seventh decades, we’re seeing more and more patients with diabetic retinopathy who are older,” says Kitchens. However, treatments are advancing.

“While we’re seeing many more diabetic patients, their outcomes are improving because I can treat it more effectively now,” says Stone.

Reversing the Clock

As little as 10 years ago, the only treatments for AMD and diabetic retinopathy, among others, were laser therapy and surgery.

While those treatments were effective at slowing disease progression, they did nothing to improve patients’ vision.

Then, eight years ago, the advent of injectable anti-vascular endothelial growth factor agents (anti-VEGFs) opened a realm of possibilities for medical treatment of these diseases. Not only do these injected medications stabilize patient’s conditions, they also restore lost vision in some patients. Stone contends intravitreal injections can “reverse the clock.” He says, “We have many patients who were legally blind, couldn’t drive, couldn’t read, couldn’t work, couldn’t read their medicine so they couldn’t live alone. In many cases we can improve their condition so they now live independent, productive, healthy lives.”

In addition to avoiding surgical intervention, the injections also help preserve normal tissue.

Dr. Rick D. Isernhagen was the second partner to join the practice and the principal investigator of the AREDS2 study for dry AMD.

Issue#82 11

Lee Thomas

Cover story

“When you apply thermal laser to the retina or macula, it actual destroys tissue in the area immediately around where you apply the laser … The injections don’t destroy any tissues,” says Moshfeghi, who uses the analogy of applying weed killer to your lawn, which kills the weeds but not the lawn.

The drawback of injections is that the results are not permanent, and they must be given every one to two months to maintain the effects. This has dramatically changed not only the way retina specialists administer treatment but also how often they see patients in the clinic.

The three gold standards of anti-VEGF treatment RAK uses are Lucentis®, Avastin®, and Eylea®, the newest treatment for wet AMD. In fact, Moshfeghi was part of the team who first described the benefits of Avastin in AMD

Dr. John W. Kitchens developed a less invasive and more controlled technique for repairing choroidal detachments.

Liz Haeberlin

patients while at Bascom Palmer in 2005.

RAK was one of 43 clinical sites selected to participate in the prestigious Comparison of AgeRelated Macular Degeneration Treatment Trial (CATT), which Isernhagen deems “one of most important studies” they have been involved in.

Sponsored by the National Institutes of Health (NIH) and National Eye Institute (NEI), the study compared the efficacy of Lucentis vs.

Avastin (which is much more cost-effective) in patients with wet AMD. The study found the two drugs were comparable in their effectiveness. “It’s particularly important in the age of the Affordable Care Act (ACA), knowing that the use of medication like Avastin could reduce overall healthcare burden by upwards of several billion dollars,” says Kitchens.

Still Cutting-Edge

Although medical treatments have replaced some surgical procedures, some common age-related retina conditions often still require surgery, including: retinal detachment, macular holes, and macular pucker. For emergency situations, such as retinal detachment, “We have someone on call at all times and available to operate whenever needed, ” says Wood.

Currently, three of the partners – Stone, Kitchens, and Moshfeghi – perform in-hospital surgery and offer medical treatments, while Wood and Isernhagen perform in-office surgery and medical treatments.

“The biggest innovation in retina surgery has been the advent of sutureless vitrectomy with microscopic instrumentation,” says Moshfeghi.

The instruments are now so small that no stitches are necessary in most cases, so patients recover much faster, have less irritation and pain, and have improved visual outcomes.

According to Stone, surgery for diabetic reti12 M.D. Update

Liz Haeberlin

nopathy has become progressively safer. “AntiVEGF medication has made the disease less fulminant when it comes to surgery, and the machinery has improved. What used to take me three hours in the operating room, I can now do in less than 60 minutes,” says Stone. These advancements also cause less pain, less discomfort, and better outcomes for patients.

RAK physicians do not just embrace innovation, they also create it. Kitchens has a particular interest in designing methods to solve surgical problems and is widely known for developing a technique to repair choroidal detachments.

“Choroidal detachments are quite rare, but can occur after glaucoma surgery if pressure goes too low. I developed a technique to drain the choroidal detachment less invasively and in a more controlled manner using a guarded needle attached to aspirations,” says Kitchens.

In the Line of Sight

“Our physicians are really national leaders in the development of wide-field imaging and were the first in Kentucky to use the OPTOS wideangle imaging angiography system,” says Wood.

Previous imaging technology only allowed physicians to see 30 to 50 degrees of the retina at one time. Wide-field visualization nearly accommodates 180 degrees of viewing, allowing physicians to see most of the whole retina.

“Another big advance, a monumental transformational technology that revolutionized the way we practice retina repair is the advent and popularization of optical coherence tomography (OCT),” says Moshfeghi. Although OCT has been around since the early 90s, it was not readily available in retina offices until 2003. Kind of like a CAT scan for the retina, it provides a quick and non-invasive qualitative and quantitative assessment of retinal problems.

Fine-Tuning

RAK is currently researching longer lasting treatments for wet AMD, as well as different formulations of injectables and combination therapy.

In diabetic retinopathy, studies are now looking to fine tune the use of newer treatments.

RAK is part of a NIH-sponsored consortium of retina researchers called the Diabetic Retinopathy Clinical Research Network (DRCR). Stone is the PI for these studies at RAK. “While we

know these medicines work in diabetics, which individual medicine might be better under certain circumstances? What role do they play in using laser vs. doing medicine? When do you recommend surgery?” asks Stone.

What will the next 10 years bring in the field of retina? Isernhagen predicts, “I think we will see more drugs not only for macular degeneration and histoplasmosis and diabetes, but we will also see some of these drugs that have come out replacing surgery where surgical diseases become medical diseases, and I think we’ll be using less invasive surgical techniques.”

Whatever the changes, RAK is poised to continue the fight against vision loss in Kentucky. ◆

Issue#82 13

Special Section  Senior Health

Forward Thinking

A partnership between TJ Samson Community Hospital and the University of Louisville fosters education and progressive geriatric and family medicine care in the rural community of Glasgow By Jennifer S. Newton Photography by Harry Spillman GLASGOW The mention of progressive medicine may conjure images of large state universities or high-profile private specialty practices. Sometimes, however, medicine is propelled forward in the most unlikely of places. Enter Glasgow, Kentucky – a small town of 15,000 people, where members of the medical community contend there is nothing small about their big ideas.

In the late 1990s, the lack of a family medicine training program in Kentucky’s second congressional district initiated a movement to establish a rural residency program. While several other south central Kentucky cities were unable or unwilling to meet the challenge, Glasgow readily accepted the invitation.

The project became a partnership between Glasgow’s TJ Samson Community Hospital and the University of Louisville (UofL). The TJ Samson Family Medicine Center clinic opened in January 1998. In July of that same year, the Glasgow Family Medicine Residency Program welcomed its first four-member class.

“What separates Glasgow from another community is we are a small town, but we are progressive. There has never been an issue of, ‘We can’t have this because we’re in a small town.’ It’s ‘how can we have this if it benefits our population and our community?’” says R. Brent Wright, MD, MMM, medical director of TJ Samson Family Medicine Center, associate dean for Rural Health Innovation at UofL School of Medicine, and vice-chair for Rural Health for the UofL Department of Family & Geriatric Medicine.

Wright joined the program in 2001, and in 2009 the program added family medicine physicians Amelia Kiser, MD, and Steven House, MD, both of whom have a special interest in geriatrics – Kiser with a large population of nursing home and wound care patients and House with a strong background in hospice and palliative care.

14 M.D. Update

Family Dynamics

As a family medicine practice, the clinic sees patients from infancy through the end of life. However, Kiser and House’s expertise

above: Below:

options for some medicines out there,” says House. Wright concurs, saying, “The toughest patient to care for is the one who cannot avail themselves of the care you prescribe.”

When transportation is a barrier, the practice’s physicians make home visits, which provide better continuity of care, help prevent unnecessary hospitalizations, and give physicians greater insight into their patients’ lives.

The clinic as a whole draws patients from Barren, Metcalfe, and Hart counties. The practice’s nursing home population is wider spread. “We have nursing home patients from several counties around because of the shortage of nursing home beds

R. Brent Wright, MD Amelia Kiser, MD

means a large population of geriatric patients.

Christian D. Furman, MD, a geriatrician based in Louisville and vice-chair of Geriatrics for the UofL School of Medicine Department of Family Medicine and Geriatrics, says dementia and polypharmacy are two of the big issues in the elderly population. Dementia symptoms are often misdiagnosed or mistakenly attributed to the aging process by primary care physicians and family members.

Polypharmacy creates a host of health and financial problems. In the Glasgow practice, physicians try to provide a big picture perspective, and their staff is integral in coordinating care for elderly patients.

Indicative of rural areas, health care access can be complicated by financial and transportation issues. “The biggest access issue in dealing with my patients is getting their medications. There aren’t cheap

in their counties or because care is too much for nursing homes to handle in their county,” says Kiser.

In Residence

The residency program is a 36-month program, divided into three years, all spent in Glasgow. Residents rotate on a four-week block rotation through a variety of specialties. “We couldn’t have the residency program without community physicians. [The

familial and caring atmosphere that extends from their very first phone call through the entire program experience.

Collaborating for Change

Nationally there is a shortage of geriatricians. On a state level, rural nursing homes have difficulty finding adequate physician coverage. Family medicine physicians can serve as extenders of geriatric care, however strict nursing home regulations, low reimbursements, and the increased time required to care for elderly patients can make nursing home visits a less desirable and less finan-

above: right:

Christian D. Furman, MD, Steven House, MD

residents] rotate with cardiology, nephrology, everything, and it’s gratis,” says House, who is the interim director of the residency program.

Furman is impressed with the geriatric rotation at the Glasgow Residency program, particularly the depth of nursing home and wound care experience they receive. “It’s also impressive how much responsibility and ownership they take with nursing home patients,” she says.

All residents in the program are exposed to increasing levels of responsibility for nursing home care. The experience helps residents grasp the difference in nursing home care vs. hospital care, where charting, expectations, and reimbursements, among other things, can be tremendously different. By rounding in the hospital and consequently seeing patients in the nursing home, physicians and residents “get to see how what you order really impacts patients,” says Kiser.

The track record of the Glasgow Family Medicine Residency is a solid one, having graduated 50 family medicine residents since its inception and boasting consistent growth and low turnover. Residents often choose the program because it feels like home, wanting to simulate the environment they came from or will be practicing in. They soon find the small-town feel is not just attractive packaging but a genuine

cially viable option for physicians.

The Glasgow Family Medicine Residency is working toward instilling a sense of enjoyment, ownership, and pride in nursing home care. “It is a culture change we’ve tried to instill here, not dreading the nursing home,” says Kiser.

Further positioning Glasgow as a leader in senior care, Furman recently visited the program as part of a joint research endeavor, the introduction of a POLST (Physician Orders for Life-Sustaining Treatment) form in nursing homes to clearly record a patient’s wishes for end of life care, beyond what is covered in a living will, and make them a permanent and easily accessible part of the patient’s chart, following them wherever they go. Furman began the initiative in her Louisville nursing homes in 2008 and brought in Glasgow this year to pursue a Practice Change Leaders Grant funded by

Hartford Foundation Atlantic Philanthropy that is looking at underserved and rural populations. “It’s kind of an urban–rural collaborative to see what other issues are involved and how that affects each population,” says Kiser.

While many of Kentucky’s neighboring states already employ such a tool, Furman will be presenting the measure to the Kentucky legislature again in January, hoping to make the form a legal document that will be widely used throughout the state. The initiative has been shown to improve satisfaction, quality of care, and avoid unnecessary hospitalizations and transfers.

The success of this urban-rural partnership is evident in the program’s achievements and its participants’ enthusiasm.

“Without a strong community hospital, without a strong board of directors there supporting the program and seeing the benefits, as well as the community of Glasgow, with the expertise and reach of UofL, we would not be where we are today. Where we feel we’re going is even more collaborative work,” says Wright. ◆

GLASGOW/ BARREN COUNTY FAMILY MEDICINE RESIDENCY www.glasgowfmr.com

Issue#82 15

Special Section  Senior Health

In the Balance

In its early days, Kindred Healthcare’s business strategy focused on institutional care for seniors who could no longer live independently. However, over the last 15 years Kindred has evolved and become a leader in rehabilitative care. Today, Kindred’s primary focus is no longer on traditional long term care, rather it is to provide post-acute medical care and therapies to enable a patient’s safe return home.

Marc D. Rothman, MD, is Kindred’s senior vice president and chief medical officer of the company’s Nursing Center Division, which includes more than 100 stand-alone skilled nursing facilities (SNFs) across the country, most of which serve both long-term institutional patients and post-acute rehabilitation care patients. For Kindred, a Fortune 500 health care services provider based in based in Louisville, Kentucky, that dual-purpose mission offers both opportunities and challenges.

“Half of the residents may be living there permanently – it is their home – but the other half are people who are in transition – being admitted, rehabilitated, and discharged home. Serving different types of patients means we have to be good at more than one thing,” Rothman says. “We are regulated as a long-term care provider for institutionalized seniors, but we have to be nimble and flexible because those regulations don’t really address what it takes to provide high quality care for patients transitioning from hospital to home.” The goals of transitional care include

Susan Sender, RN, chief clinical officer and vice president of Clinical Services for the Kindred at Home division, says Kindred is trying to address the sometimes fractured nature of the health care system.

quickly restoring people to their highest functional potential and preventing adverse outcomes and re-hospitalizations. “Those expectations aren’t built in to nursing home regulations, so our job is to merge those two competing interests,” Rothman says.

Integrating services in the name of patient care is a major element of Kindred’s approach, says Susan Sender, RN, chief

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clinical officer and vice president of Clinical Services for the Kindred at Home division. With about 113 programs in the US, Kindred at Home provides home health agency care, Medicare-certified home health care, hospice, private duty care, and durable medical equipment. Sender says Kindred is trying to address the sometimes fractured nature of the health care system, particularly in the area of senior care.

“Problems can arise when there are so many patients going from home to hospital to nursing centers or rehab facilities,” Sender says. “For many patients in the health care system overall, there’s a lack of coordination of care.” This is particularly true for older seniors (85 and above, for example) whose care often involves numerous physicians, services, and facilities. “The most important thing to know about our organization is that we provide the full complement of services. That allows us to shepherd these patients between and among settings, and fill in the blanks that are often left unfilled in seniors’ care management. The coordination we’ve created between our SNFs, home care agencies, long-term acute care hospitals (LTACs), and hospices is essential for our patients to have good outcomes.”

To help smooth the patient’s transition from one type of care to another, Kindred is hiring transitional care nurses. For each

Photograph courtesy of Kindred Healthcare

Kindred Healthcare balances institutional care with post-acute transitions, home health, and hospice to provide comprehensive, coordinated care for seniors and all ages By Graham Shelby

Brian Bohannon

Marc D. Rothman, MD, is Kindred’s senior vice president and chief medical officer of the company’s Nursing Center Division, which includes more than 100 standalone skilled nursing facilities across the country.

local market in which Kindred is offering integrated care services (the company refers to these as Integrated Care Markets), Kindred has hired a number of transitional care nurses, each responsible for 25-40 patients. According to Sender, “These nurses’ main responsibility is to be very focused on the patient’s needs regardless of the setting. They stay with patients and work very closely with the doctors and staff from one setting to another, whether it’s LTAC or in the acute care external hospitals in our system.” The presence of the transitional care nurse helps prevent the patient from missing medications, or even meals, which studies have shown are common problems that occur when elderly patients move from one care setting to another.

“As a health care organization, we’re transitioning from case management to care management. Our approach is more personal, usually in-person, and it brings the family members, staff, and the patient together,” Sender says. Care management also involves delving into pharmacy, rehabilitation goals, and expectations, and bringing in the kind of community services that a traditional telephonic case manager might never have known about. “We’re providing a much more hands on, high-touch kind of experience,” Sender says.

To further streamline the patient care process, Kindred is also going digital in its Nursing Center Division and has installed electronic health records (EHR) systems in over 100 facilities to date. Rothman says this represents an evolution in the philosophy of how nursing homes can work for both patients and physicians. All of Kindred

Healthcare’s divisions either have or are in the process of installing an EHR system.

“Nursing homes are ready and willing to step into the 21st century. There’s a bit of a misconception that nursing homes are hopelessly inefficient and stuck in the past, but that isn’t true. For physicians, it’s now a very attractive place to grow a practice.”

Rothman says. “We’re working to make it easier for physicians to practice in our settings. We’re trying to make EHR systems more accessible to physicians off-site and working with our pharmacy to streamline remote prescribing for patients.”

Rothman says that practicing in one of Kindred’s facilities is a more financially viable option than many physicians may realize because in the last 10 years, “reimbursement for physician’s visits to nursing homes have achieved financial parity with visits to hospitals.”

In addition, Rothman says, “With a concentration of well-trained nurses and rehab therapists, an invigorated approach to quality, and the influx of new technology, it’s really a pretty exciting time to be involved in nursing home care.” ◆

Issue#82 17

Special Section  Senior Health

A Template for Excellence

Lexington Clinic develops practice guidelines to improve diagnosis and treatment of non-motor symptoms in Parkinson’s patients By Tim Corkran

Parkinson’s Basics

Parkinson’s disease progresses because of the loss of dopamine generating cells in the midbrain. As neurons accumulate an excess of malformed proteins, the inclusions in which they are stored overrun and disable the cell. While the process of neuron death is readily understood, the cause of excessive protein malformation (some is normal) is not. So ultimately, the disease is idiopathic.

As the amount of dopamine delivered to the body decreases, a suite of motor and non-motor symptoms are possible.

The motor symptoms are familiar: resting tremor, stiffness or slowness of gait, and loss of fine motor skills are some of the most common. The non-motor symptoms however are less well-recognized. They include problems with cognition, bladder function, and blood pressure control and the occurrence of impulse control disorders and sleep disturbances. As such, the non-motor symptoms are readily underdiagnosed and undertreated in many Parkinson’s patients.

18 M.D. Update

The Lexington native, who has been at the clinic for 11 years, came to the field because it was “challenging, and learning how diseases of the brain affect people’s lives is fascinating.” He describes his work with Parkinson’s as “gratifying and compelling because it is treatable.”

Schneider met the challenge to produce practice guidelines for Parkinson’s treatment at the beginning of this year, and he and his partners, Craig A. Knox, MD, PhD, and Eliza E. Robertson, MD, PhD, have been employing it ever since. Schneider says they all agree, “It has definitely improved our care for

Top:

Robert L. Bratton,

The most ready treat- MD, is Chief Medical ment for Parkinson’s suf- Officer for Lexington ferers is simply to provide Clinic. right: Andrew dopamine, but only so Schneider, MD, is the much can be supple- head of Lexington mented. The body relies Clinic’s Neurology department. on a certain number of healthy neurons to continue to provide dopamine, and as these die off, degeneration ensues despite dopamine supplements. Prognosis varies greatly with individuals as the rate of disease progression is affected by so many factors. “There is no fixed rule of thumb about it. Parkinson’s is a unique disease for every patient,” Schneider says. “Fortunately, almost all patients have some response to treatment, and we can improve peoples’ lives for several years.” patients with Parkinson’s.”

Advancing the Field The practice guidelines provide a temPatients coming to Lexington Clinic’s plate for how to standardize the approach Neurology Department benefit from the stu- to a disease or disorder. Employing theirs dious and committed approach of Schneider. for Parkinson’s, the three Lexington Clinic

Photos courtesy of Lexington Clinic

The neurology department at Lexington Clinic is finding new ways to improve the condition of sufferers of Parkinson’s disease.

Led by Andrew Schneider, MD, the threeperson department has developed a diagnosis template, which ensures that every patient who arrives with symptoms of Parkinson’s receives an analysis that employs evidencebased guidelines for discerning treatable symptoms. Development of the practice guidelines for Parkinson’s, part of Lexington Clinic’s “Operation Excellence” program, helps the neurologists diagnose some of the non-motor symptoms, which are often overlooked in the motor-leaden symptoms of the average Parkinson’s sufferer. Schneider is pleased with the this new diagnostic tool because it has the potential to continue increasing the likelihood that Lexington Clinic patients can “live an active and fulfilling life while being treated for Parkinson’s.”

MD, explains that the program has three components: ensuring satisfaction of patient, physician, and employees; active assessment of the Clinic versus national benchmarks; and overall systems review to achieve AAAHC accreditation.

Bratton is proud of Non-motor symptoms are easy to Operation Excellence. He miss in a routine Parkinson’s exam says the program is “especially beneficial for patients because because we are concentrating on we are basing our decisions motor symptoms. on evidence-based guidelines, and it ensures Lexington Clinic will address the needs of the increasmotor symptoms. Once we have diagnosed ingly educated consumer of healthcare.”

Parkinson’s based on motor symptoms, we He is particularly pleased with Schneider’s can begin to apply the guidelines to assess work on the Parkinson’s guidelines, adding, for and treat other symptoms.”

“Neurology is one of several leaders in the The development of practice guidelines clinic in terms of implementation.” is an ongoing project for many Lexington Clinic physicians and an integral element of the Clinic’s comprehensive quality program, Future Guidance Operation Excellence. Developed over the While Parkinson’s is not yet as high profile last four years, Operation Excellence helps as some other diseases, it is experiencLexington Clinic adhere to national best ing increased awareness these days. With practices guidelines in a number of areas. Michael J. Fox’s return to network television Chief Medical Officer Robert L. Bratton, and his character’s open discussion of his neurologists try to screen regularly for nonmotor symptoms. Schneider notes, “The non-motor symptoms are things that are easy to miss in a routine Parkinson’s examination because we are concentrating on the

A

affliction and the loss of Linda Ronstadt’s singing voice, more people are learning about the disease. Early diagnosis is on the rise. Research funding is increasing, but clarity of the origins remains elusive. Schneider states, “Nothing is pointing toward a cure at this time.” However, he is optimistic that an increase in current research will yield valuable data in the coming years, leading to a better understanding of both pathology and treatment efficacy. He cites deep brain stimulation as one of the newer treatments that is showing some promise.

Schneider wants patients and physicians to be better informed about the prognosis for Parkinson’s sufferers. While life expectancy is reduced for them, he assures that it should be understood as “a life changing disease, not a life-ending disease.” He adds, “The range of treatments that we have is great, and many patients continue to live fulfilling and active lives.” The practices guidelines that he, Knox, and Robertson employ increase the likelihood that patients who come to Lexington Clinic for their diagnosis and treatment will be among that group. ◆

HEALTHY

PARTNERSHIP

The University of Louisville Glasgow/Barren County Family Medicine Residency is committed to solving Kentucky’s health care needs for generations to come. Because of the program, there are now 50 new physicians working in underserved, rural areas, putting doctors – and resources – where they are needed most.

Issue#82 19

Special Section  Senior Health

The Saliency of Palliative Care

Palliative care improves patient quality of life and offers value for the health care delivery system By Turner West

Palliative care is largely unfamiliar to the general public, occasionally misunderstood in the medical community, and often used synonymously with hospice care, which leads to confusion about both services. It is important for all of us to understand palliative care, as it is both an essential approach to caring for individuals living with serious illnesses and an indispensable component to the sustainability of our health care delivery system.

Benefiting Individuals with Serious Illnesses

The Center for the Advancement of Palliative Care defines palliative care as “specialized medical care for people with serious illnesses.”

While there is some variability in palliative care services based on geography and setting, palliative care is a team approach which can include a physician, nurse practitioner, nurse, social worker, and chaplain. Palliative care teams are specially trained to manage intractable pain and other bothersome symptoms that include but are not limited to physical pain, dyspnea, nausea, delirium, restlessness, and constipation. Additionally, palliative care teams bring expertise in addressing emotional and spiritual distress. Furthermore, palliative care providers are experts in communicating effectively with patients and families about prognosis and facilitating family meetings aimed at defining quality of life and goals of care for the patient to ensure that additional treatments are concordant with a patient’s values, preferences, and goals.

Palliative care is a consultation service,

Turner West, MPH, MTS, is the director of Education at Hospice of the Bluegrass and the director of the Palliative Care Leadership Center of the Bluegrass.

which means that for a seriously ill individual to access a palliative care specialist, a referral must be made by a physician. While most palliative care services are provided to patients while in the hospital, palliative care may also be available in long-term care facilities, outpatient clinics, and in an individual’s home. It is important for caregivers of individuals living with serious illness to ask health care providers about available palliative care services in the area.

Palliative Care vs. Hospice Care

It is often said that all hospice care is palliative care but not all palliative care is hospice care. While this is true, the saying does little to clarify the distinction. To receive hospice services, an individual must have a terminal illness, meaning that person is typically in the last six months of life. Two physicians must certify that a patient has a terminal illness. Additionally, once a terminally ill individual elects to enroll in hospice care, all treatments for the terminal diagnosis are palliative rather than curative, meaning treat-

ments are aimed at making an individual comfortable and improving quality of life.

Unlike hospice care, palliative care services are available to anyone with a serious illness in need of pain and symptom management.

Moreover, palliative care services can be provided concurrently with curative treatments.

Aiding our Health Care System

Palliative care is not only beneficial for patients and families, but it is also an efficient use of our health care dollar. There are three recurring themes in much of the research on palliative care: 1) Palliative care improves the quality of life of individuals living with serious illnesses; 2) Palliative care keeps health care costs minimal through goals of care conversations that eliminate both unnecessary trips to emergency departments and hospitals and that reduce treatments and testing inconsistent with patient preferences; and 3) Palliative care prolongs survival in individuals with serious illnesses. In short, palliative care teams provide an interdisciplinary, patientcentered approach to pain and symptom management that benefit patients, caregivers, and our health care delivery system. As our health care system evolves to meet the needs of an aging population, the need for palliative care becomes all the more salient.

The Palliative Care Center of the Bluegrass provides consultative services in many Central Kentucky hospitals and long-term care facilities as well as an outpatient clinic. For more information call (859) 278-4869. ◆

Cardinal Hill “Cardinal Hill Home Care is an extension of the quality care offered by Cardinal Hill Rehabilitation Hospital” Serving Fayette, Franklin, Jessamine, Madison and Woodford Counties

(859) 367-7148

20 M.D. Update

Complementary Care

The Perils of Grief

Integrating medical treatment with professional grief counseling

By Jan Anderson, PsyD, LPCC

Grieving the death of someone who has been a significant part of our lives is one of life’s most difficult transitions. Although the grief process profoundly impacts all areas of a person’s life – physical, mental, emotional, social, and spiritual – a person may first contact his or her physician seeking treatment for the physical symptoms of grief.

Like other crises, the life-changing loss of someone we love can cause stress responses such as rashes, gastrointestinal disturbances, headaches, shortness of breath, tightness in the chest, palpitations, muscular aches or weakness, exhaustion, hyperactivity, insomnia, and feeling flushed, dizzy or clumsy. Bereavement has been shown to compromise the immune system.

This increased susceptibility to illness can be exacerbated by an uncharacteristic lack of selfcare during the grieving process or the patient may go to the other extreme of hypochondria.

If the physician notices the symptoms of

Untreated complicated grief or clinical depression can contribute to life-threatening health problems, unnecessary emotional damage and even suicide.

stress are getting worse, new symptoms are showing up, or if a disturbance in sleep or eating patterns persists beyond a few months, integrating medical treatment with professional grief counseling may help the patient more quickly and effectively adapt to loss.

The most common reason people seek grief counseling is the feeling that they are falling apart or “going crazy.” Since it takes about 90 days for the numbing effect of shock and denial to wear off, this phenomenon tends to happen just about the time that friends, neighbors and family are tapering off the food, phone calls, and visits.

Dr. Jan Anderson is a Licensed Professional Clinical Counselor with a doctorate in Clinical Psychology. Her private counseling practice includes over 15 years of grief counseling experience.

Although antidepressants may relieve some of the symptoms of grief, they may also delay the mourning process. A multidisciplinary approach to diagnosis can help differentiate between normal grief and complicated grief or depression and help determine the best course of treatment.

The most common symptom of a patient needing professional help with his or her grief is an ongoing preoccupation with guilt that is not rational and that does not become less intense as time passes. Other symptoms or characteristics that generally indicate that professional help is needed are when a patient reports: Feeling irritable, annoyed, intolerant, or angry most of the time.

Fear approaching the level of panic most of the time.

Feeling restless or agitated most of the time or a need to be constantly busy, beyond what is normal for him or her.

Experiencing an ongoing sense of numbness or of being disconnected from self or others.

Acting in ways that may prove harmful over time, such as continuing use of heavy tranquilizers or new or increased use of alcohol or drugs in order to cope; engaging in unsafe or unwise sexual activity; or driving recklessly.

Feeling highly anxious most of the time about his or her own death or the death of a loved one still present.

Experiencing an ongoing preoccupation with the loved one’s death or certain aspects of it.

Experiencing an ongoing preoccupation with death wishes, which include a plan for carrying out suicide or homicide.

Feeling an ongoing fear of getting close to new people (for fear of losing them, too).

A numbing of all emotional responses or

experiencing only a few of the emotions that usually come with grief; or remembering only certain aspects of the loved one or the relationship together. For example, remembering only the good parts, as opposed to a more complete or balanced view of him or her.

Feeling like he or she is going crazy, falling apart, or is stuck in an intense state of mourning that prevents the performance of normal daily activities and is undermining other relationships.

Although grieving is a natural process of life, it has a way of tearing us down physically and emotionally. Whether the grieving patient initially presents in the medical office or in the therapy office, a multidisciplinary approach can improve treatment outcomes for our patients and a collaborative relationship between the physician and psychotherapist can enhance the perceived competency of both professionals. ◆

Issue#82 21

Complementary Care

Television, Telephones, and SOOOOO Much More!

By Kathryn Sandusky, AuD While the demographic of the average hearing aid user trends more and more into the baby boomer generation, a large percentage of our clients are over age 75. I find that although many of these seniors have technology skills that surpass my own, many of them are not familiar with all the “gidgets & gadgets” that are common today.

The word “Bluetooth” or “wireless” can often produce a negative reaction, but in truth, the manufacturers of devices that assist with TV, phones, and mobile computers have made the use of such devices extremely simple.

Throughout my 30 plus years of Audiology practice, the users of hearing aids have been plagued when trying to use the telephone, understand television, and even carry on a conversation in a restaurant or any situation where there is background noise.

While hearing aid technology itself has seen vast improvements in recent years with regard to sound quality and speech clarity,

22 M.D. Update

Kathryn Sandusky, AuD, FAAA, is owner of Central Kentucky Audiology in Lexington. Reach her at (859) 277-5090

many difficulties remained when trying to hear well with phones, televisions, and mobile devices until new technology emerged.

Oticon’s ConnectLine devices have made it easier for users of hearing aids to listen to iPods, iPads, TVs, cell, landline and business phones, and many other devices. With the Oticon ConnectLine wireless microphone, users can finally hear conversation at the dinner table even in a noisy restaurant. The ConnectLine microphone is an effective alternative for improving speech understanding immersed in background noise that is small and easy enough to actually be useful in the real world.

Due to these recent advancements, phone

conversations, TV, live performances, and music can be streamed directly into a user’s hearing aids allowing them to walk out of a room while watching TV and not miss out, walk all about the house while having a phone conversation, or hear a spouse from another room.

In addition the ConnectLine Streamer Pro contains a T coil, which allows the user to tune in directly to audio in any venue that has a “Loop” system in place. Locally, “Loop” systems are available in movie theaters, churches, and other public places.

Audiologists report that there is a huge population of seniors successfully using and reporting great benefits from all this technology. When they discover that using it is as simple as flipping the light switch, they are no longer intimidated and wonder what they would do without their wireless devices.

These wirelessly connected devices are the bridge providing a user the missing link between just hearing aids and the world of entertainment, information, and ideas.◆

Complementary Care

Holistic Care at Home

VNA Nazareth Home Care employs a holistic approach to care for Alzheimer’s and dementia patients By Sarah Schirmer, RN

According to the Alzheimer’s Association, more than five million Americans are living with Alzheimer’s disease, and by the year 2050, that number is expected to double due to our aging populations.

Caring for patients with Alzheimer’s or dementia can have its own special set of challenges. The matter is often compounded by the fact that approximately 80 percent of elderly patients have one chronic health condition and 50 percent have two or more chronic health conditions that must be managed.

In addition to physical health concerns, Alzheimer’s and dementia patients also have psychological challenges. They may be dealing with the death and dying of loved ones, struggling with their loss of independence, or even facing depression.

Caring for these individuals can often lead family and friends to make difficult decisions, such as the decision to seek home care or move their loved one to an assisted living or skilled nursing facility.

Home care visits, such as those provided by VNA Nazareth Home Care, part of KentuckyOne Health, send clinicians and nurses to private residences and assisted living facilities when it is difficult for patients to travel for care due to their medical conditions.

VNA nurses work to meet the mental and physical health needs of their patients.

Both skilled and mental health nurses provide services to patients. Partnered with physical, occupational, and speech therapists, VNA services address a wide range of health needs.

Sarah Schirmer, RN, is a mental health nurse with VNA Nazareth Home Care, part of KentuckyOne Health.

Addressing the mental health care needs of patients, in particular those with Alzheimer’s or dementia, is an important part of care. VNA has a teaching tool called “Alzheimer’s Disease: Caring for the Patient and Family,” for home health clinicians to use with caregivers and patients to help them better understand the diagnosis of and best care for patients.

If a patient has not been diagnosed with Alzheimer’s or dementia, but exhibits symptoms, VNA clinicians screen patients with the St. Louis University Mental Status (SLUMS) Examination.

In the spring of 2014, VNA Nazareth Home Care will introduce a new mental health program with a specialized track for the care of Alzheimer’s or dementia patients. The program will include evidence-based guidelines from the American Psychological Association and the Alzheimer’s Association. VNA mental health nurses will use the program as a guide for caring for patients with Alzheimer’s or dementia.

In order to meet the complete needs of the patient, VNA nurses collaborate with neurologists and other physicians regularly to ensure patients are receiving the best care and all orders are being followed. The nurses monitor

medications for efficacy and side effects and implement suggestions from physicians.

Monitoring medications is particularly important in dementia or Alzheimer’s patients.

In addition to memory issues, these patients commonly suffer from one or more illnesses for which they receive treatment. It’s important to ensure their medications are working well and not interacting or causing a negative impact.

Proper medication monitoring and educating families on the symptoms of larger health concerns are also important to help avoid unnecessary hospital admissions.

Alzheimer’s and dementia patients cannot always communicate correctly when they have physical ailments, so caregiver watchfulness is very important. Caregivers are instructed on what symptoms to watch for and to call VNA for assistance when concerns arise.

VNA mental health nurses also provide support to caregivers to help them manage through their emotions and find ways to reduce stress. For example, in an Alzheimer’s or dementia patient who also has heart failure, caregivers may be instructed to watch for weight gain that could be a sign of fluid build up around the heart. If they notice a change, they are instructed to contact their VNA nurse. VNA nurses can help avoid a hospital trip by coming out and providing care that keeps an issue from becoming severe.

Using a holistic approach to care can improve outcomes for patients. It can prolong an individual’s independence, ability to conduct activities of daily living, and overall quality of life. ◆

2335 Sterlington Road, Suite 100 Lexington, Kentucky 40517 (859) 268-1040 Fax: (859) 268-6165 Email: lprober ts@barcpa.com www.barcpa.com

Issue#82 23

Complementary Care

Sex and Aging

By Valerie Areaux MS, LMFT A couple of weeks ago, the media was all a buzz about pop icon Miley Cyrus’ interview with Matt Lauer when he asked, “Is this a phase? Is the sexual side of you that we’re seeing a lot of right now something that’s going to be around for a while and then you move onto something else?” Cyrus replied, “I heard when you turn 40, things start to go a little less sexual, probably around that time. I heard that’s when people don’t have sex anymore.” The 55-year old Today Show host couldn’t contain his dismissive smile as he shook his head and said “don’t say that.”

It’s unfortunate in our youth-obsessed society of today that ageism still exists, perpetuating the notion that the fruits of sexuality, our sensual thoughts, desires, and actions are only for the youth to savor. The need for intimacy and connection is ageless. Through sexual activity, we are able to establish and maintain intimacy and to express our affection for our partner. Yet, it is still sometimes difficult for “younger folks” to think about “older folks” as sexual beings. As J. LoPiccolo wrote, “Sexuality in the elderly is a ‘dark continent’ that most people, including physicians, prefer not to think about.”

Most health professionals now understand that sexuality remains important to patients in the fall and winter seasons of life.

For all of us, engaging in sexual activities can reduce stress, improve sleep, strengthen blood vessels, burn calories, ease certain forms of pain, diminish symptoms of depression, and boost the immune system. But as we age, our bodies change and our risk for

Valerie Areaux, MS, LMFT is a licensed marriage & family therapist and a certified sex therapist, having completed a clinical program in Sex Therapy through the Florida post-graduate Sex Training Institute in Palm Beach, Florida.

health problems increase, contributing to an overall decline in the frequency of sexual encounters. Many older adults currently take one or more prescribed medication that may directly affect their sexual response cycle.

Conditions such as cardiovascular disease, depression, anxiety, endocrine problems, high blood pressure, diabetes, dementia, and arthritis all take a toll on sexual functioning and/or the availability of a healthy sexual partner. Too often, older adults walk out of the doctor’s office uneducated about the natural physical changes occurring as part of the process of aging, the potential sexual side effects of their prescribed medications, or with any understanding of how their diagnoses may impact their sexuality.

A 2009 study found that most medical students do not have formal opportunities to learn how to talk with their patients about sexual issues (Barrett & Rand, 2009). As health providers, we are relatively comfortable answering our patients questions related to sex, but how comfortable are we inquiring about our patient’s sexual health? How often do we openly discuss the potential impact on an older patient’s sexual functioning when rendering a diagnosis or discussing treatment options? Are physicians missing important indicators of comorbidities and opportunities to support a patient’s overall health by not asking about their current sexual functioning?

As part of my practice as a sex therapist, I review each patient’s general health history and request a list of their current prescribed medications. Frequently I have encountered older males who may be experiencing symptoms of erectile dysfunction and who are currently taking a prescribed anti-hypertensive. All too often they appear completely unaware of the potential for erectile difficulties as a result of these types of essential medications.

How can physicians help older patients feel comfortable talking about their sexual health?

• Don’t be afraid or embarrassed to ask about a patient’s current sexual functioning • Ask direct questions • Use clinical terms for body parts and processes • Provide education about normal physical changes, as a result of aging, and how they may impact a patient’s sexual health • Review potential sexual side effects of any prescribed medication with the patient • Provide appropriate referrals to certified sex therapist • Be warm, open minded, accepting, and concerned There is much we can do together to help patients compensate for the normal changes that come along with aging, complicating sexual relations. Through open dialogue and intentional conversations with aging patients about their sexual functioning, we can improve the accuracy of diagnosis and expand collaborative treatment options for this growing population.

Valerie Areaux, MS, LMFT. Bluegrass Family Therapy, LLC has offices in Lexington and Danville KY. Contact her at (859) 492 9955. ◆

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Complementary Care

Exponential Growth

Cardinal Hill Rehabilitation Hospital meets the growing demand of rehab patients with home health care By Jim Kelsey For more than 60 years Cardinal Hill Rehabilitation Hospital has been a leader in rehabilitation care, featuring state-of-theart facilities and the latest technology. Just two years ago, the hospital was expanded to include the Patient Care Building, which added private patient rooms, new gyms, and an aquatic center.

An expansion on a much larger scale began a little over 10 years ago. That’s when Cardinal Hill began offering home health care, effectively expanding the hospital’s caregiving space exponentially across the Bluegrass. Now, the same expertise, compassion, and technology that had been a trademark of the hospital is being offered to patients in their homes.

While home health care is not new, Cardinal Hill has led the charge to offer more expansive and comprehensive services to home health care patients. “We do a lot of services for patients who need more rehab than just the typical patient who needs nursing,” says Pam Heissenbuttel, MSPT, and director of Outpatient Programs at Cardinal Hill.

“That is probably one of the greatest distinctions between our home care and other home cares.

Adds Heissenbuttel, “We started the program because we saw the need for patients who were coming out of our rehab hospital …

A lot of home care at the time just provided nursing service. We do provide nursing service, but we provide therapy services as well.”

The push for more home health care services has come from a variety of influences, including insurance companies urging shorter hospital stays, but perhaps most significantly from the patients themselves.

Robert F. Taylor, MD, PhD, medical director of Cardinal Hill’s Home Health Program says not only do patients feel more comfortable at home but there is a huge advantage to undergoing rehab in their daily environments. “In the home, the patient gets to practice and learn how to overcome the very obstacles that they’ll face in their day to day setting. When the therapist goes out to visit

the home, they can make an assessment and say, ‘Hey, here’s a throw rug that needs to be removed because it is a safety issue,’” he says.

In addition to home health care providers, technology is also making its way into patients’ homes. Telemedicine is a growing part of the home health care landscape, enabling physicians to receive vital information about their patients electronically.

quality and accuracy, so we get better information. But I hope that the technology never attempts to completely replace a loving, compassionate, highly trained caregiver.”

As with any health care service, the ultimate goal is to provide the best possible care to the patient. Taylor stresses that keeping the referring physician informed and involved in the patient’s rehabilitation is a key element to the success of any home health care program. Establishing and maintaining those open lines of communication is one challenge. Another is navigating the health care regulations and insurance obstacles while keeping the patient’s needs at the forefront.

“People are coming home (from the hospital) a lot sicker than they used to,” Heissenbuttel says. “They have a lot more

Pam Heissenbuttel, MSPT, and Director of Outpatient Programs at Cardinal Hill Rehabilitation Hospital Right: Robert F. Taylor, MD, PhD, Medical Director of Cardinal Hill’s Home Health Program Above:

Depending the severity of the issue, a nurse can be sent to the patient’s home or the patient can be directed to the hospital.

While telemedicine is a vital new tool, Taylor says that the personal touch is still the key to quality care.

“If we’re going to compare telemedicine with physically being there, compassionate individuals trying to really figure out what’s going on with that patient, I don’t think there’s any comparison,” Taylor says. “Technology gets better, our sensing devices improve in

needs in the home. The government and Medicare really try to limit that when they ought to be embracing treatment in the home because they’re going to get better quicker, cheaper.”

“Being in a peaceful environment, in a familiar environment, someone coming to your location … that has got to be better,” Taylor adds. “That’s got to be more comforting, less disruptive. I think it’s just one more thing a person could use to get better more quickly.” ◆ Issue#82 25

26 M.D. Update

news  events  Arts

Sparks Joins Baptist Medical Associates 

LA GRANGE L. Brad Sparks, MD, internal medicine, has joined Baptist Medical Associates’ practice located at 1031 New Moody Lane, Ste. 300.

Sparks is a 1998 graduate the University of Kentucky College of Medicine. He completed his internal medicine residency at the University of Kentucky in 2001. He is board certified in internal medicine. He is accepting new patients.

Strain Joins Baptist Medical Associates

LOUISVILLE Ann Strain, APRN, has joined Kentucky Heart Specialists, part of Baptist Medical Associates, at 3793 Poplar Level Road.

Strain is a 2000 graduate of the family nurse practitioner program at Spalding University. She also holds an associate degree in nursing from the University of Louisville and a bachelor’s degree in nursing from Spalding University. She is board certified by the American Academy of Nurse Practitioners and the American Nurses Credentialing Center.

Ambati Receives Junius-Kuhnt Award 

LEXINGTON Dr. Jayakrishna Ambati, professor and vice chair of the Department

Dr. Jayakrishna Ambati, third from left, receives the Junius-Kuhnt Award.

Send your NEWS items to M.D UPDATE > news@md-update.com

of Ophthalmology and Visual Sciences at the University of Kentucky College of Medicine, received the Junius-Kuhnt Award from the University of Bonn in Hamburg, Germany, for his group’s outstanding work and commitment to age-related macular degeneration (AMD) research.

The Junius-Kuhnt Award honors physicians and scientists who have made outstanding contributions to the study and treatment of AMD, and has been awarded annually since 2007 at “Makula Update,” an annual congress of German retina specialists.

This award is named after the German ophthalmologists Paul Junius and Kuhnt Hermann who, at the University Eye Clinic of Bonn, were the first to describe the neovascular, “wet” form of AMD. Their 1926 monograph entitled, “The disk-shaped degeneration of the retinal center,” was the world’s first on AMD, and is still considered a milestone in ophthalmic medical history. Ambati is first non-European winner of this award, and delivered a lecture on CCR3 as a diagnostic and therapeutic target for AMD.

Mannino Receives COPD Foundation Award 

Dr. David M. Mannino, professor and chair of Preventive Medicine and Environmental Health at the University of Kentucky College of Public Health, has been honored as the recipient of the Chronic Obstructive Pulmonary Disease (COPD) Treatment Achievement Award from the COPD Foundation. Mannino holds a joint appointment as professor of medicine in the UK Division of Pulmonary, Critical Care, and Sleep Medicine, and as the director of the UK Pulmonary Epidemiology Research Laboratory.

The award is given to recognize Mannino’s development of the COPD Foundation Pocket Guide for Diagnosis

LEXINGTON

and Management of COPD, a practical and user-friendly tool that assists clinicians in navigating the complex treatment options for COPD. The guide not only improves clinician educational resources, but ultimately improves COPD patient outcomes.

The COPD Treatment Achievement Award will be presented to Mannino at the COPD Foundation’s Annual Awards and Recognition Benefit on Dec. 5, in New York City.

Mannino formerly served as the chief science officer of the Centers for Disease Control (CDC) Air Pollution and Respiratory Health Branch. While at CDC he was the lead author on key publications reporting on the epidemiology of COPD and asthma.

He has authored more than 200 publications in leading peer-reviewed journals on topics that range from the epidemiology of lung disease to health effects related to air pollutant exposure. He is an active member of and adviser to several professional organizations, including the COPD Foundation, the USCOPD Coalition, the National Lung Health Education Program, and the Alpha1 Foundation.

UK Pediatric Resident Receives Grant to Spread Vaccine Awareness 

LEXINGTON Pediatric resident Dr. Akshay Sharma and the University of Kentucky College of Medicine’s Department of Pediatrics were recently awarded one of 10 mini-grants from the American Academy of Pediatrics (AAP) to support events that benefit global vaccine advocacy and the United Nations F o u n d a t i o n’s Shot@Life campaign.

With the funding, Sharma and the UK Department of Pediatrics hosted an event on Sept.

26 that featured guest speaker Dr. Issue#82 27

news Stephen Warrick of Cincinnati Children’s Hospital, who talked about the incidence of vaccine preventable diseases worldwide and what efforts are being made to eradicate them.

A movement to protect children worldwide by providing life-saving vaccines where they are most needed, Shot@ Life educates, connects, and empowers Americans to champion vaccines as one of the most cost-effective ways to save the lives of children in developing countries.

By encouraging Americans to learn about, advocate for, and donate to vaccines, Shot@ Life aims to decrease vaccine-preventable childhood deaths and give every child a shot at a healthy life.

As a founding partner of the UNFoundation’s Shot@Life campaign, the American Academy of Pediatrics (AAP) and Shot@Life provide pediatricians opportunities to talk to engage with the public and our government about the critical role of vaccines in saving and improving the lives of children around the world. The AAP spreads the message that all kids deserve a

shot at life and offers resources to help pediatricians educate parents about the importance of international vaccine programs.

Photo Caption: Dr. Akshay Sharma leads fellow residents in a vaccine information session.

Joseph Gilene Named President of Saint Joseph Hospital 

LEXINGTON KentuckyOne Health added Joseph J. Gilene, an accomplished health care executive with nearly three decades of experience, as president of Saint Joseph Hospital in Lexington effective Oct. 28.

Most recently, Gilene worked in Charlotte, North Carolina, as regional vice president for the nation’s largest hospital management organization, Quorum Health Resources. Gilene was responsible for strategic planning and cost and quality control for nine nonprofit hospitals in a threestate (North Carolina, South Carolina, and

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28 M.D. Update

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Virginia) region. Earlier he held senior executive positions at Robert Wood Johnson University Hospital in New Brunswick, New Jersey, Carolinas Medical Center in Charlotte, North Carolina, Sacred Heart Medical Center in Spokane, Washington, and Cincinnati Children’s Hospital.

Gilene is a fellow of both the American College of Healthcare Executives (FACHE) and the Healthcare Financial Management Association (HFMA). He is also a certified public accountant. He has served as an advisory council member for the American College of Healthcare Executives, an international professional society of more than 40,000 health care executives.

New Physician Course to Curb Prescription Drug Abuse

LOUISVILLE The Greater Louisville Medical Society is pleased to announce a three day intensive course for physicians aimed at improving skills in controlled substance prescribing and decreasing prescription drug abuse in Kentucky and surrounding states.

The course, named OPIOID (Optimal Prescribing is Our Inherent Duty), was developed by GLMS’s in-house Medical Society Professional Services and GLMS President and addiction specialist, James Patrick Murphy, MD, MMM, as a service to the community.

The course will lead physicians through a critical self-assessment in order to provide the best possible care. Leading clinical experts from the University of Louisville and the University of Kentucky will teach pain and addiction, behavioral psychology, clinical forensics, as well as current legal and regulatory environments.

The combination of didactics, experiential learning, role-playing by clients from The Healing Place, and interactive group dynamics make this course unique. More than just a skill set, this course will provide a framework with which physicians can build confidence in overcoming tactics used by patients seeking narcotics inappropriately and help to eliminate stress when optimal care of a patient requires a controlled substance.

Designed to provide 18-hours of Continuing Medical Education, OPIOID was recently approved by the Kentucky Board of Medical Licensure for physicians identified by the board as being in need

news of remedial training. Prior to this course, Kentucky physicians were referred to courses outside the state, such as at Vanderbilt.

Teaching this course in Kentucky keeps physicians from having to travel outside state boundaries and improves physician education in the region.

OPIOID is also listed on the Federation of State Medical Board’s website as a physician assessment and remedial education program. For more information about OPIOID, contact GLMS at (502) 7366350 or visit www.glms.org. The first class is scheduled for February 7 – 9.

UK HealthCare Releases Report Regarding Pediatric Cardiothoracic Surgery Program

LEXINGTON A comprehensive report released in mid-October by a nearly 30-member UK HealthCare taskforce outlines a series of steps that will be taken in the coming months to re-open the pediatric cardiothoracic surgical program.

UK HealthCare’s pediatric cardiothoracic surgical program was voluntarily and temporarily suspended last fall after questions were raised internally about how best to improve the program. UK Executive Vice President for Health Affairs Dr. Michael Karpf convened the taskforce and charged it with providing recommendations regarding the future of the UK HealthCare Pediatric Heart Program including program scope, resource planning, strategy for launch and a post-launch monitoring and oversight plan.

The report of the UK Pediatric Heart Program Taskforce is available at http:// ukhealthcare.uky.edu/quality/reports/.

The more than 100-page report assesses the program and offers three major, potential recommendations to re-institute the surgical program within the next several months: Change the health care delivery model from a traditional approach to a service line for pediatric heart care. In a service line approach, care delivery is integrated with specialists, doctors, nurses, and other professionals working closely together around the needs of a patient.

Increase resources in terms of hiring doctors, specialists, and nurses for the program. It would include the creation of a four-bed pediatric cardiothoracic intensive

care unit, among other measures.

Consider whether a partnership or alliance with another health system or systems should be established to take advantage of synergies that benefit pediatric patients with cardiac disease.

The report contemplates re-opening the program on or after Jan. 1, 2014. Dr. Bernard Boulanger, UK HealthCare’s chief medical officer, said the commitment is there to re-open the program as soon as possible, but only after the resources and process improvements are in place to ensure the delivery of high quality, safe and compassionate cardiac care for the children of Kentucky and beyond.

UofL Researchers Sign Global Licensing Agreement

The University of Louisville recently announced that researcher Dr. Suzanne Ildstad, representing Regenerex LLC, has entered into a license and research collaboration agreement with Novartis to provide access to stem cell technology that has the potential to help transplant patients

LOUISVILLE

avoid taking anti-rejection medicine for life and could serve as a platform for treatment of other diseases.

The University of Louisville and Regenerex LLC announced the research collaboration agreement, which will significantly enhance the university’s Institute for Cellular Therapeutics’ ability to carry out cutting edge research related to the Facilitating Cell, a novel cell discovered by Ildstad, a professor of surgery and director of the institute at UofL as well as CEO of Regenerex. Underpinning this collaboration is an exclusive global licensing and research collaboration agreement between Regenerex and Novartis.

Ildstad published results in a March 2012 Science Translational Medicine demonstrating the efficacy of this process, known as Facilitating Cell Therapy, or FCRx which is currently undergoing Phase II trials. The collaboration provides for investments in research, as well as milestones and royalty payments from Regenerex to the University of Louisville in connection with commercialization of the FCRx technology. ◆

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Issue#82 29

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events

The Doctors’ Ball

Louisville - The annual Doctors’ Ball, which recognizes Louisville area physicians and community leaders for their work in health care, was held October 19, 2013 at the Marriott Hotel in downtown Louisville. Proceeds from the event benefit Jewish Hospital & St. Mary’s Foundation, part of KentuckyOne Health, which invests in improving health care facilities, services, and education of health care providers, while furthering clinical research and access to medical care.

This year’s event raised more than $330,000. The funding will be dedicated to the Jewish Hospital Trager

(l-r) Drs. Brian and Toni Ganzel, Dean UofL School of Medicine, with Martha and Dr. Mark Slaughter and Dr. Matt Williams (back). Mrs. Slaughter was co-chair of the Doctors’ Ball with Lauren Williams and Misty McCubbin.

Drs. Ganzel, Williams, and Slaughter are with University Cardiothoracic Surgery Associates.

Jeffery Graves, MD, and wife Andrea. Dr. Graves is an anesthesiologist with KentuckyOne Health.

Transplant Center, a joint program with the University of Louisville’s School of Medicine.

Awards were given this year to Frank Miller, MD, the Ephraim McDowell Physician of the Year; Luis Scheker, MD, and Tsu-Min Tsai, MD, Excellence in Education; Bryan Carter, MD, Excellence in Mental Health; Muhammad Babar, MD, Excellence in Community Service; Mary Fallat, MD, Compassionate Physician, and Bill and Lindy Street, Community Leader of the Year.

A memorial tribute for Harold Kleinert, a past Ephraim McDowell Physician of the Year, was included to honor the recently deceased physician.

The March Madness Marching Band added a big splash of “New Orleans flash & jazz” to the Doctors Ball where the theme was “Let’s Toot Some Horns!” w

Bennie Thornton, RN, Linda Coke, RN, Kelli Marvin, PhD, Michael Marvin, MD, University Surgical Associates, gathered together for a moment at the Doctor’s Ball.

Dr. Gregory Gleis, orthopedic surgeon in private practice, with wife Dr. Linda Gleis, VAMC, enjoyed the Doctors’ Ball.

Huey Tien, MD, and Ring Tsai, MD, daughter of Honoree Dr. Tsu-Min Tsai, were on hand to support the Doctor’s Ball.

Thomas Becherer, MD, and Rebecca Hood Becherer, MD, checked out the Silent Auction items at the Doctors’ Ball.

Drs. Susan and Vijay Raghavan attended the Doctors’ Ball to support Jewish Hospital & St. Mary’s Foundation’s research Issue#82 31

events

Lexington Medical Society October Meeting - AMA President Ardis D. Hoven, MD, addressed the gathered members of the Lexington Medial Society (LMS) at the annual meeting honoring LMS past presidents, October 8, 2013 at the Red Mile Clubhouse in Lexington.

Hoven’s message was clear: “The dysfunction in Washington, DC makes it imperative that physicians maintain their focus on patients and patient care.”

Physician led health care teams using practitioners to their highest level of education, expertise, and training will be the answer to providing care for the millions of new patients that will be included under the Affordable Care Act (ACA), Hoven said. “These are not new patients,” Hoven stated. “The new Medicaid and uninsured patients are already in the

Lexington

system but using the Emergency Room and local health departments. They’re at the wrong place at the wrong time for efficient health care.”

Hoven cited the top challenges of physicians as “un-predictable income, increased workloads, administrative hurdles, a move to consolidation, concern for patient care, and the uncertainty of the effects of the ACA.” The AMA achieved gains in the federal rules by including physicians as stakeholders and adherence to state scope of practice laws, she pointed out.

“If the private medical practice goes away, the health care delivery system in our country will suffer greatly,” Hoven warned. “We must relate to each other as physicians, not as Democrats or Republicans. The ACA is not a perfect law, but at the end of the day, it is a step forward.”

Preston Nunnelly, MD, LMS past-president and medical director Baptist Health Lexington, with Melissa V. Avery, MD, medical director Bluegrass Family Health, and Pat Padgett, KMA executive vice president

(l-r) Thomas Slaybaugh Sr., MD, LMS pastpresident, with AMA President Ardis D. Hoven, MD, and Gary Wallace, MD, LMS past-president AMA President Ardis D. Hoven, MD, stressed “the importance of physicians giving back to their communities.

Organized medical societies are a form of giving back.”

(l-r) LMS Past-Presidents Terry D. Clark, MD, David B. Stevens, MD, W. Lisle Dalton, MD, and John W. Collins, MD

A Joint Commission accredited private surgery center where our physicians perform diagnostic and surgical procedures for the treatment of pain, to include:

(l-r) Kaveh R. Sajadi, MD, and Tommy Slaybaugh Jr., MD, LMS vice president 32 M.D. Update

Š 2013 Baptist Health

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