Minnesota Health care News November 2012 by Minnesota Physician Publishing

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November 2012 â&#x20AC;˘ Volume 10 Number 11

Pacemakers for pain

Plantar fasciitis

Peter Pahapill, MD

Angela Voight, MD

Sexually transmitted infections Alison Warford, MD

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C O N T E N T S NOVEMBER 2012 • Volume 10 Number 11

4 7 8

NEWS

PEOPLE

HEALTH PROFESSIONS Community health workers By Joan Cleary, MM

PERSPECTIVE Beverly Fritz Phillips Eye Institute

18 20

CALENDAR National Alzheimer’s Awareness Month

ONCOLOGY Cancer care coordinators By Connie Fiebiger, RN, BSN, MA

10 QUESTIONS Lynn Miller, DO Midwest Spine Institute, LLC

REPRODUCTIVE HEALTH Youth and sexually transmitted infections By Alison Warford, MD

LONG-TERM CARE Family-member caregiving By Michele Kimball

ORTHOPEDICS Plantar fasciitis

BEHAVIORAL HEALTH Seasonal Affective Disorder (SAD)

By Angela Voight, MD

By S. Charles Schulz, MD, and Barry Rittberg, MD

PUBLIC HEALTH The Chiron Project By Gretchen Stein, MA, PhD, and David Wettergren, MA, EdD

Nationally recognized. Patient-focused. Areas of Expertise Artificial Disc Replacement Disc Degeneration Disc Herniation Discectomy Fractures Fusion Kyphosis (hump) Minimally Invasive Surgery Pediatric Curvature Sciatica Scoliosis - Juvenile - Adult

Spinal Arthritis Spinal Cord Injury Spondylolisthesis (shifted vertebrae) Stenosis Tumors/Infections Pain Treatment & Diagnostics - Injections - Radiofrequency Neuroablation - Spinal Cord Stimulators - Vertebroplasty

PALLIATIVE CARE Pacemakers for pain By Peter Pahapill, MD, PhD

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR MaryAnn Macedo mmacedo@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com

Daryll C. Dykes M.D. (spine surgeon), Mark A. Janiga M.D. (interventional pain physician), Mark K. Yamaguchi, M.D. (interventional pain physician), Glenn R. Buttermann M.D. (spine surgeon), Thomas V. Rieser M.D. (spine surgeon), Daniel W. Hanson M.D. (spine surgeon) Seated – Stephen T. Knuff D.O. (interventional pain physician), Louis C. Saeger M.D. (interventional pain physician), Lynn M. Miller D.O. (neuro-spine surgeon), Stefano M Sinicropi M.D. (spine surgeon)

Physicians specializing in restoring lives affected by spinal injury and disorder

Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), Minnesota Medical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), Minnesota Business Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options for Mainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA), Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans. Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

Locations throughout the Twin Cities and Western Wisconsin

800.353.7720 / 651.430.3800 / fax 651.430.3827 MidwestSpineInstitute.com NOVEMBER 2012 MINNESOTA HEALTH CARE NEWS

NEWS

New Pap Test Guidelines New national guidelines for Pap tests recommend that women get tested less often, but a local physician who recently was recognized for his cancer-screening efforts reacted with caution to the new guidelines. Bradley Linzie, MD, is a pathologist at Hennepin County Medical Center (HCMC) in Minneapolis and recently received the College of American Pathologists (CAP) Foundation 2012 Gene and Jean Herbek Humanitarian Award for helping to provide free cervical and breast cancer screenings at NorthPoint Health and Wellness Center, an affiliate of HCMC. Linzie says frequency of Pap tests depends on each individual’s health history. “This [new recommendation] is mostly for people who have never had an abnormal reading,” Linzie notes. “Age, prior Pap test history, and sexual history [can affect] when you need your next Pap test.”

The new guidelines, released by the American Congress of Obstetricians and Gynecologists, say that most women should be screened for cervical cancer via Pap tests every three to five years. For many, this will replace an annual Pap test. Women ages 30–65, however, are advised to go five years between Pap tests and to be screened for human papilloma virus (HPV) at the same time as their Pap tests. Linzie says that false positive Pap tests can result in intrusive follow-up procedures for women, so he understands the reasons for the new guidelines.

Study Provides Helpline for Nonsmokers A Mayo Clinic researcher is leading a study that takes a new approach to smoking cessation. A team led by Christi Patten, PhD, is looking at the concept of providing a telephone helpline for nonsmokers who want to help a

Jim

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loved one quit smoking. After an initial study produced promising results, Patten and her team are now recruiting participants for a larger study. The study, supported by ClearWay Minnesota, an antitobacco group funded in part with payments from the state’s tobacco settlement, will include more than 1,000 participants. By participating in the study, nonsmokers (called “support persons”) can receive counseling via phone or mailed materials. The support person is encouraged to motivate the smoker to call ClearWay’s QUITPLAN Helpline, which has been shown to greatly increase the chances of quitting tobacco. Patten, a clinical health psychologist, says she got the idea for the new approach by talking to family members of smokers. “I’d get a call from a spouse or a child asking, ‘What can I do to help?’” she says. “At the time, there wasn’t much out there.” Patten says that although nonsmokers want to help loved ones quit, most do not know how.

“We’ve found that many people are interested in helping a smoker, and they’ve tried so many times, but they’re trying in ways that are not successful,” she says. “Many have tried to nag the smoker, hide their cigarettes. There’s actually been a lot of research that has found certain behaviors can help a smoker quit, but there are others that backfire.” Under the program, Quitline counselors will counsel nonsmokers on the best strategies with up to three telephone sessions, along with written support material. “We teach the support person new ways to support their smoker, based on research,” Patten says. “The goal of the counseling sessions is to get the support person to motivate their smoker to call the quitline.” She notes that the QUITPLAN helplines have a proven success record with smokers, and just getting the smoker to call is a big step forward.

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MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

Minnesota will receive an additional $42.5 million grant from the federal government for health insurance exchange planning, officials announced last week. The latest grant is one of three the state has received so far to plan for an exchange, for a total of nearly $73 million. Health insurance exchanges are a key part of the federal Affordable Care Act, and a number of states are moving forward to plan exchanges, which will become operational in 2014. The most recent round of grants went to five states and the District of Columbia. The exchanges will give uninsured individuals and small businesses the ability to shop online for insurance products, with federal subsidies helping to cover the cost in many cases. The new grant will help the state establish contracts with brokers and others to develop consumer services programs, test cost and quality measures, and continue work on financial infrastructure as well as administrative functions. “States continue to make progress toward building exchanges that work best for their residents,” said Health and Human Services Secretary Kathleen Sebelius on Sept. 27, as the new grants were announced. “The resources announced today will ensure states have the assistance they need to continue moving forward.” Despite the ongoing work by state agencies, Gov. Mark Dayton has pledged to delay some important decisions on the exchange until after the November election, and has said the state legislature will be able to weigh in on the development of the exchange.

Medica Solo Plan Offered to Families Medica has expanded one of its insurance products for individuals to cover families as well. Medica Solo, first introduced in 2007, will add a family option on Nov. 1, officials say, due to consumer demand. Insurance plans for individuals and families that lack employer-based insurance has been an area of growth for insurance companies. Medica officials say the Medica Solo product has been popular in part because it covers some services without requiring deductibles and copays. For example, preventive services are covered at 100 percent with no cost-sharing. For other services, deductibles and copays apply, but Medica officials say the pricing is competitive with other products on the market. “Medica Solo is an affordable health plan option with real value that we believe will strike the right note for families,” says Dannette Coleman, Medica vice president for individual and family plans. “We think it simplifies the shopping process and management of family finances as people increasingly become responsible for buying their own coverage for their entire family.”

Telephone Equipment Distribution (TED) Program

More Funds Given to Help Minnesota with Insurance Exchange

Do you have trouble using the telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud

The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services

Dayton Launches Long-Term Care Campaign Minnesota has launched a campaign to help people become more aware of the need for longterm care planning. The “Own Your Future” initiative has been in the works for some time, but officials with the Dayton administration officially launched the campaign on Oct. 2, unveiling a new website and phone line where Minnesotans can find information and resources on long-term care planning. Federal and state officials across the nation see a demographic tsunami coming as mil-

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News to page 6 NOVEMBER 2012 MINNESOTA HEALTH CARE NEWS

News from page 5 lions of baby boomers age and begin requiring assistance for daily tasks or to maintain their health. Many Americans believe that Medicare provides for longterm care needs, but that is not the case, state officials note. Medicare and Medicaid pay only for long-term care in limited circumstances, and under Medicaid, individuals must “spend down” their resources until they qualify for assistance. However, the campaign is not simply about planning for nursing home care, as many other options are now available for seniors. In a letter sent to Minnesotans between the ages of 40 and 65, Gov. Mark Dayton and Lieutenant Gov. Yvonne Prettner Solon say that planning now for future needs gives individuals and families more control over their future. “Planning gives you time to make changes in your home, which will allow you to remain in your home as you age. Planning allows you to decide who will

assist you as your needs change and how to manage your legal affairs and health care if you are no longer able to do so,” the letter says. In addition to the letter, the state has established an “Own Your Future” website, at www.mn.gov/ownyourfuture. State officials are also launching an Internet ad campaign, and other awareness-raising efforts are being considered.

Cancer Drug Makers Have A “Monopoly,” Physicians Say Manufacturers of cancer drugs enjoy a “virtual monopoly” in the marketplace, which plays a role in the relatively high cost of those drugs, according to a new article in Mayo Clinic Proceedings. The commentary, by oncologist Mustaqeem Siddiqui, MD, and hematologist Vincent Rajkumar, MD, points out that a recently introduced cancer drug was judged to extend the life of a

cancer patient by 3.7 months. The cost for the drug was $120,000. “Sadly, the benefit of these new drugs is typically short-lived, and many of these drugs are very expensive,” says Siddiqui. The authors note that there are many causes behind the high cost of cancer drugs, including regulatory costs, drug development costs, and the tendency to want the newest and best treatments for a life-threatening disease such as cancer. Because of these and other factors, the authors write, drug manufacturers have a kind of monopoly when it comes to cancer drugs. With other medical conditions, there are a variety of treatments and competition holds down costs, they note. Cancer drugs, on the other hand, often work only for a limited time, and the use of one drug does not preclude the use of another drug. “Most of these drugs provide benefit for a short duration, typically measured in weeks or months, and then the

tumor begins not to respond to the therapy. In this scenario, physicians really do not choose the most cost-effective option; they only decide the timing at which each option is used,” the authors write. “Thus, each drug is an effective monopoly because each one will be indicated at some point during the course of a patient's illness. As in any monopoly, drugs that extend the survival of patients with incurable malignancies, even by a few weeks, can, therefore, be priced at whatever price the market will bear.” The authors call for “valuebased pricing” as one means of addressing this situation. Such a system would create metrics for estimating the number of years added to a patient’s life by a drug, adjusted for quality of life. They also suggest implementing price controls on such drugs, as other countries have done.

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MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

Health h Clinics

www.nwhealth.edu/patients www .nwhealth.edu/patients

PEOPLE Okeanis Vaou, MD, has joined the Noran Neurological Clinic in Minneapolis. She graduated from Semmelweis University in Budapest, Hungary; continued her training in neurology at New York Medical College; and completed fellowships in movement and sleep disorders at Boston University Medical Center. Her clinical interests include Parkinson’s disease, dystonias, Okeanis Vaou, MD

autonomic nervous system disorders, essential

tremor, and sleep-related disorders. The Courage Center has named Aaron Cross its 2012 Judd Jacobson Memorial Award Winner. The annual award, which is named for the late Minnesota business leader who became a quadriplegic as a result of a diving accident, recognizes the pursuit or achievement of an entrepreneurial business endeavor by a person with a physical disability or sensory impairment. Cross was left with quadriplegia as the result of a bicycle accident when he was 15. He will use the $5,000 award in connection with his motivational speaking and services business, Motivation on Wheels. Byron Marquez, DO, has been named senior medical director and chief of community primary

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care at Hennepin County Medical Center (HCMC), and is now seeing patients at Whittier Clinic in

Call C all for for more more information information

Minneapolis. In addition to direct patient care,

952.848.2065 952.848 8.2065

Marquez will work with clinicians in six community primary-care clinics, two convenience clinics, and one worksite-based clinic to improve the care

Byron Marquez, DO

7700 France Ave., Ave., Suite Suite 100, Edina, MN w w w. r a d i a n t r e s e a r c h . c o m www.radiantresearch.com

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they provide their patients. Marquez completed a family medicine residency in Detroit and worked as a family physician for 12 years in Madison, Wis., before joining HCMC. Michaela Tsai, MD, has joined Minnesota Oncology. In addition to practicing at the group’s Minneapolis clinic, Tsai will hold the endowed Martha Bacon Stimpson Chair in Medical Oncology at the Virginia Piper Cancer Institute. Tsai’s areas of special interest include clinical research, leukemia and lymphoma, and genetic counseling for breast and ovarian cancer Michaela Tsai, MD

syndromes. Tsai holds a medical degree from

Harvard Medical School and completed her fellowship in medical

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Minnesota. She is board-certified in internal medicine, medical oncology, and hematology.

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Martin Bosch, BSN, a registered nurse supervisor at the

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t Take your medicines as directed t Talk to your doctor

health nursing specialty through patient and public advocacy, demonstrating evidence of continuously improving skills and knowledge through a variety of self-enhancement activities, and providing mentorship and supervision of other nurses. Bosch, who has worked at the Minnesota Department of Human Services for 14 years, will be honored along with eight other psychiatric mental health nurses at the APNA annual conference this month.

Minnesota Diabetes & Heart Health Collaborative

NOVEMBER 2012 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

Early Youth Eyecare Community Initiative Removing vision problems from the classroom

Beverly Fritz Phillips Eye Institute

Beverly Fritz is the foundation director for Phillips Eye Institute, which is part of Allina Health and is a specialty hospital dedicated to preserving, protecting, and restoring vision. Integral to the community service mission of Allina Health, the E.Y.E. Community Initiative is funded through the Institute’s Foundation. It has received the Minnesota Hospital Association Community Benefit Award for Small Hospitals; the Minneapolis Regional Chamber of Commerce Quality of Life Award; and the Minneapolis/St. Paul Business Journal July 2011 Jefferson Award for Corporate Giving. To learn more about E.Y.E., visit www .phillipseyeinstitute .com.

evin was a typical fourth grader who needed glasses. But not until he went through a routine eye-screening exam at Jenny Lind Elementary School in Minneapolis was that basic health need recognized. Now, Kevin is one of nearly 400 children receiving ongoing vision treatment and free glasses that the Phillips Eye Institute’s Early Youth Eyecare (E.Y.E.) Community Initiative provides for children of families that have little or no insurance. Since this program began in 2007, 813 children have been helped.

• Providing interpreter services for screenings and follow-up treatment

Vision screening is an efficient and economical method of detecting vision problems. Unfortunately, vision assessment is no longer standard at many schools because routine screenings have been crowded out by competing demands on school budgets and nursing priorities. As a result, many vision issues in school-aged children go undetected.

achievement gap that plagues children in poverty and minority populations by ensuring all students have one of the most basic tools for learning: healthy vision.

Since the program’s inception in the spring of 2007, E.Y.E. has conducted over 45,000 vision screenings for all kindergarten, first-, third-, fifth-, and sixth-grade students in Minneapolis public schools. The impact of E.Y.E. is particularly profound once you realize that ethnic minorities and children from poor urban areas fail vision screenings at twice the rate of the general population. Children with impaired vision are often unaware of Nearly 70 percent of the Minneapolis public their vision defect and conschool students we serve sequently do not complain are students of color and 64 or seek help. Having always Children with impaired percent are eligible for free seen things in a blurred or reduced lunch, which is a vision are often unaware or distorted way, they accept standard indication of low imperfect images as normal income. of their vision defect. and don’t realize their A recent Campaign for vision may impede their Educational Equity study academic performance, social interactions, ability rated vision as a top priority to address educato play sports, and participation in other activities. tionally relevant health disparities. Further, the Vision and learning correlate study noted that effective interventions must be E.Y.E. strives to remove vision problems as a comprehensive in nature, reaching beyond the major roadblock to learning by providing regular threshold step of vision screening to include vision screenings and subsequent treatment serv- timely follow-up and treatment—like the E.Y.E. ices to Minneapolis public school children. The Community Initiative. correlation between vision and learning is well The response to this initiative has been overestablished: Nearly 80 percent of early childhood whelmingly positive from school administrators, learning takes place through vision. Imagine nurses, teachers, students, families, and the combeing unable to see the board or read the book in munity. Our local business partners, OGI Eyewear front of you at school. Approximately 25 percent and Walman Optical, have helped provide free of children have vision problems significant glasses and lenses. Grants from Allergan Foundaenough to affect their performance not only in the tion and Transition Lens, plus funds from private classroom, but also in their daily lives. Early donors, help support this program. detection and treatment of vision problems are The comprehensive services of the E.Y.E. Comcritical to a child’s development. munity Initiative help address the academic

The E.Y.E. Community Initiative is committed to removing vision problems as roadblocks to learning by: • Providing free, regular vision screenings in 48 Minneapolis public schools • Facilitating and funding timely and comprehensive follow-up treatment for children whose vision screenings reveal unmet vision needs • Coordinating and funding transportation to select doctors’ offices for care

Addressing health disparity

MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

Making a difference Since Kevin entered the E.Y.E. program he has received three pairs of glasses, including sports glasses that allow him to play football. His mom said that the expense would have made it impossible for her to have replaced Kevin’s glasses as he outgrew his prescription if not for E.Y.E. Kevin himself says it best: “I can read better, I can do math better, and I can see the blackboard better.” To learn if your family may be eligible to participate in the E.Y.E. program, contact Cody Engelhaupt, program coordinator; (612) 775-8968, or cody.engelhaupt@allina.com.

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10 QUESTIONS

Treating the whole person, not just the spine Lynn M. Miller, DO Lynn M. Miller, DO, is a fellowship-trained neurosurgeon on staff at Midwest Spine Institute, LLC, where she cares for patients who have specialized spine care needs. Please tell us what the DO degree means and how it differs from the MD degree. Osteopathy is a branch of medicine that was started in 1894 by Andrew Still, MD, who emphasized the relationship between body structure and function of the patient as a whole person. Differences between a DO (osteopathic doctor) and an MD stem from historical differences in teaching focus during training. While this was a major difference in the past, both DO and MD training programs are now embracing the “whole person” approach. DOs are licensed to practice the full scope of medicine: prescribe medicine, perform surgeries, and practice any medical specialty anywhere in the United States. For example, DOs specializing in spinal neurosurgery, as I do, treat spine damage or irritation from disc herniation, tumors, trauma, fractures, degenerative disease, or spinal collapse (osteoporosis, compression fractures, and degenerative bone conditions). Are there differences in the way that a neurosurgeon and an orthopedic surgeon might approach the same spine condition? Not necessarily. Both specialists treat disease and inflammation of neural structures—nerve tissue and spinal cord—as well as bony structures. (A nerve is a branch off the spinal cord that relays signals between the brain and spinal cord and the muscles and bones.) Training prepares a neurosurgeon, whether MD or DO, more for nerve and spinal cord–related issues and an orthopedic surgeon, more for bone-related issues. However, MDs and DOs who are both trained in spine care will likely treat the same medical problem with similar techniques. What is the most common misconception you encounter about spine care? Patients with back problems often fear surgery, but surgery isn’t always necessary. I consider conservative care options first, avoiding surgery whenever possible. I collaborate with my colleagues—specialty-trained physician assistants and nurse practitioners, plus physical therapists, other spine surgeons, and interventional pain physicians—to tailor individual treatment plans to help patients regain active lives. Correcting misconceptions about the inevitability of surgery reassures patients and helps them understand their conditions and options. Which spinal conditions do you see most frequently? Spinal cord inflammation, damage from direct compression or underlying disease (such as tumors), pain or structural integrity problems, narrowing (stenosis) of neural structures, nerve damage, and irritation that results from disc herniation, infections, masses, or degenerative disease. How should someone choose a health care provider to handle a particular spinal condition? Patients need to feel comfortable with the provider they choose. They also need to feel the provider understands their concerns and will be responsive to their questions. Choosing a provider who has completed fellowship training (i.e., additional specialty training) in spine surgery and devotes his or her practice to spinal disorders will yield a more tailored treatment plan.

Photo credit: Bruce Silcox

If someone injures his or her back, what symptoms should prompt medical attention? Symptoms that should prompt an immediate call to your physician are severe acute pain, pain lasting more than five days, weakness, balance issues, and problems controlling your bowel or bladder.

MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

Research into ideal

Are there simple steps people can What developments do you foresee treatment of traumatic take to maximize their spinal in the field of spine surgery? The health? Spinal health is largely measured trend toward improved outcomes and shorspinal injuries has become by how much support the spine has from ter hospital stays will continue. With new widely accepted, improving the surrounding tissue. For example, a changes in health care and training, I anticispinal column may be healthy and still have pate more subspecialization. New fusion patient outcomes. pain if the surrounding musculature is supplements will increase the success of weak, even if the patient is physically fusion surgery typically performed to relieve healthy in other areas. In contrast, a degenerative spine may not have pain, numbness, tingling, and weakness; and/or to restore nerve funcany pain if the surrounding structures can provide additional suption, particularly from conditions that cause spinal collapse (such as port. Maintaining a routine exercise program that includes a focus on osteoporosis, compression fractures, degenerative disease) or spinal core strength—muscles in the abdomen, hips, and buttocks—can help instability (abnormal movement of the spine). Continued development maintain spinal health. Good posture and a healthy, well-balanced of minimally invasive surgical options will increase patient satisfaction diet help. To promote bone strength, both women and men should while decreasing hospital stays and postoperative pain. take a daily vitamin rich in calcium, magnesium, phosphorus, and vitamin D. Please share a patient success story with us. A 60-year-old patient came to my office with a severe narrowing of the spinal cord Please tell us about advances in treatment of spinal in his neck due to a bruise within the spinal cord itself. He was injuries during the last decade. New techniques support the unable to walk and was confined to a wheelchair. I had to advise him spinal column and increase its structural integrity, such as disc that he might never walk again, and recommended surgery designed replacement surgery and expandable devices. There has been a trend to prevent his condition from becoming even worse. Surgery to in medical training over the past 10–20 years toward subspecializarelieve his spinal cord’s narrowing and to subsequently reconstruct tion within neurosurgery and more specifically, spinal surgery, yieldhis neck was successful. He attended a rehab facility for four weeks ing physicians more highly trained in spinal disease. Also, research and subsequently underwent outpatient physical therapy. Several into ideal treatment of traumatic spinal injuries has become widely months following his surgery, he walked into my office and said he accepted, improving patient outcomes and minimizing long-term hadn’t felt this good in more than 20 years. He now has nearly full deficits. mobility of his neck and is walking with only a cane. Stories like this make my job worthwhile.

“Multiple sclerosis upended the plans I had, forcing me to face uncertainty. I’ve learned to adapt and focus on what’s truly important to me.” — Susan, diagnosed in 1995

MS = dreams lost. dreams rebuilt. What does MS equal to you? Join the Movement® at MSsociety.org NOVEMBER 2012 MINNESOTA HEALTH CARE NEWS

REPRODUCTIVE HEALTH

Youth and sexually transmitted infections

Why is the rate rising? By Alison Warford, MD

Minnesota has seen a startling increase in sexually transmitted infections (STIs) among teens and young adults. According to the Minnesota Department of Health (MDH), the number of STIs increased by 100 percent during the last decade. While young people ages 15 to 24 years account for only 25 percent of the sexually active population, they represent approximately 50 percent of STI cases. The infections they contract, including Chlamydia and gonorrhea, can cause lifelong health problems if not detected and treated. Risk factors Teens and young adults are at particularly high risk for STIs due to biologic, cultural, and behavioral factors.

Supporting Our Patients. Supporting Our Partners. Supporting You. In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life. Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient. To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.

David Palmer, M.D. & Zawadi’s brother Russ McGill, OPA-C & Zawadi

Appointments:

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MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

Biologically, the cells on a female’s cervix Chlamydia infection in pregnancy can be transmitted to an infant and are particularly susceptible to infection with cause eye or lung infections. Gonorrhea can cause abscesses in genital Chlamydia during the teen years. As a woman organs and even in joints, where permanent joint damage can develop gets older, these cells become less susceptible. if untreated. In females, gonorrhea and Chlamydia can cause abnorCultural factors contributing to increased mal vaginal discharge and can cause a serious and painful upper geniinfection rates among teens may be a lack of access tal tract infection called pelvic inflammatory disease (PID) that involves the uterus, fallopian tubes, and ovaries. to condoms and other barrier methods, a lack of An asymptomatic vaginal infection can develop into PID if treathealth insurance, and a lack of reliable transportament is delayed, if the female is infected with a particularly aggressive tion to access medical help. organism, or if the patient who is prescribed antibiotics for treatment One behavioral factor may be reluctance to fails to complete treatment. Both untreated PID and recurrent episeek medical attention because of concerns regardsodes of PID can cause infertility, chronic pelvic pain, or an ectopic ing confidentiality. As a result, teens may not want to use a parent’s insurance or disclose their sexual pregnancy. (Another term for ectopic pregnancy is tubal pregnancy, a activity to a parent or a primary medical provider. potentially life-threatening condition in which a fertilized egg Also, since many STIs may not implants outside the uterus.) cause symptoms until years later, Antibiotic-resistant gonorrhea teens may not know they are infectThe CDC One of the most worrisome public health aspects of STI ed. Thus, they can be unaware recommends management is the emerging resistance of gonorrhea to they’re passing the infection to sexumost antibiotics. Neisseria gonorrhea, the bacteria that yearly al partners. Because teens often causes gonorrhea, can disarm certain antibiotics and thus believe they are invincible, they tend Chlamydia continue to live in the human body. This resistant bacteto believe disease happens to someria is then passed to sexual partners, which can rapidly screening for one else; they tend to focus on the lead to development of a resistant strain of the bacteria. here and now rather than future all sexually consequences. Unfortunately, the active females Do minors need parental consent? fact that many of these infections Because of the danger posed by delaying testing and don’t cause symptoms right away under age 24. treatment, many states have laws that allow a minor may reinforce this belief. Youth and sexually transmitted infections to page 34 Lack of education may be another reason: Teens may not know the risks or symptoms of infection, nor how to protect themselves. A teen may not realize there are low-cost or free testing options and birth control methods. How to reduce infection The Centers for Disease Control and Prevention (CDC) recommends yearly Chlamydia screening for all sexually active females under age 24. “Screening” means testing for the presence of Chlamydia even if there are no symptoms of infection or disease. In the Twin Cities, screening is easily accessible at the metro area’s many teen-focused clinics, both freestanding community clinics and school-based heath centers in the Minneapolis and St. Paul public school systems. These clinics help promote STI education and prevention of STIs among adolescents. Additionally, both the CDC and the MDH recommend “expedited partner therapy” as a way to reduce infection. This means a patient who is diagnosed with an STI can be provided additional doses of antibiotics for his or her sexual partners. This helps prevent reinfection of the patient and decreases infection in the wider population. Even though this is well accepted as a public health strategy, we prefer that partners be seen themselves for testing and to assess any other risk factors or symptoms if at all possible. Short- and long-term consequences STIs can cause significant physical and emotional distress. Both gonorrhea and Chlamydia can cause painful urination in males and females, and an infection with one STI can make it easier to acquire another STI. Infection with gonorrhea and/or Chlamydia during pregnancy can lead to premature delivery and low birth weight. Untreated NOVEMBER 2012 MINNESOTA HEALTH CARE NEWS

PUBLIC HEALTH

The Chiron Project Easing female vets’ transition from soldier to civilian By Gretchen Stein, MA, PhD, and David Wettergren, MA, EdD

omen make up the fastest growing group of military veterans, according to the United States Department of Veterans’ Affairs (VA). The female veteran population has more than doubled since 2000 and today, 11 percent of military service personnel is female. Although they are exposed to nearly all of the same stressors as their male counterparts, female vets are much more likely than males to develop symptoms of post-traumatic stress disorder

Leg Pain Study Do your legs hurt when you walk? Does it go away when you rest? Or, have you been diagnosed with PAD? You may have claudication, caused by lack of blood supply to the leg muscles The University of Minnesota is seeking volunteers to take part in an exercise-training program, funded by the National Institutes of Health

(PTSD). An estimated 20 percent of female vets have been diagnosed with PTSD compared to 8 percent of male vets. Among veterans of Iraq/Afghanistan “Gulf War” combat, females are twice as likely to develop PTSD as males who were exposed to the same trauma. PTSD, military sexual trauma (MST), or other challenges of military service, plus the challenges of transitioning back to their civilian life, significantly increase the risk of suicide for all veterans, including females. More veterans are dying of suicide than have died in combat in Iraq and Afghanistan.

Military health risks In fact, a veteran of either gender attempts suicide every 80 minutes. Female vets age 18 to 34 are at highest risk for this behavior, which is additionally tragic since this age group includes mothers of young children. These children are at risk of developing behavioral problems as a result of separation from their mothers due to suicide or to one or more deployments. The ripple effects of military service don’t end there. A vet with PTSD is three to six times more likely to get divorced. Female vets are four times more likely than male vets to be homeless. Add to these statistics the fact that recent studies of veterans have found that 27 percent report dangerous use of alcohol and that nearly 50 percent of Iraq/Afghanistan combat vets, including women, report being disabled by their service to our country. Clearly, the aftereffects of military service exact a toll from society as well as the individual and, as such, can be considered a public health concern. The Chiron Project, a program provided by the nonprofit, nonreligious, integrative health organization A Place of Grace, is working to ease that burden.

The Chiron Project To see if you qualify, contact the EXERT Research Team at

612-624-7614 or email EXERT@umn.edu or visit EXERTstudy.org

EXERTstudy.org 14

MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

This endeavor is named for Chiron, a mythological Greek character who served as mentor and teacher to heroes, helping them attain their potential. The Chiron Project strives to help female vets from the Vietnam era to today heal all their wounds—physical, mental, and spiritual—through an integrative approach to better health, a service we hope someday to offer to male vets as well. Currently, this project’s three programs support the female vet and those affected by her military service. One is a summer camp for mothers who have served and their children, affording them professional parenting guidance, free time, and recreational activities. This helps both mother and child to begin reconnection and readjustment after the veteran’s absence. Another program is a summer camp for female vets and their female supporters, during which vets can re-establish the support net-

Resources works that strengthen and sustain the vet’s transition • PTSD Coach is a mobile app that includes a VA questionback to civilian life. “Hands down, this is the BEST naire that screens for PTSD. It also provides stress experience and exactly what my sisters and I have management tips and links to resources. needed. Even with the ups and downs of this very www.ptsd.va.gov/public/pages/ptsdcoach.asp emotional weekend and rough journey, this is a very • VA “sister to sister” program provides a female vet to beneficial and encouraging experience and program. meet another female vet who is visiting a VA health facility for an appointment. The host vet accompanies the visiting Thank you,” said a female vet who has attended a vet to her appointment. This is designed to reduce the vet-and-supporters camp. visitor’s anxiety about being in a male-dominated environAnd finally, there is an annual military ment. Ask your local VA if this program is available at a women’s retreat that provides “…[an] atmosphere VA site near you. of trust, camaraderie, [and a] beautiful setting,” • MEG (magnetoencephalography) is a brain-imaging techaccording to one female veteran who attended last nique that identifies PTSD with 97 percent accuracy. This is year’s retreat. Said another, “[It] not yet covered by insurance but helps to validate what vets made me realize why I do some have said for years, which is that PTSD is a real condition. things that I do. (Because I am For vets encountering roadblocks in seeking PTSD treata women veteran.)” ment, it may be helpful to reference this research, con“Powerful information,” was ducted at the Minneapolis VA by A. Georgopoulos, MD, and B. Engdahl, PhD, University of Minnesota. the feedback from another participant at last year’s retreat. “Never thought tion into civilian life. The project plans to continue its work on there were so many things to grieve. behalf of these heroes and to expand the number and frequency of Really made me think about what I need the programs it offers. Registration for the Chiron Project’s 2013 to work on.” programs begins in spring 2013. For more information, visit This year’s rural weekend of respite www.aplaceofgrace.us. offered attendees the opportunity to hear from female vets who have sucGretchen Stein, MA, PhD, is a behavioral health specialist and David Wettergren, MA, EdD, is an educator. They are the co-founders of cessfully navigated their return to the Chiron Project. civilian life; yoga, massage, canoeing, art, and free time; consultation with a psychologist specializing in grief and loss; information from a physician on the role of nutrition in psychological Nearly 50 percent well-being; parenting tips; of Iraq/Afghanistan instruction in mind-body selfhealing techniques designed to combat vets, help participants handle life including women, changes and stress; and career report being disabled. counseling. Attendees also received a list of resources.

Acknowledge and validate Running throughout the annual weekend retreat is acknowledgment of the veterans’ sacrifices and those of their families, as well as an alltoo-often-overlooked validation of their traumatic experiences. Talking about those experiences, which sometimes include sexual trauma inflicted by male military personnel, is easier when men are not present, which is the reason that adult men are currently not participants in the Chiron Project’s programs. (Male children are welcome to participate in the mother/child camp.) Previous female participants have found the annual retreat so valuable that some registered for the retreat two years in a row. The retreat in October 2012, held in Marine on St. Croix, attracted registration inquiries from as far away as the state of Washington.

Ongoing support Data is being collected to statistically support participants’ feedback that the Chiron Project benefits their health and aids their reintegraNOVEMBER 2012 MINNESOTA HEALTH CARE NEWS

HEALTH PROFESSIONS

Community health workers Bridging barriers to care By Joan Cleary, MM (Masters in Management)

innesota consistently ranks among the nation’s healthiest states, but below our stellar averages lie significant health disparities. While the causes are complex, community health workers are an integral part of the solution. Community health workers (CHWs) are bicultural, often bilingual, health personnel who address health disparities by serving low-income, medically underserved, hard-to-reach populations to improve access to coverage and care, promote healthy behaviors, and help manage chronic illness. Local assets Minnesota CHWs reflect the state’s diversity, as they include members of African American, Native American, Bosnian, Cambodian, Hmong, Karen, Lao, Latino, Liberian, Somali, Vietnamese, Caucasian, and deaf communities. “Our goal is to educate deaf people to become active participants in their own health and wellness,” says Anita Buel, a nationally recognized deaf CHW who heads the Minnesota Deaf CHW Project and works for the Deaf and Immigrant Center for Education at Hennepin County Medical Center (HCMC). She and her colleagues help deaf immigrants, seniors, cancer survivors, and others access culturally and linguistically appropriate care and navigate the complicated health system.

Varied titles, varied roles

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MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

CHWs are known by different titles and encompass multiple roles, including patient navigator, peer advisor, care guide, community health representative, and promotores de salud. In 2010, the Department of Labor Standard Occupational Classification system first recognized CHW as a distinct profession with the following job responsibilities: Assist individuals and communities to adopt healthy behaviors. Conduct outreach for medical personnel or health organizations to implement programs in the community that promote, maintain, and improve individual and community health. May provide information on available resources, provide social support and informal counseling, advocate for individuals and community health needs, and provide services such as first aid and blood pressure screening. May collect health data to help identify community health needs. “The diversity of our roles and functions is a strength that enables us to meet both community and system needs,” explains Sophia London, CHW, vice president of the Minnesota CHW Alliance, co-chair of the Minnesota CHW Peer Network and a care coordinator in the Health Care Home Program at HCMC’s Richfield Clinic. “We operate within a defined scope of practice.” Training “Our state is the first in the U.S. to develop and implement a statewide, competency-based CHW curriculum based in higher education,” reports Anne Willaert, South Central College, Mankato, who led CHW curriculum development on behalf of the Minnesota State College and University System. With funds from Blue Cross and Blue

Left: CHW LaTrisha Vetaw checks a client’s blood pressure. Below: Sophia Warsame, center, is a CHW who works in Rochester. Bottom right: Latina CHW and baby Photos by Scott Streble, used with permission of Blue Cross and Blue Shield of Minnesota Foundation.

Minnesota CHW certificate programs • Minneapolis Community and Technical College: Evening program summer/fall • Normandale Community College: Launching program 2013–2014 academic year • Rochester Community and Technical College: Evening program • Saint Catherine University, St. Paul: Offered as part of baccalaureate program and as a one-year stand-alone course Mondays and Tuesdays • South Central College, Mankato: Pilot online version fall 2012 • Summit Academy OIC, Minneapolis: Offered throughout the year as a day program that includes certified nursing assistant (CNA) training

Shield of Minnesota Foundation and the Robert Wood Johnson Foundation, CHW training was designed through a collaborative process involving CHWs and other health disciplines. • Northwest Technical College, Bemidji: Launching program spring Training was launched in 2013 2005 and requires an internship and 14 credits, including core competencies and health use care appropriately. “Providers appreciate what we do because we promotion and disease mancan follow up on a lot of things and make sure they get done—we agement competencies. Five can also get to the bottom of certain issues,” explains CHW Mariela training programs are currently Adremagni-Tollin at HCMC’s East Lake Clinic. “In a short visit, it’s available in Minnesota, includimpossible for the physician to do everything; we need a care team.” ing Mankato’s South Central The American Academy of Pediatrics-Minnesota College pilot online program, Chapter (AAP-MN) is funding a pilot project at sedesigned to expand CHW training into rural veral Twin Cities pediatric practices to improve precommunities to improve access to health care ventive care for Somali children by contracting CHW for the state’s rural population. services from Wellshare International, Minneapolis. Willaert adds, “What we’ve found is that “Partnering with CHWs is an effective way for pediaCHW students, often the first in their families tricians serving foreign-born families to improve culto enroll in post-secondary schools, both tural competence as well as increase rates of well-child inspire and guide relatives and other communCommunity health workers to page 19 ity members to pursue higher education. It’s another key benefit because we know that people with more education earn more and live longer.” More than 500 CHWs have completed this training thus far, earning a certificate of completion. While this certificate is not curDonate Your Car, Boat, Motorcycle or RV rently required for CHW employment, it is increasingly identified as a preferred credential for job applicants. WHY SHOULD YOU DONATE TO Diagnostic-specific health education COURAGE CENTER? CHWs improve services provided by CHW certificate ŽĨ ƉƌŽĐĞĞĚƐ ŚĞůƉ health outcomes holders under clinical supervision are covered by insurance under Minnesota’s ĨĂŵŝůŝĞƐ͕ ĨƌŝĞŶĚƐ ĂŶĚ ŶĞŝŐŚďŽƌƐ among minority Medical Assistance and MinnesotaCare ĂĐƟǀĞůǇ ƉĂƌƟĐŝƉĂƚĞ ŝŶ ůŝĨĞ͘ programs. Minnesota and Alaska are and immigrant ŽƵƌĂŐĞ ĞŶƚĞƌ ŝƐ Ă local the only states to date that have this ŶŽŶͲƉƌŽĮƚ ƌĞŚĂďŝůŝƚĂƟŽŶ ĂŶĚ Medicaid authorization. populations.

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Teaming up for better outcomes Health providers, social service agencies, and community-based organizations find CHWs to be critical links with the communities they serve. For example, community clinics employ CHWs to facilitate patient enrollment in public programs, conduct outreach, and provide health education services to uninsured and underinsured patient populations. Increasingly, CHWs are being hired by hospitals, clinic systems, and local public health agencies to strengthen team-based services to patients and families and are integral members of clinic care teams at Hennepin County Medical Center, NorthPoint Health and Wellness in north Minneapolis, and HealthEast Care System in the east metro. CHWs reduce demand on overburdened providers by promoting healthy behaviors and helping patients understand how to access and

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November Calendar 12

Look Good … Feel Better Female cancer patients, you are invited to a class designed to help you feel beautiful through makeup and beauty tips and to provide a supportive community during your treatment. Free. To register, call (800) 227-2345. Monday, Nov. 12, 4–6 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater Mental Health Parenting Workshop This workshop will familiarize parents with the Minnesota Comprehensive Children’s Mental Health Act, designed to provide youth with mental health needs a care system that will allow them to develop. Free. To register, call (952) 838-9000. Monday, Nov. 12, 6:30–8:30 p.m., PACER Center, 8161 Normandale Blvd., Minneapolis Employment after Cancer Cancer Legal Line presents attorney Charles Firth, Esq., who will discuss employment issues faced by cancer survivors and the legal remedies available. Free. Call (651) 472-5599 to register. Tuesday, Nov. 13, 6:30–8 p.m., Wescott Library, 1340 Wescott Rd., Eagan Knee Replacement Seminar If knee pain is slowing you down and keeping you from activities you used to enjoy, come to a seminar hosted by Peter Daly, MD, to learn about the knee replacement options available to you. Free. To register, call (651) 232-6704 or visit www.healtheast.org. Wednesday, Nov. 14, 6–7:30 p.m., Orthopaedic Specialty Ctr., 1925 Woodwinds Dr., Woodbury Ataxia Support Group The Twin Cities Ataxia Support Group meets the third Saturday of every month to support afflicted individuals and their family and friends. Join, and make new connections! For more information, call Lenore at (612) 724-3784. Saturday, Nov. 17, 10 a.m.–12 p.m., Langton Place, 1910 W. Cty. Rd. D, Roseville

National Alzheimer’s Awareness Month Did you know that the most common early symptom of Alzheimer’s disease is difficulty remembering newly learned information? A progressive disease beginning in the part of the brain that affects learning, Alzheimer’s and its symptoms become increasingly severe as the disease advances through the brain. Other early Alzheimer’s symptoms include challenges in planning or solving problems, difficulty completing familiar tasks, confusion with time or place, misplacing things, decreased or poor judgment, and changes in mood or personality. Alzheimer’s is the most common type of dementia, a general term for loss of memory and mental ability that impairs daily activity. Many people with Alzheimer’s may not recognize there is a problem, and signs of dementia are often more apparent to family members or friends. Anyone experiencing dementia-like symptoms should contact a doctor as soon as possible. Though no cure currently exists for Alzheimer’s, treatments are available that can temporarily slow the worsening of dementia symptoms. If you or a loved one has been diagnosed with Alzheimer’s, you are not alone. Find more information at www.alz.org, or by calling the Alzheimer’s Association 24/7 Helpline: (800) 272-3900.

10 Holidays with Alzheimer’s Alzheimer’s Association is offering a special class for those with an Alzheimer’s diagnosis, their care partners, and professionals. Learn about managing a sentimental season with this disease. Call (800) 272-3900 for more information. Saturday, Nov. 10, 9–10:30 a.m., Normandale Lutheran Church, 6100 Normandale Rd., Edina

Friends and Families of Suicide This peer-facilitated support group provides a place of support and comfort for those who have lost a loved one to suicide. Meets third Monday of every month. Free. For more information, call Tracy at (651) 587-8006. Monday, Nov. 19, 7–9 p.m., Twin Cities Friends Meeting, 1725 Grand Ave., St. Paul

Lupus Online Get-together If you have lupus, you are invited to a monthly online support group sponsored by Lupus Foundation of Minnesota. Log on from the comfort of your home computer and connect with others for ideas, tips, and tools to enhance your quality of life. To register, contact Cheryl at ccomo@lupusmn.org or call (952) 746-5151 to be placed on the Monthly Online Get Together mailing list.

Dec. 7

Autism, Diet, and Environment The Healthy Legacy Project presents Martha Herbert, MD, PhD, discussing the relationship of diet and environment to autism. $10. Tickets available on www.brownpapertickets.com. For more information on this event, call Kathleen at (612) 870-3468. To learn more about The Healthy Legacy Project, visit www.healthylegacy.org. Friday, Dec. 7, 8:30–10:30 a.m., Plymouth Congregational Church, 1900 Nicollet Ave., Minneapolis

Send us your news: We welcome your input. If you have an event you would like to submit for our calendar, please send your submission to MPP/Calendar, 2812 E. 26th St., Minneapolis, MN 55406. Fax submissions to 612-728-8601 or email them to mmacedo@ mppub.com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

America's leading source of health information online 18

MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

needs, and provide home interventions. “CHWs have been found to play an important role in promoting healthy housing, leading to better health and lower costs,” reports Dan Newman, executive director of Sustainable Resources Center, Inc., Minneapolis, which offers specialized training for CHWs on healthy housing practices. CHW asthma interventions are planned for Minnesota.

Community health workers from page 17

care such as immunizations,” reports Kathi Cairns, AAP-MN executive director. Measurable impact

Growing evidence and recognition of CHW contributions to better outcomes indicate an increasCHWs reduce ing role for CHWs in the health system of the future. demand on “Research studies show that community health workers improve health outcomes among minority overburdened Key to healthier communities and immigrant populations,” says Jose Gonzalez, “As a best practice for tackling health disparities, director of the Minnesota Department of Health’s providers. CHWs are an essential component of Minnesota’s Office of Minority and Multicultural Health. “That’s health reform strategies,” emphasizes Julie Ralston why our state’s Eliminating Health Disparities Aoki, JD, board president of the Minnesota CHW Initiative invests in many projects that use CHW Alliance. “We see exciting opportunities for CHWs strategies as an evidence-based practice.” to make a difference in new structures such as For example, studies of CHW programs show health care homes, accountable care organizations, significant improvement in patient use of preventive and our state’s health insurance exchange ...” services such as mammography and cervical cancer CHWs bring trust and know-how to the federally screening among low-income and immigrant women. required navigator role charged with facilitating enrollment Economic analysis published by Wilder Research of low-income, uninsured individuals and families into coverage Center in June 2012 found that every dollar invested in CHW cancer options under the new health insurance exchange. outreach and prevention saves society $2.30. Another example of the benefit of CHWs is found in Seattle and Joan Cleary, MM, is interim executive director of the Minnesota Community Boston, where CHW interventions improve childhood asthma in low- Health Worker Alliance, a broad-based partnership of CHWs, nonprofits, and public agencies (www.mnchwalliance.org). income neighborhoods, reducing costly hospital admissions. In those cities, specially trained CHWs conduct home visits to reinforce Top: Minnesota community health workers reflect our state’s diversity. provider messages about asthma control, identify and address family Bottom: CHW Maria Elena Escoto and clients.

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ONCOLOGY

Cancer care coordinators Easing the patient’s journey

oday’s typical health care system is a lot like a very complex maze—difficult to navigate. This is especially true for people facing a cancer diagnosis. At one of the most uncertain moments in their lives, having to figure out how to move through a health care system can be completely overwhelming. At the Virginia Piper Cancer Institute, part of Allina Health, we work to ease this worry by providing each patient with a cancer care coordinator. Coordinators are experienced registered nurses who have expert knowledge about cancer and its impact. Their primary role is to educate patients about their cancer and serve as a single point of contact for patients and their families throughout their cancer journey. The more a person understands about the diagnosis and treatment plan, the better prepared and less anxious they will be. This is true for all patients, regardless of the nature of their health concern. Fortunately, care coordinators are becoming more commonly available at hospitals. Coordinated care

By Connie Fiebiger, RN, BSN, MA

MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

A cancer care coordinator’s job begins with establishing all of the necessary connections for patients. This starts with the coordinator’s participation in treatment conferences that include doctors and other members of the health care team. At these conferences, the team discusses the best treatment plan for patients newly diagnosed with cancer. Open communication among these experts ensures that everyone involved in the care of patients is informed and that patients are receiving optimal care. Cancer care coordinators are also responsible for connecting patients with oncologists (cancer specialists), obtaining the referrals patients need for additional physicians such as hepatologists (liver specialists) or pulmonologists (lung specialists), and scheduling consultations with other members of the patient’s team, such as radiation oncologists (specialists in using radiation to treat cancer). Cancer care coordinators are with patients at each step in this process. They help patients understand, evaluate, and make decisions about what is happening and what will happen next. Coordinators’ direct access to appropriate contacts allows them to make the referral process as smooth as possible, which reduces patients’ wait time between visits and procedures. A good example of this coordination is the experience of a patient recently diagnosed with head and neck cancer. The complexity of this patient’s diagnosis was evident in the number of doctors and specialists who were involved in his care. This individual’s cancer care coordinator arranged initial appointments with the medical oncologist. Once a treatment plan was created with the patient, the coordinator helped to plan the patient’s surgery and his follow-up appointments with specialists that included a radiation oncologist, plastic surgeon, and dentist.

The coordinator also worked with cancer rehabilitation specialists to ensure that the patient received the therapies he needed to help him regain function. Rehabilitation needs for this patient included physical therapy, speech and swallowing therapy, and nutrition counseling. He also needed lymphedema therapy to reduce the swelling that sometimes occurs in tissue after cancer treatment. Since this patient’s swelling was in his neck area, it had the potential to impede his swallowing, so it was critically important to get the therapy arranged by his coordinator. The coordinator made sure that the patient saw the right specialist at the right time and in a timely manner, which eased many of the worries he and his family had and helped to keep his recovery on track. Education informs decisions Cancer care coordinators help patients and their families make informed decisions about their care and treatment plans. For example, when a man is diagnosed with prostate cancer he may have a choice of treatment paths that include surgery (robot-assisted or not) and radiation therapy, as well as systemic treatment options such as hormonal therapy and immunotherapy. Each treatment path may have a different effect on his life as a cancer survivor, with potential loss of fertility, erectile dysfunction, and/or incontinence. Cancer care coordinators talk through all the options with the patient, educating him about the possible effects of each one. This prepares the man to choose the treatment path that will best meet his needs. Cancer care coordinators can also connect patients with genetic counselors if needed, so that the counselors can provide a comprehensive assessment of the risk of hereditary cancers for the patient and his or her relatives. One reason for obtaining genetic counseling is that in some situations, the family medical history that is uncovered during counseling may change the recommended course of treatment. For example, a genetic assessment of a woman diagnosed with breast Cancer care cancer may suggest that her long-term survival will be enhanced if she has a coordinators mastectomy (removal of the entire help patients breast) rather than a lumpectomy (removal of the tumor). and their Cancer care coordinators at our hosfamilies make pital are also in constant contact with our research nurses. This allows them to informed alert patients to opportunities they may decisions. have to participate in clinical trials of experimental treatments. A wealth of support The diagnosis of cancer can take a significant toll on an individual’s psychosocial and emotional well-being. Patients with cancer may face financial concerns because they are unable to work or don’t have insurance coverage. Some patients with cancer have young children and are not sure how to talk with them about mom or dad’s diagnosis. Others lose self-esteem and self-confidence as their hair, eyebrows, and eyelashes fall out. Still others may be dealing with their own mortality and end-of-life concerns. Cancer itself and/or the treatment for it may affect an individual’s sexuality, both physically and emotionally. Whatever an individual patient’s circumstance, cancer care coordinators make sure that patients and their

families have access to a wide variety of support services. In most hospitals this includes social workers, chaplains, family counselors, support groups, palliative care, cosmetic services, and psychoCancer logical services. Beyond diagnosis

survivorship begins at diagnosis.

Cancer survivorship begins at diagnosis and lasts for the rest of the person’s life. Cancer rehabilitation and integrative health therapies such as massage, acupuncture, and guided imagery can be essential factors in helping patients overcome or cope with pain, cancerrelated fatigue, or the inability to perform daily activities. Cancer care coordinators make patients aware of these services and the benefits they provide. Access At Allina Health, as at most health care systems, there is no cost for the services of cancer care coordinators, nor is it necessary to have a doctor’s referral. Cancer care coordinators are in place to ensure that patients and their families get the guidance and support they need throughout their cancer journey. Connie Fiebiger, RN, BSN, MA, is the director of clinical programs for the Allina Health Oncology Clinical Service Line.

In the next issue.. • Celiac disease • Appealing claim denials • Coping with bereavement NOVEMBER 2012 MINNESOTA HEALTH CARE NEWS

LONG-TERM CARE

Family-member caregiving You may qualify for compensation By Michele Kimball

Nationwide, more than 42 million caregivers provide an estimated $450 billion worth of care annually to a parent or grandparent or to a family member living with a disability. Virtually all of this care is provided for free. While the care is free, impact on the caregiver can be costly in every way—emotionally, physically, and financially. The average caregiver spends up to 20 hours a week providing care, which amounts to a part-time job. For the 57 percent of caregivers still in the workforce, caregiving means they have a second job. And since many caregivers have children at home, caring for a loved one is added to the already tiring job of raising a family. Not surprisingly, a recent study by the American Association of Retired Persons (AARP) found that nearly half of all caregivers expressed having “quite a bit” or “a great deal”

WHO’S GOT BETTER MOVES ON THE DANCE FLOOR, YOU OR ME? Every day is a reason for a person with Down syndrome to smile. And find joy in things the rest of us often overlook. To learn more about the richness of knowing or raising someone with such an enthusiasm for life, call your local Down syndrome organization. Or visit ndsccenter.org today. It is the mission of the Down Syndrome Association of Minnesota to provide information, resources and support to individuals with Down syndrome, their families and their communities. We offer a wide range of services, programs and materials at no charge. If you are interested in receiving one of our information packets for new or expectant parents, please email Kathleen@dsamn.org or For more information please call:

(651) 603-0720 • (800) 511-3696 22

MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

of fatigue. One in five responResources dents reported feelings of emo• Consumer Directed Community Supports: tional stress or guilt and 53 www.dhs.state.mn.us/cdcs percent indicated they needed • Senior LinkAge Line: (800) 333-2433, M–F 8:00 a.m.–4:30 p.m., more help and support. www.mnaging.org It’s also no surprise that • Caregiving Resource Center: www.aarp.org/caregiving 15 percent of caregivers report • Minnesota Department of Human Services online toolkit: that helping aging or disabled relatives www.mn.gov/dhs/general-public/own-your-future creates substantial financial hardship. • Wilder Foundation: www.whatisacaregiver.org, (651) 280-CARE Many caregivers are forced to take time Information in this article is not meant to substitute for professional off work, reduce their hours, or quit tax advice. working entirely to meet caregiving obligations. This threatens not only their current financial stability but their That person needn’t live with you, but you must provide retirement as well. more than 50 percent of his or her basic living expenses, including Financial help is available, however. Here’s how to access it. housing, food, clothing, and other necessities. “Housing” could State compensation include your paying half or more of the rent for the recipient’s In Minnesota, the Consumer Directed Community Supports (CDCS) apartment or assisted living expenses. The tax exemption is $3,800 for each care recipient for the program provides people whose income is low enough to qualify 2012 tax year. But be careful: The recipient’s earnings, excluding for Medicaid with a waiver that they can use to pay a long-term Social Security, cannot exceed the exemption amount. So if, for care provider of their choice. Nearly 6,000 recipients currently use example, your parent’s pension or investment income in 2012 totals this program, with more than 6,500 family members compensated more than $3,800, you cannot claim your parent as a dependent. for providing care. To apply for this program, a person who wants to receive a waiver must be a Medicaid enrollee. Contact Minnesota Senior LinkAge Line at (800) 333-2433 to find out what steps to follow to access this program.

Head of household. An unmarried caregiver whose care recipient qualifies as a dependent can save money on taxes by filing as Family-member caregiving to page 32

Private pay If a family’s financial resources permit paying a family member to provide domestic services, personal care, and/or medically related duties such as counting out pills, it’s important for a caregiver contract between caregiver and recipient to be in place. This contract shows that the recipient is paying the caregiver, as opposed to giving a cash gift. It’s important to establish this “private pay” relationship because a history of cash gifts from recipient to caregiver could disqualify the The national recipient from future Medicaid enrollment, which pays nursing home fees for average pay those who cannot afford them. rate for It’s also important for a caregiver to: home health • Pay tax on his or her earnings, and for recipients to report payments to their aides is caregiver on their income tax forms. currently • Charge an hourly rate for caregiving about $10 that mirrors the national average pay rate for home health aides, currently an hour. about $10 an hour.

Long-term care insurance • A recipient’s long-term care insurance policy may allow the policyholder to spend a defined amount of money each month on inhome assistance. This can be used to pay a personal caregiver.

A diagnosis of

Cancer is overwhelming news.

It raises many questions few of us are prepared to answer, such as: • How can I take time off from work? • Can I get help paying bills? • What is the difference between a health care directive and a power of attorney? • Can I keep my health insurance even if I lose my job? • And many others. If you or a loved one is facing cancer, we are here to help.

We are a nonprofit organization funded entirely through grants and donations. Your tax-deductible donations are welcome.

We provide free cancer related legal information on a wide range of topics.

Please visit our web site to find out more: www.cancerlegalline.org

Tax advantages Dependent exemption. If you are caring for someone but none of the payment options above apply to your situation, consider claiming the care recipient as a dependent on your income tax return.

educate.inform.empower NOVEMBER 2012 MINNESOTA HEALTH CARE NEWS

ORTHOPEDICS

Plantar fasciitis

ne of the most common causes of heel pain is plantar fasciitis, an inflammation in the bottom of the foot. It affects the plantar fascia, a large band of tissue that starts at the heel and ends at the toes. When this tissue becomes damaged or inflamed, pain starts at the bottom of the heel and the foot may ache or have a burning sensation. Often, pain is worse in the morning or at the end of the day. This condition affects up to 2 million people in the United States annually. Approximately 10 percent of people develop plantar fasciitis at some point during their lifetime, 30 percent of whom have symptoms in both feet. The good news is that risk factors for this condition can generally be eliminated or controlled and treatment can often be managed by simple measures at home.

Hospital and Clinics

Risk factors Risk factors for plantar fasciitis include obesity, jobs that require prolonged standing, excess running, flat feet or high arches, tight calf muscles, and improper footwear. Poor footwear choices include shoes that do not provide arch support, such as flip-flops or minimalist running shoes; heels that are too high; By Angela Voight, MD and shoes with worn-out soles. These conditions cause excess strain on the plantar fascia, which eventually leads to inflammation. Eventually, the inflammation goes away, but the plantar fascia is still worn out, frayed, and not as strong as before it became inflamed. Biomechanical factors can contribute to plantar fasciitis as well. A study reported in 2005 by the Clinical Journal of Sports Medicine showed an association between hip muscle strength imbalance and lower extremity overuse injuries in runners. It is also thought that weakness in core muscles (abdominals, hips, and buttocks) contributes to excess stress on the lower extremities and can lead to plantar fasciitis. Plantar fasciitis used to be blamed on the presence of a bony extension called a heel spur, but it is now known that heel spurs do not cause plantar fasciitis. Therefore, treatment does not involve surgically removing a heel spur.

A common cause of heel pain

Nonmedical treatment

In fact, surgery is generally not needed to successfully treat plantar fasciitis. The first recommendation is to rest from activities that cause pain, such as running or prolonged standing. A week or two of rest often decreases symptoms but usually does not completely get rid of the pain. It can be helpful to stretch the plantar fascia by grabbing the big toe, pulling back until you feel a stretch in the bottom of the foot, and maintaining that position for 20 to 30 seconds. You can also stretch by sitting with your legs straight out in front of you: Place a towel around the ball of your foot and pull back on the towel to flex the foot, keeping your knees straight. Hold for 20 to 30 seconds and then rest for a few seconds. Repeat each stretch five to 10 times on both feet. Ice is an effective anti-inflammatory tool and can reduce pain when applied to the painful area; roll a frozen water bottle on the bottom of your foot for 15 minutes. Orthotics (shoe inserts) have been shown to be beneficial in plantar fasciitis treatment. A 2008 Cochrane Database System MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

Review found that over-the-counter orthotics are rently considered investigational due to lack of eviSurgery is just as effective as custom foot orthotics for pain dence of their effectiveness. generally reduction. Good, supportive footwear is helpful, All in good time not needed. especially for those who stand on their feet for In summary, the first line of treatment for plantar prolonged periods of time. Night splints, which can fasciitis is self-care: rest, stretching, NSAIDs, ice, be purchased over the counter, have been shown orthotics, and perhaps a night splint. If these to decrease morning pain by keeping the plantar treatments donâ&#x20AC;&#x2122;t provide relief within three to fascia stretched out at night. four weeks, contact your health provider to ask if Physical therapy can be very beneficial in longphysical therapy and perhaps an injection are term treatment of plantar fasciitis. Physical therapists can teach appropriate next steps. stretching and strengthening techniques and can use soft tissue treatPlantar fasciitis can be frustrating because there is no single ments such as deep myofascial massage to relieve muscle tightness treatment that has been shown to relieve symptoms. Rather, the use and pain. Physical therapists also are able to detect problems with muscle strength imbalance or weakness, either or both of which can of multiple treatments over time can lead to resolution of pain. It can take several months for this condition to improve, but the planlead to increased stress on the plantar fascia. tar fascia will eventually heal and rarely requires surgery for treatIontophoresis is a treatment available from physical therapists; ment. Patients who are able to take a short period of rest, use good it causes medicine applied to the skin to be absorbed into the soft supportive shoes with orthotics, and see a physical therapist tend to tissues of the foot via painless electrical pulses. According to a have the best outcomes. study reported in the American Journal of Sports Medicine, ionOnce a person has had plantar fasciitis, it is more likely to tophoresis combined with traditional physical therapy treatments recur. Therefore, reduce risk factors by maintaining a normal provided an immediate reduction in symptoms during the first weight, gradually increase activity after symptoms abate, stretch two weeks of treatment, but no significant difference was seen after tight calves, strengthen core muscles, and always wear supportive one month of treatment. shoes. Extracorporeal shock wave therapy (ESWT) is available from physical therapists and is approved by the Food and Drug Angela Voight, MD, is a fellowship-trained sports medicine physician practicing at Summit Orthopedics in Administration for people who have had plantar fasciitis for more Eagan and Woodbury. than six months and who have tried at least three other treatment methods that have not worked. ESWT is thought to work by inducing additional inflammation of the already inflamed area via lowenergy shock waves. This is believed to create new blood flow into the area, which promotes tissue healing. However, a 2005 review in the scientific journal BMC Musculoskeletal Disorders found conflicting evidence for the efficacy of this treatment, and the highestquality studies of ESWT showed that it provided no benefit. Medical treatment Anti-inflammatories. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen can help reduce pain and The plantar inflammation, especially during the first week or two of symptoms. fascia will Check with your primary doctor eventually heal. first to ensure that these medications are safe for you to use. Injections. Multiple types of injections have been used for plantar fasciitis, although there is a small risk (about 1.5 percent) that the plantar fascia will rupture when it receives an injection of any kind. The most commonly prescribed injection is corticosteroid. However, despite widespread use of corticosteroid injection, the journal American Family Physician reported in 2011 that there is limited evidence of this treatmentâ&#x20AC;&#x2122;s effectiveness. Injection of platelet-rich plasma (PRP) has been studied as a way to induce a healing response by injecting growth factors into the damaged plantar fascia. However, these injections are curNOVEMBER 2012 MINNESOTA HEALTH CARE NEWS

B E H AV I O R A L H E A L T H

Seasonal affective disorder (SAD) Winter blues By S. Charles Schulz, MD, and Barry Rittberg, MD

easonal affective disorder (SAD) is a mood disorder, which means it belongs to a group of fairly common illnesses that can include depression and are associated with symptoms such as alterations in sleep, appetite, concentration, interest, and the ability to experience pleasure, and, sometimes, with slowed physical movement. Someone with a mood disorder reacts inappropriately to events that occur in his or her life, either by feeling either very sad and “down” or by feeling excessively elated, which is a state called hypomania. Symptoms SAD symptoms classically appear in fall and winter and disappear in spring. They typically include low energy, sadness, loss of interest in formerly pleasurable activities, increased appetite (especially for carbohydrates), and a tendency to want to sleep excessively. By definition, someone with SAD experiences it for several consecutive years and has few, if any, episodes of depression outside of the fall/winter season. Who has SAD?

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wherever you are!

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MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

SAD incidence varies depending how it’s reported. Self-administered questionnaires filled out by the general population suggest an incidence as high as 10 percent, or one of 10 people. However, interviews administered by experienced interviewers suggest an incidence closer to 0.5 percent, or 1 of 200 people. Regardless how incidence is reported, it increases with increasing distance from the equator and can be very high in far northern latitudes such as Finland and Alaska. SAD is thought to be associated with the significantly reduced length of daylight during fall and winter in higher latitudes. Variants and complications Variants. Some people’s SAD turns into hypomania in spring, with their mood evening out during summer. As people with SAD age, depressive episodes sometimes no longer change seasonally and may occur any time. Over time, episodes of mood disorders in these people may be triggered by stresses other than reduced daylight or may even occur without detectable stress. Complications. Work performance and interpersonal relationships can suffer, since a person who wants to sleep all the time and becomes apathetic often is not the same person that others are used to interacting with. Such social withdrawal is often accompanied by depression. The carbohydrate cravings that can accompany seasonal depression often produce weight gain, with the cumulative effect of multiple seasonal depressions producing enough extra weight to eventually lead to obesity and associated medical problems. The most worrisome complication of SAD is the risk of suicide. Most people have support systems that would prevent them from acting on suicidal thoughts. However, when someone is severely depressed, his or her focus narrows and those supports seem less important to the person suffering the depression. Contrary to the

old adage that people who talk about suicide don’t act on it, in fact, people who talk about suicide are much more likely to accomplish it. Who gets SAD? Women are twice as likely as men to experience depression of any type, including SAD, and women who have mood changes around their menses seem to have a higher incidence of SAD. Many more people in northern countries than southern ones have what is called “seasonal energy disorder,” a recurrent loss of energy in the fall and winter that abates in spring. It lacks some of SAD’s symptoms but can be troubling nonetheless. Bright light therapy has been shown to help with these seasonal energy changes and is sometimes used to augment other depression treatments. Bright light therapy SAD can be treated through bright light therapy that counteracts shortened daylight hours. The light therapy is believed to act on an area of the human brain that functions like a biological clock, by using the duration of light that enters the eye to reset that clock. It’s felt that a reduced duration of light cannot set the clock adequately for a person to maintain their normal body rhythms. Bright light therapy is used every fall and winter morning before the sun has fully risen, to trick the brain into thinking that daylight hours are longer. This re sets the person’s internal clock to coincide with a normal rhythm. Light used in this treatment is from a “light box” that produces 10,000 lux of illumination. (Lux is a measurement of light intensity.) To understand what that looks like, consider that lighting in a lit room is typically 500 lux and that noontime sun in the middle of summer can be 80,000 lux. Typical artificial lighting is not sufficient to reset our internal biologic clock, so it is recommended that people using a light box sit in front of it for approximately 20 to 30 minutes each morning before the sun has fully risen. Most people experience improved mood and energy within several days of first using light therapy and if so, should continue using the light box until days lengthen in the spring because the benefit rapidly disappears if they stop using the light. This therapy does not require someone to look directly at the light source; reading, knitting, watching TV, exercising, working crossword puzzles, or other activities underneath the bright light all suffice. There are many styles and prices of light boxes, but the primary factor is light intensity, which should be at least 10,000 lux. Light boxes can be obtained without a prescription and from many stores and via the Internet. Some insurance companies will pay for box rental or purchase with a physician’s written prescription.

clock reaches the switch-on time, a lamp turns on and gradually increases the intensity of its light, thereby simulating dawn. Outdoor exercise during daylight, such as a brisk walk, skating, or skiing, has been found to be very helpful for some patients who are also using light therapy or antidepressants.

The most worrisome complication of SAD is the risk of suicide.

When to see a doctor It’s important to seek physician input in diagnosing and treating SAD if you think about suicide during episodes of depression, if light boxes don’t help, or if you develop hypomania in the spring once SAD ends. Hypomania symptoms include elevated mood, decreased need for sleep, thinking faster than usual, rapid speech, thoughts jumping from topic to topic, inflated self-esteem, and increased time spent in pleasurable activities. This can lead to impulsivity and poor decision-making. The good news is that treatment can alleviate or banish SAD symptoms. S. Charles Schulz, MD, is a professor and head of the Department of Psychiatry, University of Minnesota. Barry Rittberg, MD, is an assistant professor in the same department.

Public Health Certificate in Clinical Research The University of Minnesota School of Public Health offers a program for people who work with research clinical applications on human beings but who do not have an advanced degree in clinical research.

Other treatments SAD patients who don’t want to spend time on light box therapy may receive relief from treatments used for treating nonseasonal depression, such as antidepressant medications, psychotherapy, talk therapy, or a combination of these treatments. Alternative treatments for seasonal depression that have shown some benefit are: Negative ion generators, which tend to leave a person feeling somewhat more peaceful. Dawn simulators are turned on by a clock set for approximately half an hour before a person wants to wake up. When the

Coursework is conveniently offered online and the program can be completed in six terms.

www.sph.umn.edu/programs/certificate/cr NOVEMBER 2012 MINNESOTA HEALTH CARE NEWS

PA L L I AT I V E C A R E experience depression and anxiety that creates a vicious cycle of escalating pain and depression. Neuromodulation

Pacemakers for pain Spinal cord stimulation systems By Peter Pahapill, MD, PhD

hronic neuropathic pain (CNP), defined as pain persisting longer than three months, affects approximately one in four Americans and is estimated to cost more than $500 billion per year in health care and lost productivity. CNP results from injury to the nervous system that damages nerves and alters the nervous system’s functioning after the injury occurs. Up to 30 percent of this type of pain has an unknown cause; known causes include alcoholism, HIV, diabetes, and degenerative disk disease. CNP typically does not respond to treatment, creating enormous emotional and financial cost to sufferers, caregivers, and society. In addition, chronic pain sufferers often

Fortunately, CNP is amenable to neuromodulation, the intersection of science, medicine, and bioengineering that is the fastest-growing medical field worldwide, both in number of procedures performed and number of medical conditions that respond to these procedures. An estimated 10 million people in the U.S. today, including approximately 150,000 Minnesotans, would qualify for an FDA-approved neuromodulation implant. However, only 1 percent to 10 percent of potential candidates are aware that such therapies exist. Examples of neuromodulation devices include deep brain stimulators for Parkinson’s disease and tremors, chemical pumps for spasticity and pain, vagal nerve stimulators for epilepsy, sacral nerve stimulators for urinary incontinence and retention and for fecal incontinence, and spinal cord stimulators (SCS) for chronic pain. SCS technology

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SCS uses electrical stimulation of the spine, a technology that began in the mid-1960s as an outgrowth of cardiac pacemaker technology. More than 250,000 patients worldwide have received SCS pain therapy systems since the 1970s. The way that SCS works is that electrodes on one or more leads deliver current that can be closely controlled and modified. The leads are connected to a generator implanted under the patient’s skin. The generator contains a power source and a computer program that controls electrical signals. Mild electrical signals are generated and sent to nerves along the patient’s spinal cord. These signals are thought to mask a person’s perception of pain by replacing it with a gentle massaging sensation. The right treatment for the right patient

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SCS works best in patients who understand that it aids overall management of chronic pain but is not a cure. Patients and their health care teams must be committed to subsequent, lifelong management of SCS. SCS is an appropriate aid in managing chronic, intractable pain of the trunk and/or limbs. Before requesting it, patients should first try conservative approaches to pain management under the direction of a chronic pain physician. Conservative approaches might include nonsteroidal anti-inflammatory medication (NSAIDs); opioids; certain prescription pain medications such as Neurontin, Cymbalta, and Lyrica; cortisone injections; and physical therapy. After these treatments, including only a brief trial of opioids, have failed, SCS should be considered immediately, to avoid escalating opioid use.

Likelihood that SCS can provide good long-term pain control

Factors affecting SCS’ likelihood of providing good long-term pain control are listed in the table on this page. However, because most patients have mixed pain patterns that require both SCS and additional treatments for muscle, joint, and other pain, a screening trial is essential. Screening trial A three- to eight-day trial of SCS therapy duplicates the definitive procedure and is the best indicator of whether or not SCS will succeed. To be successful, a trial produces a combination of greater than 50 percent pain relief with improved function, mood, sleeping pattern, and reduced pain medication intake during the trial. If the trial is successful, the patient then decides whether to add spinal stimulation therapy to his or her overall chronic pain treatment plan. Once implanted, the system can be adjusted at home or the physician’s office to produce varying degrees of stimulation and also can be turned off by the patient.

Patient/Pain characteristic

Good response to SCS

Pain in arm or leg

++++

Pain in back or neck

Limited response to SCS +

Pain caused by damage to the part of the nervous system responsible for bodily sensation (example: bumping your “funny bone”)

++++

Pain caused by stimuli approaching or exceeding harmful intensity (example: hitting your thumb with a hammer) Constant pain

+ ++++

Periodic, mechanical pain

Deep, aching, burning pain

++++

Sharp, stabbing pain

Pain is distributed along specific spinal nerve(s)

++++

Pain is not distributed along specific spinal nerve(s) Known biological cause of nerve injury

+ ++++

Unknown biological cause of nerve injury Pain for less than 1–2 years

+ ++++

Pain for more than 2–5 years

Addiction history

Motivations for treatment are other than pain relief

Ongoing psychosis/behavioral disorders

Common uses of SCS in the U.S. Failed back/neck surgery. The most common use of SCS in the in U.S. is for nerve pain following failed back/neck surgery or for pain due to disease progression after previous spine surgery. In the latter case, patients continue to have pain and disability with a low quality of life despite anatomically successful cervical or lumbar discectomy, laminectomy, and/or spinal fusion to treat spinal cord compression. Often, when spine surgery fails to relieve pain in the trunk, back, neck, arms, or legs, additional spine surgery is recommended. Given the high cost and risk of spine surgery, It is reasonable it is reasonable to consider SCS as an alternative, since SCS has been to consider shown to be effective for this type SCS as an of pain. Complex regional pain synalternative to drome. SCS has also shown good spine surgery. results in treating complex regional pain syndrome (CRPS), sometimes called reflex sympathetic dystrophy (RSD), which leads to loss of function and severe pain. SCS can help these patients have pain relief, improved blood flow (in those who have vasoconstriction), and increased tolerance of physical rehabilitation. These benefits help patients reduce muscle atrophy, preserve their physical movement, and maintain their strength via physical therapy and home exercise. A study comparing results from SCS plus physical therapy versus physical therapy alone showed that patients who received SCS had significantly better outcomes for as long as two years posttreatment.

Start sooner, not later It’s important to start SCS therapy as soon as possible after chronic pain has been diagnosed, ideally within one to two years of chronic Pacemakers for pain to page 30

Where do you turn for your child’s emotional development? Help is near. The new Children’s Mental Health Clinic at St. David’s Center will partner with your family to identify concerns and promote social and emotional growth.

stdavidscenter.org/mentalhealth 952.939.0396

NOVEMBER 2012 MINNESOTA HEALTH CARE NEWS

Pacemakers for pain from page 29

More relief on the horizon?

pain syndrome’s onset. This is because the risk of SCS failure increases 10 percent to 15 percent for every year of delay. After a patient has experienced chronic pain for more than five years, SCS has less than a 50 percent chance of success. Risks and complications As with any surgical procedure, implantation of SCS systems has a risk of complication. The vast majority of devices are placed and maintained without problems but, when they do occur, the most common complications are fracture of the electrical leads, migration of the leads, and infection. Infection occurs in 2 percent to 10 percent of cases. Injury to the spinal cord and/or nerves is extremely rare, as is bleeding and the body’s immunologic rejection of the device. Results Goals of SCS therapy are 50 percent or greater pain relief, improved quality of life and function, and decreased use of pain medication. Optimal long-term results of SCS therapy occur when it is provided by a pain center accredited by the American Academy of Pain Management.

The future may bring additional uses for this therapy. Current evidence is very strong for its usefulness in treating refractory (resistant to treatment) angina pectoris, in which brief episodes of chest pain are caused by insufficient oxygenation of heart muscle. In fact, this condition is the No. 1 indication for SCS use in Europe, although SCS is not FDA-approved for angina pectoris treatment in the U.S. Another future application may be for treatment of migraines; a recent multicenter study examined occipital nerve stimulation by SCS for the treatment of that condition. Results should be complete in the near future and may lead to a new, approved treatment for the estimated 36 million Americans (approximately 10 percent of the total population) who suffer from this condition that contributes to the more than $13 billion lost by employers each year due to headache or migraine.

Chronic neuropathic pain affects approximately one in four Americans.

Peter Pahapill, MD, PhD, is a neurosurgeon with United Neurosurgery Associates, St. Paul.

Now accepting new patients

A unique perspective on cardiac care Preventive Cardiology Consultants is founded on the fundamental belief that much of heart disease can be avoided in the vast majority of patients, and significantly delayed in the rest, by prudent modification of risk factors and attainable lifestyle measures.

Elizabeth Klodas, M.D., F.A.S.C.C is a preventive cardiologist. She is the founding Editor in Chief of CardioSmart for the American College of Cardiology www.cardiosmart.org, a published author and medical editor for webMD. She is a member of several national committees on improving cardiac health and a frequent lecturer on the topic.

We are dedicated to creating a true partnership between doctor and patient working together to maximize heart health. We spend time getting to know each patient individually, learning about their lives and lifestyles before customizing treatment programs to maximize their health. Whether you have experienced any type of cardiac event, are at risk for one, or

are interested in learning how to prevent one, we can design a set of just-for-you solutions. Among the services we provide • One-on-one consultations with cardiologists • In-depth evaluation of nutrition and lifestyle factors • Advanced and routine blood analysis • Cardiac imaging including (as required) stress testing, stress echocardiography, stress nuclear imaging, coronary calcium screening, CT coronary angiography • Vascular screening • Dietary counseling/Exercise prescriptions

To schedule an appointment or to learn more about becoming a patient, please contact: Preventive Cardiology Consultants 6545 France Avenue, Suite 125, Edina, MN 55435 phone. 952.929.5600 fax. 952.929.5610 www.pccmn.com

MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

You call it â&#x20AC;&#x153;reminding mom to take her pills.â&#x20AC;?

We call it caregiving.

You or someone you know may be a caregiver. WhatIsACaregiver.org

Future caregiving

Family-member caregiving from page 23

head of household. This is a more favorable tax status than filing as a single person, and makes the caregiver eligible for lower tax rates and additional tax credits. Deductible medical expenses. Paying to install a wheelchair ramp at a care recipient’s home and using your vehicle to drive him or her to medical appointments are examples of costs that can be deducted on the caregiver’s tax return, as long as the cost exceeds 10 percent (as of Jan.1, 2013) of the caregiver’s gross adjusted income. This is the case even if the recipient doesn’t qualify as a dependent, as long as the caregiver pays more than 50 percent of the recipient’s medical fees.

Support

Minnesota will reduce Medicaid payments to family caregivers by 20 percent starting July 2013. This means that caregivers will receive less than a nonfamily personal care aide earns for providing the same service. Is this fair? Should we compensate family caregivers less for work because it’s considered their duty? Should family caregivers be paid at all because they’re expected to provide this care as part of personal responsibility? These are the questions we need to ask our policymakers. Today’s caregivers will be tomorrow’s elderly, and we need to build a system that is responsive to their needs both now and in the future.

Even tax breaks and the satisfaction of helping others don’t change Michele Kimball is the director of AARP Minnesota, which has nearly the fact that caregiving can be exhausting. “We want caregivers to 700,000 members. feel acknowledged and understood, so they realize they are not alone,” says Liz Bradley, AARP’s strategic communications director. AARP’s online Caregiver Support Center (www .aarp.org/caregiving) provides caregivers with helpful artiHelping aging or disabled cles, resource guides, and online forums where they can relatives creates substantial connect with experts or other AARP members facing similar challenges. It’s not necessary to be an AARP member to financial hardship. access the website. Another resource is the Minnesota Department of Human Services’ online toolkit. It helps families create long termcare plans and share them with each other online (www.mn.gov/dhs/general-public/own-your-future/).

Minnesota

Health Care Consumer October survey results ... Association

Each month, members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around topics that affect our health-care delivery system. There is no charge to join the association, and everyone is invited. For more information, please visit www.mnhcca.org. We are pleased to present the results of the October survey.

3. I feel the presidential candidates have made their views on health-care related issues clear enough for me to understand.

1. Health-care related issues are an important part of determining my vote in the presidential election. 60

39.1%

40 30 20 10

6.5% 2.2%

Strongly agree

15.2% 8.7%

40 30.4%

19.6%

20 10

6.5%

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

0.0% Strongly agree

Agree

No opinion

Disagree

Strongly disagree

50 40 30

28.3%

20 10.9%

10 0

Strongly disagree

6.5% 0.0% Strongly agree

Agree

No opinion

Disagree

Strongly disagree

5. I feel that turning the challenges of improving our health-care delivery system into partisan political issues impedes the process of improvement. 60

4.3%

Disagree

Percentage of total responses

23.8%

10 0

No opinion

43.5% Percentage of total responses

Percentage of total responses

Agree

0.0%

30 20

Percentage of total responses

43.5% 40

54.3%

52.2%

4. I feel the candidates in statewide and local elections have made their views on health-care related issues clear enough for me to understand.

2. Health-care related issues are an important part of determining my vote in statewide and local elections.

54.3%

50 40

34.8%

30 20 10 0

4.3% Strongly agree

Agree

No opinion

2.2% Disagree

4.3% Strongly disagree

Minnesota

Health Care Consumer Association

Welcome to your opportunity to be heard in debates and discussions that shape the future of health care policy. There is no cost to join and all you need to become a member is access to the Internet.

Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org

Join now.

â&#x20AC;&#x153;A way for you to make a differenceâ&#x20AC;? NOVEMBER 2012 MINNESOTA HEALTH CARE NEWS

Youth aand sexually transmited infections from page 13

• Are 15 to 50 years old

(someone under 18 years of age) to consent to some types of health care without the explicit approval or knowledge of that minor’s parents. These are generally referred to as Minor Consent and Confidentiality Laws. It’s been shown that without minor consent laws, teens may delay treatment or not seek treatment at all. These laws also grant a teen confidential health services, which increases the likelihood that he or she will seek care. Because of this, and specifically in the case of STIs, this becomes a public health issue: Treating an STI early reduces the complications for the individual, and decreases the risk of spreading the infection to others. In the state of Minnesota, a minor may consent for medical services without a parent’s knowledge:

• Are at or below 200 percent of the federal poverty guidelines. • Wish to prevent or delay pregnancy

Many STIs may not cause symptoms until years later.

• To determine the presence of treatment of pregnancy and conditions associated with pregnancy • For sexually transmitted infections • For alcohol or other drug abuse Minnesota minor consent law does not allow a parent to access medical records in the above situations without the minor’s written consent. This law also stipulates that a teen is financially responsible for services he or she accesses under minor consent. The state of Minnesota recognizes the societal and public health cost of unintended pregnancies and STIs and thus provides access to free pregnancy prevention and to STI testing and treatment. The Minnesota Family Planning Program (MFPP) is available for Minnesota residents who meet all of the following criteria:

Teens and young adults do not have to include their parents’ income to qualify. Although the primary goal of this program is to prevent pregnancy, testing and treatment for STIs as part of a family planning visit are covered by MFPP. Most adolescent health clinics in the Twin Cities enroll teens in MFPP, as do school-based health clinics and many reproductive health clinics throughout the state. Resources

• MFPP providers are listed by county on the MDH website: www.health.state.mn.us/divs/fh/mch/familyplanning/directory.html • Minnesota Family Planning and STD hotline: (800) 78FACTS, (800) 783-2287, http://sexualhealthmn.org. Call, live-chat online, text, or browse this site’s online resources for information about STIs and reproductive health. This organization’s staff provides guidance, gives accurate information in real time, and helps direct callers to the services they need. Affiliated with the Minnesota Department of Health; hotline hosted by Family Tree Clinic. Alison Warford, MD, is board-certified in family medicine and adolescent medicine. She sees patients at the Emily Program, and is medical director at Family Tree Clinic and at Face to Face Health and Counseling, all in St. Paul.

A One Stop Shop for Minnesota Seniors

Call to get helpp with: with s Planning for long-term care s Remaining independent in your community s Arranging for in-home services s Getting help from state agencies s Becoming involved in your community

s &INDING A VOLUNTEER OPPORTUNITY s &IGHTING FRAUD s Understanding Medicare &IND MORE RESOURCES AT

MINNESOTA HEALTH CARE NEWS NOVEMBER 2012

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