Minnesota Physician February 2015 by Minnesota Physician Publishing

Vo l u m e x x v i i I , N o . 11 F e b r u a r y 2 015

Workforce shortages in long-term care A growing problem in Minnesota By Patti Cullen, MA

etween now and 2030, Minnesota will experience an increase in people aged 65 and older, with 414,000 older adults joining that age segment. Implications from this demographic are significant: • Older adults have less savings to pay for future long-term care needs. • Aging Minnesotans will need more services (especially as they reach age 85 and beyond). • There will be a proportionately smaller labor force to provide services of any kind.

Reporting child maltreatment and abuse What every physician should know By Alice Swenson, MD, FAAP; Chris Derauf, MD, FAAP; and Sarah Lucken, MD, FAAP

ne of the toughest challenges that primary care physicians face is what to do when confronted with a child who may have been maltreated. This may occur in the inpatient setting when a child is hospitalized with suspicious injuries or failure to thrive. Or it may occur in an outpatient setting, such as an emergency room or clinic, derailing an otherwise routine day and requiring immediate action.

• Since this demographic has fewer children, there will be a shortage of both formal and informal (unpaid) caregivers. • A ll of these facts mean increased costs for both health care and longterm care. It also means that the current workforce shortage we are seeing in MinWorkforce shortages in long-term care to page 12

Physicians often have questions about who is mandated to report, which acts trigger mandated reporting, and to whom a mandated report must be made. These topics are addressed in more detail in the Minnesota Reporting of Maltreatment of Minors Act in Minnesota (Statute 626.556).

Reporting child maltreatment and abuse to page 10

rehabilitation services from P ost-acute the Good Samaritan Society. Post-acute care is designed to heal and assist patients with care and support following a hospitalization from serious illness, injury or elective surgical procedure. Multiple in-patient and out-patient post-acute locations are located throughout the Twin Cities metro area and state of Minnesota. To learn more about our post-acute services, call us at 866-GSSCARE or visit www.good-sam.com/minnesota.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. ÂŠ 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G0066

February 2015 • Volume XXVIII, No. 11

Features

MINNESOTA HEALTH CARE ROUNDTABLE Reporting child maltreatment and abuse What every physician should know

By Alice Swenson, MD, FAAP; Chris Derauf, MD, FAAP; and Sarah Lucken, MD, FAAP

Workforce shortages in long-term care 1 A growing problem in Minnesota By Patti Cullen, MA

The New Face of Health Care

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

Jon Hallberg, MD

A long-term plan for long-term care By Rep. Joe Schomacker

Practice Management

Expanding medical professional relationships

Guidelines for managing asthma By Wendy Brunner, MS, PhD, and Pamela Van Zyl York, MPH, PhD, RD, LN

Professional Update: Behavioral Health Integrating behavioral services 16 By R ichard Sethre, PsyD, LP, and John E. Simon, MD

Special Focus: Complementary and allied providers Respiratory therapists By D erek Hustvet, BS, RRT-NPS, LRT

Thursday April 23, 2015, 1:00-4:00 PM

Taking care beyond the office By Andrew Dorwart, MD

Mill City Clinic

Public Health

Policy

Integrative mental 24 health strategies for kids By Timothy Culbert, MD, FAAP

Cognitive behavioral 22 coaching By Deborah Friedman, MD, FAAPMR

Downtown Minneapolis Hilton and Towers

Background and Focus: With dramatic population growth, and as baby boomers become senior citizens, the demand for health care is exceeding the supply. Addressing the shortage of medical doctors involves creating new relationships between medical professionals. Training and licensure for Physician Assistants, Advanced Nurse Practitioners, Chiropractors, Respiratory Therapists, Physical Therapists, Home Care Providers, Dentists, and many other health care professions have become increasingly rigorous and provide expanded support to our health-care delivery system. Greater integration of these professions allows medical doctors to work to the top of their license but requires new pathways for communication and care coordination. Objectives: We will examine many of the new partnerships that are emerging between medical doctors and other medical professionals. We will look at the ways leveraging these new relationships can improve access to care while reducing costs and improving outcomes. We will consider points of resistance to forming these kinds of health care teams and what should be avoided in creating them. We will discuss what the proper oversight for these relationships should entail and how to maximize the coordination of care that they require. Panelists Include: • Mehul Desai, MD, Minneapolis Advanced Pain Specialists • Derek Hustvet, RRT-NPS, LRT, Director of Respiratory Service, Pediatric Home Service • John Gulon, DDS, President of Park Dental • Craig Johnson, PT, MBA, President MNPTA, Director of Clinical Integration Therapy Partners Sponsors Include: Minneapolis Advanced Pain Specialists, Park Dental, and Pediatric Home Service

Publisher Mike Starnes | mstarnes@mppub.com Senior Editor Janet Cass | jcass@mppub.com Editor Lisa McGowan | lmcgowan@mppub.com Assistant Editor Patricia Mata | tmata@mppub.com Art Director Alice Savitski | asavitski@mppub.com Office Administrator Amanda Marlow | amarlow@mppub.com Account Executive Stacey Bush | sbush@mppub.com Account Executive Jan Ehrlich | jehrlich@mppub.com Minnesota Physician 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 the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub.com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable. Name Company Address City, State, ZIP Telephone/FAX Card #  Check enclosed  Bill me

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Please mail, call in, or fax your registration by 4/20/2015 February 2015 Minnesota Physician

capsules

Health Inequities Significant in State, Report Finds Minnesota has considerable health inequities across racial and ethnic groups, preferred languages, countries of origin, and geographic regions in the state, according to a new report from MN Community Measurement (MNCM). The report analyzed standardized data collected by medical groups throughout the state. The data included health outcomes for diabetes care, vascular care, asthma care for adults, asthma care for children, and colorectal cancer screening. “Minnesota is one of the healthiest states in the nation, but we also have some of the largest inequities in health status and incidence of chronic disease,” said Jim Chase, president of MNCM. “Patients from specific populations, including people of color, people who identify as

Hispanic, immigrants, and people who do not speak proficient English are less likely to receive preventive care and more likely to suffer from serious illnesses and have negative health outcomes.” The 2014 Health Equity of Care Report is the first of its kind in the state. In the future, MNCM plans to add measures for maternity care, depression, and preventive pediatric care. “To reduce and eliminate health inequity, we must understand where it exists and its scope,” said Anne Snowden, director of performance measurement and reporting at MNCM. “Never before has data on health outcomes been available at this granular level in Minnesota—making it actionable for advocates, policymakers, public health professionals, community leaders, and medical groups.” The most notable inequities were found for Somali patients. Those born in Somalia and/or those who preferred speaking

Minnesota Physician February 2015

Somali had the lowest health care outcomes in the state for four of the five measures. Only 22 percent of Somali immigrants were screened for colorectal cancer, compared to 70 percent of all patients statewide. Only 25 percent of adults with Somali as their preferred language received optimal asthma care, compared to 47 percent of adults statewide.

born in the U.S. in the three categories where Vietnamese patients were reportable. Those who preferred speaking Vietnamese had the highest health care outcome rates in the state for diabetes care and vascular care, and Vietnamese immigrants had the highest rate in the state for diabetes care of any country of origin group.

Overall, the report found that white and Asian patients had high health care outcomes, and that Native American or Alaskan Native and Black or African patients had low health care outcomes. Hispanics tended to have lower health care outcomes than non-Hispanics, except in the east metro and St. Paul regions, where Hispanics had higher rates of vascular care and asthma care for adults than non-Hispanics.

While Asian immigrants tended to have high health care outcomes across the state for multiple measures, those born in Laos and/or those who preferred speaking Hmong had lower health care outcomes overall.

Patients born in Vietnam and/or those who prefer speaking Vietnamese had some of the highest health care outcomes. The group had higher outcomes than English-speaking patients

Geographically, the east and west metro regions had high health care outcomes across multiple measures and multiple populations, while regions in southwest and northeast Minnesota generally had worse health care outcomes. Central Minnesota had high rates of asthma care for adults and children across all racial groups. MNCM says this report is

just the beginning. “Data alone won’t reduce disparities or achieve health equity goals,” said Snowden. “The real achievement will come when we begin to see the elimination of health inequities across our state and nation.”

New House Committee to Focus On Senior Care Rep. Joe Schomacker (R-Luverne) will chair a new committee in the Minnesota House, dedicated to addressing senior care issues from a statewide perspective in 2015. “We need to get off this path of doing what gets us by from year to year,” said Schomacker. “We’re facing a silver tsunami in senior care through 2035, and it’s going to be the next generation workforce who pays for it. Longterm care needs a long-term plan in Minnesota.” Schomacker said the Committee on Aging and Long-Term Care Policy will be a platform to discuss demographics as well as social and economic implications of the state’s aging population. The committee’s work will focus on addressing rates and reimbursements, including the impact of inadequate funding on quality, workforce issues, and personal responsibility for financing longterm care needs. “It’s very difficult to try and find people that want to work in long-term care settings, even though we know that when people do work in long-term care settings and stay there a long time, that helps with the quality of life and quality of care that the residents get,” said Schomacker.

Access to Physician Info in Minnesota Rated Highly

Minnesota was once again one of only two states to earn a grade of “A” on the State Report Card on Transparency of Physician Quality Information from the Health Care Incentives Improvement Institute.

The annual report assesses

states’ availability of quality information on physicians and how accessible that information was to consumers. The authors note that the report did not include information publicly reported by health plans because consumer research has indicated that consumers distrust quality information that comes from insurance providers. Only six states received a “C” or higher on the report. A large majority of states—40—received an “F.” Washington was the other state to receive an “A”; California and Maine received a “B”; and Wisconsin and Massachusetts received a “C.” Four states earned a “D.” According to the report, this means independent and objective public quality information is only available for 16 percent of clinicians in the U.S.

Request foR nomination 2015 HealtH care arcHitecture & Design

Seeking Exceptionally Designed Health Facilities in Minnesota Nomination Closing: Friday, May 8, 2015 Publication Date: June 2015 We are seeking nominations of exceptionally designed health care facilities in Minnesota. the nominees selected for the honor roll will be featured in the June 2015 edition of Minnesota Physician, the region’s most widely read medical publication. eligible facilities include any construction designed for patient care: hospitals, individual physician offices, clinics, outpatient centers, etc. interiors, exteriors, expansions, renovations and new structures are all eligible.

“Consumers are flying blind when it comes to selecting hospitals and physicians, and the overall quality and affordability of American health care won’t be improved until we find a way to solve this problem,” said Francois de Brantes, executive director of the Health Care Incentives Improvement Institute.

in order to qualify for the nomination, the facility must have been designed, built or renovated since January 1, 2014. it also must be located within Minnesota (or near the state border within Wisconsin, North Dakota, South Dakota or Iowa). color photographs are required at 300 dpi resolution (no more than eight) with caption of each to amarlow@mppub.com. if you would like to nominate a facility, please fill out the form below and, a brief project description (150-250 words) by Friday, May 8, 2015.

The report’s authors began their evaluation with the Robert Wood Johnson Foundation’s national directory, which lists online public resources and programs for each state to help consumers find cost and quality information for health care providers in their communities. They reviewed each state program for four base criteria: if the information was available to the public at no cost; if it was from an independent and objective third party; if it was specific to primary care physicians or specialists; and if it was from data captured and scored as of 2011 or later. If a state met these criteria, the program was analyzed and scored. Any state that did not meet the base criteria received an “F.”

Honor Roll nomination form

For more information, call (612) 728-8600.

Facility name Type of facility Location Ownership organization Owner address, phone Architect/interior design firm Architect address, phone Engineer Contractor Completion date Total cost Square feet Brief description

“The goal of this report is to not only highlight efforts that are doing well, but also to grab the attention of lawmakers in states lacking this vital information for their residents,” said de Brantes. Capsules to page 6

February 2015 Minnesota Physician

Capsules from page 5

“If your state isn’t receiving an “A” or a “B,” it can and should.”

MinnesotaCare Receives Federal Funding The Centers for Medicare & Medicaid Services approved MinnesotaCare as the first state-funded program under the Basic Health Plan, effective Jan. 1, 2015. The Department of Health and Human Services will receive the funds to help pay for MinnesotaCare and ensure its availability for those who need it in the future. According to Lucinda Jesson, Human Services commissioner, some of the federal funds allocated for insurance subsidies now will go toward funding MinnesotaCare. “What the federal government basically says is, ‘Look, states, we’ll give you the opportunity to take 95 percent of what we’d

otherwise pay for premiums and cost-sharing for someone who goes to the exchange, and give it to you to fund your own program for poor working adults,’” she said. While officials say most enrollees will not be affected, there will be some changes, including eliminating the four-month waiting period and an inpatient hospital coverage limit. Jesson added that the amount of federal funding will be based on MinnesotaCare enrollment and will be determined quarterly. “Our MinnesotaCare program has been in existence for the last 20 years, and it’s really done a lot to make sure that poor working families have health coverage, and this is a new way to fund it,” said Jesson.

CentraCare Health Broadens Services CentraCare Health has announced the addition of two ser-

vices to its health care offerings in Central Minnesota. The CentraCare Kidney Program, a division of St. Cloud Hospital and CentraCare Health System, will open a new dialysis center in partnership with Renville County Hospital and Clinics. The center will be located in the current location of the Renville County Hospital and Clinics–Olivia Clinic. The groups plan to start renovating the building to be better suited for dialysis services in fall 2015 and to open the center in early 2016. It will offer in-center hemodialysis, home hemodialysis, and peritoneal hemodialysis. “Kidney dialysis has long been identified as a service need for our local communities,” said Nathan Blad, MBA, CEO of Renville County Hospital and Clinics. “Over the past few years, we have looked at options for how we might make this crucial service available.”

The decision to partner with CentraCare to open the center was due to the operational complexity, technical requirements, regulatory demands, and economics of running a dialysis center, according to Blad. In addition, Adult & Pediatric Urology, the largest full-service urology clinic in Central Minnesota, has joined CentraCare Health. The clinic has changed its name to CentraCare Clinic– Adult & Pediatric Urology, but it will retain the same location, providers, phone number, and hours. “Other than changing our name, we don’t expect our patients or the community to notice any big changes,” said Greg Parries, MD, PhD, urologist at Adult & Pediatric Urology. “However, by integrating more closely with CentraCare Clinic, our patients will benefit from many behindthe-scenes advanced services that a larger clinic can provide.”

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Minnesota Physician February 2015

Medicus Michael Georgieff, MD, director of the University of Minnesota Department of Pediatrics Division of Neonatology, has received the 2014 Samuel J. Fomon Nutrition Award from the American Academy of Pediatrics’ Committee on Nutrition in recognition of his research in neuronutrition. Georgieff graduated from Washington University Medical School, St. Louis; completed Michael Georgieff, a pediatrics residency at The Children’s Hospital of Philadelphia; and served fellowships in neonaMD tology at the University of Pennsylvania, Philadelphia, and the University of Minnesota. He is board-certified in neonatal-perinatal medicine. Robert G. Hauser, MD, senior consulting cardiologist at the Minneapolis Heart Institute, has received the 2014 Shotwell Award from the West Metro Medical Foundation of the Twin Cities Medical Society, presented annually to a person within Minnesota who has made significant contributions in the field of health care. Hauser received this award in recognition of his leadership as a cardiologist and researcher, including Robert G. Hauser, advocacy for the safety and efficacy of implantMD able cardiac devices. Hauser graduated from the University of Cincinnati College of Medicine, and served an internal medicine residency at Cincinnati General Hospital and a cardiology fellowship at Rush-Presbyterian-St. Luke’s Medical Center, Chicago. He is a Fellow of the American College of Cardiology and a founder and Fellow of the Heart Rhythm Society.

Osmo Vänskä

/// Music Director

SpiritSpring Classical music radiant with the vitality of spring

KyleeAnn Stevens, MD, has assumed the position as medical director of Minnesota Security Hospital, St. Peter, a secure treatment facility serving people who have been committed by the court as mentally ill and dangerous. Board-certified in general and forensic psychiatry, Stevens previously was director of forensic services at St. Elizabeths Hospital in Washington, D.C. She graduated from the University of North Dakota KyleeAnn Stevens, School of Medicine and Health Sciences, Grand MD Forks; completed a psychiatry residency at Georgetown University in Washington, D.C.; and completed a forensic psychiatry fellowship at Georgetown. Andre Terzic, MD, PhD, was awarded the American Heart Association 2014 Basic Research Prize for pioneering applications of emerging technologies to advance the diagnosis and treatment of cardiovascular diseases. He is the director of the Mayo Clinic Center for Regenerative Medicine and holds a dual academic rank as professor of medicine and pharmacology at Mayo. Terzic earned his medical degree from the University of Belgrade, in what is now Serbia, and his PhD in pharmacology from the University of Illinois, Chicago.

The Light Above: Music for Easter Weekend Thu Apr 2 11am / Fri Apr 3 & Sat Apr 4 8pm

Osmo Vänskä, conductor / Erin Keefe, violin / Timothy Lovelace, piano Our series opens with the transcendent Russian Easter Overture, The Lark Ascending featuring Erin Keefe and Messiaen’s piano showpiece Exotic Birds. Andre Terzic, MD, PhD

Michael Thurmes, MD, board-certified in internal medicine, cardiovascular disease, and interventional cardiology, has joined the Brainerd Lakes Heart & Vascular Center at Essentia Health–St. Joseph’s Medical Center, Brainerd. Thurmes earned a medical degree at the University of Minnesota; completed an internal medicine residency at Abbott Northwestern Hospital, Minneapolis; and completed a cardiology Michael Thurmes, fellowship at Loyola University Stritch School of MD Medicine in Maywood, Ill., and a fellowship in invasive cardiology at St. Vincent’s Hospital in Indianapolis, Ind. Previously, he practiced at Regions Hospital Heart Center, St. Paul.

Song of the Earth: Mahler's Das Lied von der Erde Fri Apr 10 & Sat Apr 11 8pm

Mark Wigglesworth, conductor / Mihoko Fujimura, mezzo / Stuart Skelton, tenor To end Haydn's Farewell symphony, the musicians stop playing one by one, extinguish their lights and walk offstage. Fortunately they return for Mahler's magnificent The Song of the Earth.

Primal Paradise: Stravinsky's Rite of Spring Thu Apr 23 11am / Fri Apr 24 8pm

Michael Stern, conductor / Simon Trpčeski, piano A century after its debut caused riots in Paris, The Rite of Spring is as riveting as ever as is Rachmaninoff’s demanding Third Piano Concerto and Griffes’ The Pleasure Dome of Kubla-Khan.

minnesotaorchestra.org / 612.371.5656 / Orchestra Hall Media Partner:

February 2015 Minnesota Physician

Interview

The art of healing P lease tell us about the philosophy of community care that guides your work at the Mill City Clinic. When we created the clinic in 2008 we really wanted to do something new and different. We didn’t want it to look like a clinic; we wanted it to reflect the new and emerging and exciting Mill District neighborhood in which it’s located, taking design cues from the Zenith Condominiums in which the clinic is housed, Gold Medal Park, the Guthrie Theater, the Mississippi River, and the businesses and residences in the area. 

Jon Hallberg, MD Mill City Clinic Dr. Hallberg is an associate professor in the department of family medicine and community health at the University of Minnesota Medical School, where he is an award-winning educator and clinician. He is the founding medical director of the university’s innovative Mill City Clinic, an inter-professional primary care clinic in Minneapolis located near the Guthrie Theater.

In addition, we wanted to seamlessly merge into the fabric of the neighborhood, to be more than “just” a clinic. We wanted to be a true neighborhood asset. We refer to our waiting room as our lobby and it’s full of light and original art. We often have University of Minnesota music students performing there. We have art gallery openings and receptions on a regular basis, and we’ve hosted book signings, theater performances, yoga sessions, and receptions. And perhaps most important, we have an outstanding team of providers and support staff who deliver exceptional care. Since the day we opened we’ve been practicing as a true health care home—before that became a formal designation. As a result, we’re a neighborhood-centered clinic that also treats patients from all across the county. e understand that you are involved W with performing arts medicine. What are some examples of your work with the unique issues this field poses? When I was thinking of going to medical school I never imagined that there would be a way to combine my love of music and the arts with my desire to heal and help. When I was a first-year medical student, I came across an article in The New Physician magazine describing the field of performing arts medicine. Immediately I knew I wanted to incorporate this into my practice.



Right out of residency I joined a well-established clinic located in the Medical Arts Building on Nicollet Mall. We offered flu shots to the cast of Beauty and the Beast in 1995 and took care of a few of their sick actors. Soon, through word of mouth that part of my practice took off. Over the years I’ve provided care for the casts of traveling Broadway shows, visiting orchestra musicians, stage and movie actors, and the occasional rock musician. My niche is in providing primary and acute care to performing artists, rather than treating overuse injuries that are so common. (I refer those patients to my sports medicine colleagues.)

Minnesota Physician February 2015

As you can imagine, there’s always a sense of urgency in their care, a sense that the show must go on. I understand what they’re trying to do and they appreciate that. Over the years I’ve learned a few “tricks” on how to relieve pain and improve voices and decrease symptoms that won’t interfere with performances. I take great pride in helping these supremely talented people bring such joy (and healing) to others. lease provide some background on the P Hippocrates Cafe. What is it? How did it start and how are you involved with it? Hippocrates Cafe was created in 2009 on the oneyear anniversary of the Mill City Clinic as a way to celebrate our first year of operation. Since then we’ve done 75 shows in eight states. I describe it this way: It’s a live made-for-radio show that explores health care in context through story and song using professional actors and musicians. I typically use two musicians and two actors (one male, one female). Each show has a theme that’s explored through words and music. I write the shows and serve as the narrator and it’s a way for me to bring several of my passions (radio, literature, music, the arts, and medicine) together in a creative, iterative, meaningful way. We perform for conferences and special events. 

hat innovations have been important W to you and your practice? Until I had the opportunity to work on our new clinic I didn’t really appreciate the importance of good design—and what a true innovation it is. Now I’m a complete convert and I have a hard time dealing with poor design of any kind, whether it’s clinical space or a computer interface. I feel that good clinic design is very democratizing—it elevates the human spirit, creates a kind of healing itself, regardless of who that person is (rich or poor). 

No innovation has affected my daily clinical life and practice (for good and bad) more than the electronic medical record. I have a total love/hate relationship with it. Its benefits are endless, of course, but I hate how “clunky” it is, how poorly I interact with it, how disruptive it is to use when I interact with patients. In addition, we’re just starting to grapple with how patients and providers will interact with one another through it. Many people know you as a medical analyst for All Things Considered on MPR. What have you found surprising and rewarding about this work? I’ve had the incredible opportunity to serve as the regular health and medical analyst on the regional 

ence at Dartmouth on reporting scientific information to the public. At that time I wasn’t sure what the difference was between health reporting and health communication. With reporting, information is being shared by someone who likely isn’t a health care provider. With health communication the in-

“All Things Considered” program on Minnesota Public Radio since 2003, appearing nearly 400 times. I’m so honored to be able to do this. I love working with the show’s host, Tom Crann, as well as the wonderful team of producers. I love trying to find just the right way to talk about medicine in a way that’s accessible to all listeners—to those who know nothing about a particular topic, as well as to those who might know a lot about it. As a result, I approach every single conversation with a little trepidation—and a lot of preparation. Every single time I leave the studio I think about what I said during our prerecorded conversation and think how I could have done it differently or better. MPR’s educated, curious audience is so appealing—and quite intimidating. Knowing who’s listening encourages a lot of self-reflection in me! You list health communication as an area of special interest. What can you tell us about this subject? I was a Bush Medical Fellow in 2006 and my focus was health communication. I used that fellowship to go to the Center for Documentary Studies at Duke University for three sessions to make audio documentaries. In addition, I went to an NIH confer

demanding more and have (through portals like MyChart) more access to us than ever before, and we’re often asked to do more with less. This isn’t sustainable. Something has to change.

I think the key will be very interprofessional, collaborative, physician-led primary care. I think that what we’re doing in our clinic is an effort in that direction. Our clinic is led by a medical director, with sevPeople need primary eral primary care physicians (family medicare physicians. cine, med-peds, women’s health, sports medicine) working side by side with physician assistants, nurse-practitioners, and (soon) doctors of nursing practice (DNPs). CMAs formation often comes from the perspective (certified medical assistant), LPNs, and of someone who’s less neutral; who is doing nurses need to provide more direct patient the work. Health communication technically care, seeing patients with us in the exam occurs every time we’re conveying health rooms. Scribes (perhaps sadly) will become and medical information to someone. a necessity and a vital part of our clinics, allowing physicians and other providers to  H ow do you see the role of the prifocus on the practice of medicine and not on mary care physician changing as data entry and the technology itself. we move into a future of workforce The longer I practice medicine the more shortages in the health care industry? I’m convinced that people need primary care I think we’re going through some really physicians. Patients need us for context and interesting, profound, unsettling changes in continuity, wisdom and guidance, and the health care right now. Technology is wonsimple presence of a caring, compassionate derful and necessary but it has created more soul. work and stress for us. Patients seem to be

University of Minnesota - Continuing Professional Development (formerly the Office of CME) Education is essential to achieving and sustaining quality healthcare. Through partnership with healthcare leaders, our educational activities help advance quality improvement and patient care initiatives.

2015 CPD Activities

(All courses in the Twin Cities unless noted)

LIVE COURSES Pediatric Dermatology Progress & Practices February 20, 2015 Integrated Behavioral Healthcare Conference: Building Partnerships & Teams for Better Care March 13, 2015 Fundamentals of Critical Care Support March 26-27, 2015 Cardiac Arrhythmias: An Interactive Update for Internal Medicine, Family Medicine & Pediatrics April 3, 2015 Psychiatry Update Spring 2015 April 9-10, 2015

Maintenance of Certification in Anesthesiology (MOCA) Training April 18, 2015 Live Global Health Training (weekly modules) May 4-29, 2015 Midwest Cardiovascular Forum Controversies in Cardiovascular Disease May 16-17, 2015

www.cmecourses.umn.edu ONLINE COURSES (CME credit available) www.cme.umn.edu/online • Adolescent Vaccination • Nitrous Oxide for Pediatric Procedural Sedation • Preventing Chronic Pain - A Human Systems Approach • Global Health - To include Travel Medicine & Refugee Health - Family Medicine Specialty - Pediatric Specialty For a full activity listing, go to www.cmecourses.umn.edu

Bariatric Education Days: Advances in Bariatric Care May 27-28, 2015 Workshops in Clinical Hypnosis June 4-6, 2015 Topics & Advances in Pediatrics June 4-6, 2015

Office of Continuing Professional Development 612-626-7600 or 1-800-776-8636 • email: cme@umn.edu

Promoting a lifetime of outstanding professional practice February 2015 Minnesota Physician

Which acts trigger mandated reporting? Acts that would be considered reportable under the statute are broadly defined as physical abuse, sexual abuse, and neglect.

Reporting child maltreatment and abuse from cover

Who is a mandated reporter? Anyone can voluntarily report suspected maltreatment. However, physicians, medical care providers, and other professionals who work with children are legally required to report cases of child maltreatment or neglect that are suspected, ongoing, or have occurred in the past three years. They also must report cases involving maltreatment of two or more children unrelated to the perpetrator that have occurred in the past 10 years.

Physical abuse means “any physical injury, mental injury, or threatened injury inflicted by a person responsible for the child’s care.” This may include, but is not limited to, throwing, kicking, burning, biting, cutting, striking with a closed fist, shaking a child under 3 years

ICSI 2015

COLLOQUIUM May 4-6, 2015, St. Paul

Better Care Better Costs

Are we there yet? Keynote Speakers Kevin Kling, Minnesota playwright and storyteller. David Katz, MD, director and co-founder, Yale Prevention Research Center. > 20+ sessions on health care transformation > Special discount and workshop for emerging leaders > Breakfast with health plan executives

Learn more and register online at http://bit.ly/1J9K1Vy

holidays). CPS then takes on the responsibility for investigating the report, ascertaining the child’s safety, and implementing a safety plan during the investigatory period.

Physicians … and other professionals who work with children are legally required to report cases of child maltreatment or neglect.

Those making reports in good faith are legally immune from criminal and civil liability. However, a mandated reporter who does not report a case of suspected child maltreatment or neglect is guilty of a misdemeanor.

Better Health

of age, inflicting any injury on a child 18 months old or younger, interfering with a child’s breathing, threatening a child with a weapon, striking a child under 1 year old in the face or head, and unreasonable physi-

Minnesota Physician February 2015

cal confinement. It is noted that abuse “does not include reasonable and moderate physical discipline of a child administered by a parent or legal guardian that does not result in injury.” Sexual abuse includes sexual assault, rape, prostitution, and statutory crimes in which a child who is under the age of 16 becomes involved in sexual activity. Although specific laws governing sexual conduct for teens may be confusing to the mandated reporter, it is clear that an adult who is in a caregiving role is guilty of sexual abuse if he or she engages in sexual conduct with the child, regardless of age. Neglect includes medical, nutritional, educational, and other forms or acts of omission or commission that result in inadequate care and potential or actual harm. Minnesota is one of many states that allow for religious exemptions from routine medical care, but not if the lack of medical care may cause serious danger to the child’s health. To whom must a mandated report be made? When maltreatment is suspected, a verbal report should be made to the local child protective services (CPS) and/or the law enforcement agency. A follow-up written report must be submitted within 72 hours (exclusive of weekends and

If CPS cannot be reached and there is immediate concern about the patient’s safety or the safety of other minor children in the home or daycare setting, the physician should call 911; ask for the police, in particular the child abuse unit; and make a report.

What should a physician consider before reporting child maltreatment? Try to determine whether the child has been abused or neglected. Take a careful history from the child’s caretaker, carefully delineating this firsthand account from other histories that may have come secondhand. The physician also should use trained interpreters when taking histories from non-English speakers in order to be as accurate as possible. If the child is developmentally capable and medically able, the physician also should ask the child directly what happened; depending on the situation, this may occur either with or without the caregiver present. Children often can spontaneously give many corroborating details about how their injuries occurred. A physician also may partner with an experienced social worker to help obtain this information. A thorough physical exam should be done to look for any injuries/physical findings in addition to the presenting complaint. Additional lab tests and X-rays may be ordered if indicated. The physician then must attempt to determine if the physical findings and test results fit with the history given by the caregiver. In some cases this may be easy. For example, a nonmobile infant would not sustain a broken femur and posterior rib fractures from

rolling off a bed. In other cases it may be more challenging. A pattern injury, such as an iron burn, may occur when a toddler trips over an iron left on the floor or it may have been inflicted. The physician also should look for other red flags. Has the child had suspicious injuries before? Was there a delay in seeking care and why? Are there different histories about how the injury happened, including a changing history from the caregiver? The most important question the physician then must address is: What are the immediate safety needs of the child? Can the child safely be discharged home with the parents/ guardians, particularly if they are possible perpetrators of the injury? If they are not the perpetrators, can they protect the child? The safety and health of the child must come first. It must take priority over consideration of the family’s and provider’s reputations, and the family’s relationship with the physician. Is there a protocol to follow when evaluating a possibly maltreated child? Depending on the type of abuse and age of the child, there are standard workups that occur for children who may have been physically abused. For example, an infant with suspected abusive head trauma would typically have a careful history and physical exam, head CT, skeletal survey, and ophthalmologic exam performed, as well as liver function tests, amylase, lipase, and urinalysis to screen for possible abdominal trauma. A child suspected of having been sexually abused would typically undergo a careful history and physical exam, and evaluation that might include laboratory tests for sexually transmitted infections, and a colposcopic and forensic exam depending on the age of the child, the type of sexual abuse, and how long ago it occurred. For the child with “failure to

explains to them the laws about mandated reporting and the need to put the child’s safety first when uncertainty about the circumstances of an injury occurs. When the time is right, caregivers can be informed of the need Those making reports to make a report to in good faith are legally CPS using some variant of the following: “Ms. immune from criminal Johnson, I want to and civil liability. thank you for all your patience this afternoon—I know it has been a long day for you and that rule out significant medical you have been really concerned etiologies at the same time the about Jenny. I’m concerned, physician initiates close montoo. As you know, we discovitoring of feeding practices ered that she has a broken arm. of the child, including calorie Unfortunately, we don’t know counts. how this happened, and when The latter workup can occur in an outpatient setting but may I see an injury like this in a child her age, one of the possirequire inpatient admission for bilities is that someone might management. In these cases, it have caused this injury to her. is the cooperation and concern of the caregiver and their ability Because of this, I’m required to make a report to Child Protecto follow up with medical rective Services so that together we ommendations that determines can do our best to make sure whether neglect is present. she is safe. I know you want the thrive,” most often the causes are multifactorial. A careful history and physical exam, examination of growth charts, and diagnostic testing can help

best for her; so do I. And, I’m going to do my best to help you and Jenny through this situation.” The caregiver then should be told what to expect from the CPS worker, and that the physician’s role will be to help CPS understand the medical findings and provide any needed medical background or pertinent social information. Using language like the above usually (but not always) sets the stage to allow the physician to maintain an ongoing working relationship with the family. What if the family is not cooperative and wishes to leave immediately with the child? If there is concern that the child is potentially in immediate danger, hospital/clinic security should be called if available and a 911 call placed to police, who can then place a 72-hour police Reporting child maltreatment and abuse to page 38

What options do physicians have if they suspect that abuse and/or neglect may have occurred, but cannot make a definitive determination with the information at hand and do not know whether to file a report? The physician can always call the appropriate social services agency, such as Child Protection Services (CPS), and run the case by a screener for advice— in essence, to find out whether CPS would most likely open a case and to help determine whether the child can safely go home. For situations in which there is concern for serious injury, threatened harm, child abduction, flight, or where the child needs ongoing medical care, the provider can send the child to the nearest emergency room or admit the child to the hospital for treatment and further medical evaluation and testing. How should parents be informed? Many parents, though upset, are able to understand if one February 2015 Minnesota Physician

Workforce shortages in long-term care from cover

nesota won’t be improving anytime soon. While workforce shortages are not unique to the long-term care profession—employers in Minnesota reported 84,700 job vacancies in second quarter 2014—there are some unique challenges facing longterm care that exacerbate the problem. Reasons for the shortage Long-term care providers are experiencing a disproportionate share of worker shortages for a variety of reasons. First, our wage structure is built into rates that are set by the state government. For nursing homes, over 70 percent of their costs are tied to staff wages and benefits. The Medicaid rates they receive to cover these costs are set by state law and are matched by a federal Medicaid payment. In Minnesota, nursing homes cannot charge their privately paying residents

insurance, so health insurance has become an important factor in recruiting and retaining employees. The competition for direct-care workers and professional nursing staff continues to grow as long-term care is delivered today in a variety of ways and in a variety of settings, including family homes and residential settings. As more consumers choose home settings or smaller In some quadrants of the settings to receive long-term care, it state there are no available means that more long-term care workers. trained staff will be needed to meet their needs in a employers don’t offer affordable larger number of settings. The efficiencies of staffing for larger health insurance benefit opnumbers in a congregate setting tions to their employees. With are lost, and the competition for the health insurance mandates workers increases. under the Affordable Care Act (ACA), employers are required to provide health insurance for The scope of the shortage their employees or pay a penalSo, what is the scope of longty. The ACA also requires that term care workforce shortagindividual citizens carry health es? In 2013, the total vacant full-time equivalent (FTE) of direct-care positions (nursing staff, certified nursing assistants, and trained medication aides) exceeded 1,800 in Minnesota for nursing homes alone. Staff shortages vary by position and geographic location in the state. For example, the nursing home registered nurse vacancy rate is highest in the northwestern part of the state at nearly 11 percent; the nursing home nursing assistant vacancy rate is highest in the northeastern part of the state at nearly 14 percent. any more for services than they charge those on Medicaid. Years of state and federal budget stresses mean that these rates don’t cover rising labor costs. The gap between the rates of the primary payer, Minnesota’s Medicaid program, and the costs in nursing facilities is over $30 per day. Due to budget stresses, many long-term care

Historically, worker shortages in long-term care were limited to professional nurses or nursing assistants. Today’s worker shortage encompasses all types of positions, including nurses, dietary aides, and housekeeping. In 2013, there was a statewide 45 percent turnover rate of dietary aides, with the highest turnover rate of 70 percent occurring in northeastern Minnesota. With the state job vacancy rate reaching a 13-year high, we are competing for workers along with manufacturing companies and retail establishments, not

Minnesota Physician February 2015

just other health care providers. Response to the shortage What happens when long-term care providers face a worker shortage? The response to the current worker crisis has been varied, depending on the geographic area of Minnesota. In some quadrants of the state there are no available long-term care workers, so some providers are bringing people in from other communities and housing them in temporary settings. Other long-term care settings— nursing homes in particular— are placing holds on admissions due to the shortages despite the fact that they have vacant beds. This means not being able to place frail elderly patients in nursing homes in or near their community so they often end up quite a distance from friends and family. Staff is working extra hours and double shifts and we are concerned about burnout. We know that there is an increasing emphasis on the recruitment of new Americans (immigrants), working in collaboration with the International Institute of Minnesota’s Medical Career Advancement program. These new American workers often need additional training, as many are not proficient enough in English to pass the certification tests. The International Institute provides additional training in English proficiency, test-taking, and enhanced clinical practice to aide these workers in passing their certification and licensure examinations. Barriers to recruiting and retaining staff Because of the limitations to the wages and benefits that long-term care providers can offer to prospective employees due to limited government-set rates, it is difficult to compete with other employers to fill the entry level positions we have open. It is not uncommon for our direct-care workers to leave our employ when a new business opens in the area and offers higher wages and full benefits. When it comes to hiring professional nurses,

scheduling and staffing difficulties. Prior to these regulations, long-term care providers would actively recruit younger workers on a part-time basis as a way to get them interested in working in this specialized profession. These young workers often would There is an increasing stay and work their way up the career ladder emphasis on the from nursing assistant recruitment of new to professional nurse. Americans (immigrants). Since so many of the residents in nursing homes require the use of mechanical lifts for even per year on average working the most basic transfers, some in a hospital than they could nursing homes have chosen not in a nursing home, or $32,053 to actively recruit high school more per year working in a students because of the schedhospital compared to working uling challenges in making sure for a home care agency. Certithere were enough “matches” of fied nursing assistants earn on employees under and over the average $5.42 more per hour or age of 18 to work the lifts. As a $11,274 more per year workresult, we now have far fewer ing in a hospital compared to young workers entering our long-term care settings. Clearly, wages aren’t the only factor that facilities to work on a short- or long-term basis. prevents workers from staying at long-term care jobs, but when the wage gap is so significant it Conclusion is an undeniable and significant We know we are merely at the barrier. beginning stages of a workforce crisis in the long-term care Demographics alone can be profession. We have tried to a significant barrier to finding address some of our vacancies people to work in long-term directly by asking the Legislacare. When we look at the averture for rate increases specifage age in certain rural counically tied to wage increases. ties in Minnesota, the out-miUnfortunately, employers in gration of 25- to 50-year-olds other industries have followed far exceeds any in-migration. suit and increased their wage As a result, there are counties structures in order to fill their in the state, especially in the vacant positions. Staffing for central and west-central part long-term care always has been of Minnesota, that simply don’t easiest during recessions—we have enough workers to fill any had very few vacant staff posipositions, not just long-term tions in long-term care during care. the most recent recession, but There also are smaller barwe are not giving up. riers that have appeared in reThere are several things that sponse to regulatory changes at the long-term care profession the state and federal level. Sevbelieves will help reduce the eral years ago, the federal Deworkforce crisis that we are partment of Labor issued new experiencing now and in the Occupational Safety & Health future: Administration regulations that placed limitations on how 16• We have requested that the and 17-year-olds could operate state’s health insurance mechanical patient lifts in longexchange consider waivterm care settings. The new ing employer penalties regulation requires that employin situations where our ees under the age of 18 only can workers are eligible for the assist staff members who are 18 basic health plan under or older when using a mechanthe state’s health insurance ical lift. This regulation causes exchange. Tax penalties the largest barrier for us is the wage gap that exists between average salaries for nursing staff in hospitals versus nursing homes or home care. In 2012, RNs could earn $35,880 more

apply when employers don’t provide affordable health care coverage. (MNsure’s response is still pending.) • We will be proposing a new payment system to the 2015 Legislature that would allow nursing homes to have competitive staff wages and benefits. This proposal includes paying for the costs of staff wages and benefits within certain caps. • We are expanding our partnerships with higher education to entice more young workers into health care professions, and specifically into long-term care. • We are investigating the various targeted resources and programs within the state’s Department of Employment and Economic Development and the state’s Workforce Centers to make aging services

careers a high priority. • We are proposing enhancements to the current Minnesota Nursing Facility Employee Scholarship Program to expand the program’s reach to more positions and career ladders. We know how important staff retention and consistent staffing are to the provision of quality long-term care services. We are committed to finding solutions that will not only ease the current workforce shortage in long-term care, but that also will provide us with a stable workforce on a long-term basis.

Patti Cullen, MA, is the president/ CEO of Care Providers of Minnesota, which is a long-term care association with nearly 800 members and is the Minnesota affiliate of the American Health Care Association/National Center for Assisted Living. Ms. Cullen is a Certified Association Executive.

February 2015 Minnesota Physician

PUBLIC HEALTH

sthma is a relatively common condition in Minnesota, impacting an estimated 7.1 percent of children and 7.7 percent of adults across the state. These rates are lower than the national average; however, there are notable disparities in asthma prevalence across the state. According to data from the 2013 Minnesota Student Survey, Native American and Black/African American middle and high school students are more likely than their peers to report having an asthma diagnosis. And 2013 data from the Minnesota Behavioral Risk Factor Surveillance System indicate that the prevalence of asthma is nearly two times higher among Black/ African American adults than Caucasian adults. According to the Centers for Disease Control and Prevention (CDC), 9.3 percent of children and 8.0 percent of adults in the U.S. currently have asthma. For reasons that remain unclear, the prevalence of asthma rose

Guidelines for managing asthma Addressing disparities in morbidity By Wendy Brunner, MS, PhD, and Pamela Van Zyl York, MPH, PhD, RD, LN

dramatically between 1980 and the mid-1990s when the proportion of children with asthma more than doubled. Since then,

Asthma morbidity and mortality are largely preventable. asthma prevalence has continued to rise, though at a slower pace. In addition to the direct impact on the health of individuals with asthma, the monetary costs of asthma are high. An analysis by the CDC shows that

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in Minnesota in 2010, asthma cost an estimated $544 million in direct medical expenses and $62 million in indirect costs

Minnesota Physician February 2015

of missed school and work, including work days missed by parents taking care of their children with asthma. Disparities in asthma morbidity and mortality There are striking disparities in asthma morbidity in Minnesota. In 2011, age-adjusted asthma hospitalization rates among children living in the Twin Cities metropolitan area were 50 percent higher than for children living in Greater Minnesota (see the figure on page 15). Within the city of Minneapolis, rates of asthma hospitalizations among children in the ZIP codes 55404 and 55411 for 2007–2011 were four times higher than the statewide rate for children for the same time period. As asthma is a multifactorial disease, there are a range of possible explanations for these disparities in asthma morbidity. It may be that the prevalence of asthma is higher in these areas, increasing the number of people at risk for exacerbations that can lead to emergency department (ED) visits and hospitalizations. It also is possible that these disparities are indicators of differential exposures to risk factors for asthma exacerbations. In general, these risk factors include poor medical management and exposure to asthma triggers such as air pollution, secondhand smoke, respiratory infections, pollen,

and work-related chemical or dust exposures. These risk factors also include what are sometimes referred to as “upstream factors” that are associated with poor asthma control such as poverty, lack of health insurance, poor housing quality, and living near a busy road. Lack of transportation or the inability to take time off from work may also be barriers to accessing primary care. Rates of asthma hospitalizations for adults age 18 and older in Minnesota are 3.4 times higher in low-income communities than in high-income communities, according to an analysis by the Agency for Healthcare Research and Quality (AHRQ). The Minnesota Department of Health (MDH) has produced interactive maps showing rates of asthma hospitalizations and ED visits for children and adults by ZIP code for the seven-county Twin Cities metropolitan area and by county. These maps are located on the Minnesota Public Health Data Access portal (https://apps. health.state.mn.us/mndata/ asthmazip_map). Asthma exacerbations can be fatal. In 2012, there were a total of 71 asthma deaths in Minnesota; 42 of these were among individuals age 65 or older. Asthma death rates fell dramatically between 1999 and 2006, but have increased to a smaller degree since then. As with asthma prevalence and morbidity, there are striking disparities in asthma mortality in Minnesota. According to an analysis of data from the Minnesota Center for Health Statistics for 2004–2011, Blacks/ African Americans were nearly four times more likely to die from asthma than Caucasians. Optimal Asthma Care measure As part of Health Care Reform legislation in 2008, Minnesota adopted a number of standardized health-care quality measures including an Optimal Asthma Care measure. This measure has been defined as the percentage of patients ages 5 to 50 having asthma controlled (as measured by a

standardized control test), no elevated risk of exacerbation (fewer than two ED visits or hospitalizations in the past year), and asthma self-management education in the form of a written asthma action plan. Forty-nine percent of child and 40 percent of adult asthma patients in Minnesota met the criteria for Optimal Asthma Care in 2013. However, there are significant differences in care by payer. As reported in MN Community Measurement’s 2013 Health Care Disparities Report, the Optimal Asthma Care score for adults ages 18 to 50 enrolled in Minnesota Health Care Programs (Medical Assistance and MinnesotaCare) was 31.4 percent compared to 45.2 percent for enrollees in commercial managed care programs. For children ages 5 to 17, the average Optimal Asthma Care score for Minnesota Health Care Program enrollees was 42.8 percent compared to 53.7 percent for other payers. Both are statistically significant differences at p<0.05. According to a January 2014 University of Minnesota evaluation of health care homes (HCH) (also known as medical homes), HCH-certified clinics in Minnesota had significantly higher rates of optimal asthma care than those non-HCH clinics (42.3 percent vs. 23.2 percent). Asthma management Controlling asthma requires a multifaceted approach focusing on patient behaviors; home, work, and school environments; knowledge and skills of health care providers; and public health programs and policies that influence asthma management and self-management practices. The National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute (NHLBI) convened three expert panels to initially prepare and then update guidelines for the diagnosis and management of asthma. A common organizing principle across the three reports has been the definition of the four components of effective asthma management.

Age-adjusted asthma hospitalization rates by age group and region, Minnesota  Twin Cities metro children G reater MN children  Twin Cities metro adults G reater MN adults

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Source: M innesota Department of Health Asthma Program using data from the Minnesota Hospital Association and U.S. Census

• Component 1: Assessment and Monitoring. Diagnose and assess the characteristics and severity of asthma and monitor whether asthma control is achieved and maintained. • Component 2: Education. Build a solid partnership for effective asthma self-management education among the patient, family/caregiver, and health care provider.

patient self-management, regular follow-up visits with a primary care provider, and control of environmental triggers that worsen the patient’s asthma. Our current understanding of asthma is that it is a multifactorial disease that is associated with genetic, infectious, allergenic, socioeconomic, psychosocial, and environmental factors. How these factors

interact to cause asthma is not completely understood. However, we know that asthma morbidity and mortality are largely preventable. With improved patient education that promotes self-management, appropriate medical management, and with public policies that support people who have asthma, the impact of asthma Guidelines for managing asthma to page 32

• Component 3: Environmental Control. Implement multifaceted strategies to control environmental factors and treat comorbid conditions that affect asthma. • Component 4: Pharmacologic Therapy. Select the appropriate medications and review the patient’s technique and adherence to meet the patient’s needs and circumstances. The third and most recent report is the Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3). You can access this report at NIH Publications Number 08-5846, April 2008 (www.nhlbi.nih.gov). The NAEPP EPR-3 Guidelines are the nation’s gold standard for asthma care and management and identify critical measures that have the greatest impact on asthma care and patient health. These critical measures include the use of inhaled corticosteroids to control asthma, the use of a written action plan to guide February 2015 Minnesota Physician

Professional Update : Behavioral health

“Integration is in response to the fragmentation of health care. As individuals we are not fragmented, we are whole people. The current health care system does not recognize this. Integration is trying to fix a big problem, which is that we have two separate systems that take care of our health. Integration is a game changer for health care.” Benjamin Miller, PsyD, A Family Guide: Integrating Mental Health and Pediatric Primary Care

G N I ! EN OP CERT N CO

Integrating behavioral services Challenges and benefits By Richard Sethre, PsyD, LP, and John E. Simon, MD

ehavioral health (BH) services are part of general medical services, but typically function in parallel, or even separately, from the rest of the medical field. There are many reasons for this, but there also are many benefits when integrating care. While integrating care may be challenging for professionals, it would provide significant benefits to patients with behavioral concerns—and professionals are likely to benefit as well.

specialists, and other BH professionals appear to have a lot in common, they traditionally have not excelled at coordinating care with each other. There are several possible reasons for this.

Care integration between behavioral professionals Even though psychiatrists, psychologists, chemical health

Psychiatrists tend to come from training programs with relatively uniform training standards, while psychother-

There is a long-standing, significant shortage of psychiatrists. As a result, psychiatrists are extremely busy, and are likely to view coordination of care with psychotherapists as a lower priority than their many other pressing tasks.

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apists (psychologists [LP], marriage and family therapists [LMFT], social workers [LICSW], and mental health counselors [LPC and LPCC]) come from very diverse training programs, with a wide range in the quality of training standards, and little, or no, training in coordination of care. Psychiatric training programs routinely emphasize the importance of coordinating care with other medical professionals, but coordination often does not include psychotherapists. While many psychotherapy training programs now teach the benefits of coordination of care, the current ranks of psychotherapists include several generations for whom coordination of care is either a low priority or not part of their routine practice. In general, only recent graduates have had training that emphasizes the importance of coordinating care.

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Minnesota Physician February 2015

Since behavioral services often involve highly personal problems, many BH providers are highly sensitive to patient concerns about sharing personal information with others “outside” of the therapeutic relationship. Rather than categorically not sharing information, and therefore not coordinating care, the current thinking is that it is possible to work collaboratively with the patient to carefully select which information can be shared. This is a relatively new process that has not yet been adopted by many behavioral professionals. How the patient benefits There is an evolving understanding of how behavioral patients benefit from the coordination of care between psychiatrists, psychotherapists, and other BH specialists. Considerable research shows that medication can help behavioral patients, especially those with more severe and disruptive

symptoms. Medication can have a wide range of effects, from simply making the patient more comfortable to reducing severe symptoms. Some patients even find that medication provides a cure for their behavioral problems (as long as care continues). For those patients in therapy who need medication, their

and these patients often benefit from adding psychotherapy to their treatment plan. For some behavioral conditions the combination of medication and psychotherapy has been established to be more effective than medication alone, sometimes providing faster, broader, or more durable benefits.

Most people with behavioral problems … initially seek treatment from their PCP. psychotherapists must routinely coordinate services with the patient’s psychiatrist or other prescriber. A recent and emerging body of research supports the benefits of psychotherapy services for most patients with behavioral problems, including both psychiatric and substance use issues. For example, behavioral patients who have received only medication may continue to have behavioral symptoms,

Psychotherapists typically have more time to spend with their patients than psychiatrists, and that enables them to develop a higher level of rapport, obtain more detailed information, and evoke questions and concerns that the patient has about their behavioral treatment plan. Psychotherapists have specialized training and skills that enable them to provide illness education and address behavioral treatment

compliance concerns. Psychotherapists also may be the first professionals to recognize the patient’s response to medication therapy, by identifying side effects as well as benefits. It is in the patient’s best interest for psychiatrists to routinely discuss the potential benefits of seeing a psychotherapist, and to coordinate services with psychotherapists and substance abuse colleagues. In addition, psychiatrists with full schedules could potentially partner with behavioral colleagues who could see new patients while they wait for the intake appointment with their psychiatrist. This could help with a patient’s comfort and initiate the treatment process more promptly by providing psychotherapy, education, and support to the patient and their family. Overall, both groups of BH Integrating behavioral services to page 18

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Integrating behavioral services from page 17

setting. Research tells us that about a third of the patients seen in the typical PCP office will meet the criteria for a behavioral disorder. In addition, another third will have behavioral symptoms even if they do not meet the criteria for a specific disorder. Unfortunately, re-

professionals would benefit from exchanging information about their shared patients. Each professional has a unique understanding about patients based on their training and treatment orientation, and likely will have gaps that may be filled in by a professional from a different behavioral specialty.

About a third of the patients seen in the typical PCP office will meet the criteria for a behavioral disorder.

Integrating primary care physicians into BH care Primary care physicians (PCPs) provide a sustained partnership with patients and families that is often the gateway to BH services. Most people with behavioral problems, including psychiatric disorders, substance use disorders, and health behavior problems initially seek treatment from their PCP. Patients may feel more comfortable in a primary care setting due to the stigma associated with seeking care in a BH care

search also tells us that PCPs, for various reasons, tend to not diagnose co-occurring behavioral conditions adequately. They typically provide behavioral diagnoses for less than one third of their patients with behavioral needs. Many patients with chronic medical conditions have more behavioral symptoms than the average patient, such as un-

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There are several possible factors that may contribute to coordination of care challenges

Minnesota Physician February 2015

for PCPs and BH specialists. Medical, or “physical,” health care professionals and BH professionals historically have had separate training tracks, often with little or no opportunity to work collaboratively during their professionally formative years. While psychiatrists probably make reaching out to their patients’ PCPs part of their standard practice, most psy-

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chotherapists probably do not do this. Their reasons for this range from, “Psychotherapy is too personal to discuss with outsiders,” to “Family doctors don’t want to be bothered with information from nonmedical providers.” When PCPs have a patient receiving BH treatment they often describe the behavioral component as a “black box.” They know that their patient is receiving some sort of treatment, but do not have access to the details. In addition, PCPs have historically been trained using the biomedical model, which focuses on biological explanations for diseases. This model historically has viewed nonbiological factors as relatively unimportant, or even irrelevant. This model has promoted a mind/ body distinction that results in more attention to biological factors, and less attention to “mental” or behavioral factors. Another challenge to coordi-

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nation of care comes from the typical office schedule for PCPs, who have intense demands and expectations to manage during their typical office day. In an ideal world, a PCP who becomes aware that a patient also is seeing a BH professional would take the time to discuss the benefits of coordinating care. The PCP would obtain a release authorizing coordination of care, would use the release to reach out to the BH colleague, and maybe even bird-dog the situation to make sure that they obtain a response from the colleague. Obviously, this is just not practical for the average PCP, who probably already feels overwhelmed by daily tasks. What needs to be done? It is clear that the U.S. health care system is undergoing historic structural changes. There are powerful factors that now promote, among many major changes, the importance of

primary care services and, in particular, the benefits of integrating behavioral services with medical services. At the local level, the Minnesota Department of Human Services (DHS) is promoting coordination of care between PCP and BH providers. In the past, DHS had a benefit that covered psychiatric consultations provided to primary care physicians. According to DHS staff, no psychiatrists ever billed for this service, so obviously it was not being provided to primary care physicians even though it was a potentially helpful service. DHS recently expanded this benefit to cover consultations to PCPs by licensed psychologists, as long as the psychologist works within the scope of his or her license. This benefit may significantly expand opportunities for formal, structured coordination of care by direct consultation. At a national level, the

Patient Protection and Affordable Care Act (ACA) has several provisions that promote and support the integration of primary and behavioral care, such as establishing accountable care organizations and patient-centered medical homes. These provisions likely are to include “pay for performance” measures that will reward integrated services that improve treatment outcomes. Many of these measures have behavioral components, such as improving treatment compliance. In the future, PCPs are likely to benefit from close partnerships with BH specialists who can help them with their “numbers.” The value of PCP services relies on providing optimally comprehensive care, which is the most effective treatment approach for caring for patients with chronic medical problems, many acute disorders, and patients in need of preventive services. Medical outcomes

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A M AND C

E BAS

research has clearly established that comprehensive, coordinated care provides higher quality care and results in better treatment outcomes. Optimal coordination of care will clearly benefit the people who matter the most, the patients. In addition, it will help PCPs with many of their most complex, challenging, and time-consuming patients. It also will help BH professionals by increasing treatment resources for the biological factors, such as mood, energy, appetite, and sleep disturbances that often are part of the patient’s treatment needs. Richard Sethre, PsyD, LP, has a general practice in psychology in Golden Valley, with a special interest in coordinating care with PCPs, pre-surgery assessments for bariatric patients, and BH consultations on general medical units at Fairview Ridges Hospital. John E. Simon, MD, is board-certified in psychiatry and practices geriatric and addiction psychiatry in Minneapolis and Litchfield, Minn.

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612-333-6669 February 2015 Minnesota Physician

Special Focus: Complementary and Allied Providers

fficially established less than 100 years ago, respiratory care is not as well recognized as other medical fields. During the early years, respiratory therapists were called oxygen technicians and later, inhalation therapists. These respiratory front-runners were typically trained on the job before short training programs were developed in the late 1940s to 1950s. As the profession progressed through the 1960s and 1970s, two-year associate programs were introduced, becoming the primary educational institutions to this day. These were followed in the 1980s by a small number of four-year baccalaureate programs. Today’s respiratory therapists (RT) may even hold advanced master’s or doctoral degrees. While the original oxygen technicians were mostly focused on the movement of oxygen tanks and oxygen delivery, today’s RTs have ever-increasing

Respiratory therapists A progressive role in patient care By Derek Hustvet, RRT-NPS, LRT roles throughout the medical field. The table on page 36 shows long-standing credentials such as certified respiratory therapist (CRT) and registered respiratory therapist (RRT), along with much newer credentials such

The role of RTs in hospitals Hospitals remain the largest employer of RTs, and hospital RTs carry out the greatest variety of duties/roles. They are seen on general care floors, where they provide patient

Respiratory therapists work as the physician’s eyes and ears in a patient’s home. as the sleep disorders specialty (SDS) and the adult critical care specialty (ACCS). It is important to note that an individual may hold many credentials and can be included on the chart in

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Minnesota Physician February 2015

assessments, oxygen delivery, inhaled medications, airway clearance treatments, and patient education. Hospital RTs also are members of critical areas, such as emergency rooms and intensive care units, where they may be responsible for ventilator support, hemodynamic monitoring, airway management, assisting with bronchoscopies, and collection/analysis of patient data and specimens. RTs often are part of diagnostic or research groups, through which they identify and treat sleep disorders; direct and administer pulmonary function testing; or assist with cardiac stress testing. They also can be found working in operating rooms or on air-ground transports, running extracorporeal membrane oxygenation (ECMO) machines, as well as working with pulmonary or cardiac rehabilitation groups. The role of RTs in DME/home care companies Durable medical equipment (DME)/home care companies likely are the next largest employer of RTs. Patients are frequently discharged from hospitals while still requiring medical interventions. These interventions range from basic nebulized medications to full

ventilator support. Therapists working in this realm must have not only strong clinical skills, but also be adept educators and coaches. As care transitions from the structured and controlled environment of the hospital to a home setting, which is as varied as each individual patient, these RTs also must be flexible in their approach and dedicated to addressing all types of environmental and social issues. Other RT employers and roles include specialty clinics, such as those specializing in cystic fibrosis; research facilities; sales; medical device manufacturers; and equipment/ supply development. The role of home care RTs in assisting physicians In the hospital, RTs are a known resource to physicians, often consulting on patient assessments, treatment plans, and interpreting test results. But, DME/home care RTs also can be a resource to physicians treating outpatients by offering technical information on the ever-changing technology used both in and out of the hospital, especially drawing attention to the differences between seemingly similar hospital and home medical devices. Respiratory therapists work as the physician’s eyes and ears in a patient’s home, relaying environmental factors that may impact a patient’s outcome and identifying changes in a patient’s baseline appearance, oxygenation, end-tidal carbon dioxide readings, etc., as they routinely follow patients over extended periods. Advance notification of clinical changes by an RT may allow the physician to evaluate and treat a patient sooner than waiting for a patient to schedule a follow-up appointment, possibly preventing hospitalization. DME/home care RTs often have access to equipment and compliance information, such as hours of use that can be

helpful in explaining declines in patient condition or recurrent pneumonias/infections. With a therapist in the home on a routine basis, a physician may feel more comfortable managing a patient at home rather than in a hospital, allowing for an earlier discharge or preventing initial hospitalization altogether. DME/home care RTs often are well versed in regulatory and payer limitations unique to home care, as well as health and community services that can vary county to county. Perhaps the biggest benefit a physician may see from having a therapist involved at home with patient care is during the time surrounding the initial discharge of a patient from the hospital. DME/home care RTs pick up the role of the hospital RTs, reinforcing the training provided in the hospital and adding education that is specific to home care. While reports of patient/caregiver training re-

tention vary even in the best of circumstances, patients will not retain 100 percent of what has been presented to them. With this is mind, continued education is imperative to ensuring a safe care plan in the home setting. In addition, many patients and caregivers who have no medical background are stressed about a new diagnosis or financial issues related to treatment. Other factors to consider are language barriers or even learning disabilities that may further reduce a patientâ&#x20AC;&#x2122;s ability to remember information. Experienced therapists will continually ask for return demonstrations and re-educate new patients and caregivers at each visit using basic language, pictures, and interpreters until they are comfortable that all aspects of care are understood. The ultimate goals are to achieve optimal patient outcomes, ensure patient safety,

ded. The American Association for Respiratory Care (AARC) has taken steps to address this issue with House Bill H.R. 2619, which is the Medicare Respiratory Therapist Access Act. If passed, Medicare would recognize and reimburse RTs who hold a minimum of a bachelorâ&#x20AC;&#x2122;s degree or other advanced degree in a health science field and are credentialed as a registered respiratory therapist (RRT). Medicare would not reimburse RTs who do not meet

and decrease health-related expenses such as hospital readmissions. Challenges facing the RT profession Just as the current and potential roles of RTs are vast and varied, so too are the challenges that face the profession. One challenge is the lack of payment/reimbursement for RT services. While Medicare recognizes other nonphysician practitioners, such as occupational therapists or physical therapists, RTs are not inclu-

Respiratory therapists to page 36

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February 2015 Minnesota Physician

Special Focus: Complementary and allied providers

s we discover more about the complex nature and mechanism of pain, the treatment for chronic pain has been evolving as well. It is now well established that the best approach to treating chronic pain is a multidisciplinary approach. Treating pain with medication alone has been shown to have poor outcomes in the chronic pain populations. While it was not always the case, physical therapy now plays an integral role in the treatment of chronic pain. However, in many patients, psychological barriers may interfere with their recovery in even the most comprehensive rehabilitation programs. Anger, anxiety, depression, fear, resentment, and other psychological factors can prevent individuals with chronic pain from optimally responding to rehabilitation. For example, a patient who is injured at work has to recover from physical injuries, and also conquer the fear of re-injury prior to a successful return to work. To get the best

Cognitive behavioral coaching A multidisciplinary approach to treating chronic pain By Deborah Friedman, MD, FAAPMR results, it is important to find a way to treat the physical injuries and the psychological barriers concurrently.

Treating pain with medication alone has been shown to have poor outcomes. Cognitive behavioral coaching Physicians’ Diagnostics & Rehabilitation (PDR), a practice specializing in the treatment of individuals suffering from chronic neck and low back pain, initiated a cognitive behavi-

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oral coaching (CBC) program at the end of 2012. After treating patients with chronic spine pain for approximately 20 years, they realized that the psycho-

logical barriers were not always optimally addressed. The CBC program includes a series of six group sessions in which a licensed clinical social worker leads participants in performing cognitive behavioral therapy (CBT). CBT allows the staff to provide more comprehensive care to their patients. CBT is a psychotherapeutic approach that addresses dysfunctional emotions and maladaptive behaviors through goal-oriented techniques. There has been significant research done on the effectiveness of CBT for chronic pain. In 2007, Benson Hoffman, PhD, of Duke University School of Medicine, along with other researchers, performed a meta-analysis of 22 articles on the psychological interventions for chronic low back pain, which was published in Health Psychology. The results demonstrated the positive effects of psychological interventions for chronic lower back pain. A study by Sarah Lamb and other researchers at the University of Warwick, U.K., published in The Lancet in 2010, found that group cognitive behavioral therapy was both effective in reducing low back pain and cost-effective compared to other interventions. PDR’s CBC program is an attempt to apply CBT techniques during everyday patient encounters without assigning a psychological diagnosis. The

Minnesota Physician February 2015

MN Physician - Mar 15.indd 2

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CBC classes are available at no additional cost. CBC is a flexible program that patients can begin at any point during the series. Individuals do not have to attend the entire course; in fact, some patients select the classes with topics that are most interesting or relevant to them. Identifying limiting factors Each patient with neck or low back pain who enters the rehabilitation program completes the Keele STarT Back Screening Tool, a questionnaire developed at Keele University, U.K., that identifies patients’ psychological limiting factors and categorizes patients based on the risk of psychological barriers hindering their physical rehabilitation. Physicians review patients’ Keele STarT Back results and recommend CBC if results indicate that patients would benefit from the educational support groups. Results from the Keele STarT Back rehabilitation participants in 2013 indicated that 45.6 percent of patients were at low risk, 31.2 percent were at medium risk, and 23.1 percent were at high risk. Sarah Nevin, MSW, LICSW, clinical social worker at PDR, facilitates the CBC groups. The six classes are: • Class 1. Automatic Thoughts and Self-Talk: Patients are helped to identify the first, often inaccurate or psychologically harmful thoughts they have when they feel emotionally vulnerable. This session also focuses on how and why patients interpret the statements or actions of others. • Class 2. Restructuring Your Thought Process: Participants are taught ways to change their thoughts and interpretations. • Class 3. Stress Management and Understanding Chronic Stress: This class focuses on developing strategies for coping with persistent pain, which can contribute to chronic stress. • Class 4. Increasing Ways to Close the Gates to Pain: Drawing on the gate control theory of pain, patients

are encouraged to identify positive actions or thoughts that shift the mind away from fixating on physical and emotional pain. • Class 5. Increasing Positive Experiences and Emotions: “What can you do today that will make you feel 5 percent, 10 percent, or 15 percent better?” is a question asked of participants in this session. • Class 6. Acceptance, Willingness and Being Effective: Patients are shown how to accept that chronic pain is part of their lives but that it should not define them. Unfortunately, not all patients with psychological factors affecting pain are able to attend these classes. The time and location of the classes do not always work for each patient. Also, some patients have a difficult time accepting that there may be other factors associated with their pain. There often is a stigma associated with seeking help for mental health. Patients do not like to be made to feel that their symptoms are “in their head.” Careful explanation of the complicated nature of pain can be helpful. Despite that, some patients still choose not to attend. For these patients, physicians and therapists have chosen to modify their practice to incorporate CBC into their therapy visits and even their doctor visits so patients still benefit despite not taking the classes. Understanding the patients’ role In January 2013, every member of the practice attended a CBC two-day course led by Sarah Nevin. They went through each of the classes and considered the issues from the patient perspective as well as from the perspective of the treatment team. Since then, the culture of the practice has changed. Helping patients reach conclusions on their own, instead of telling them what to do, has become the goal. Active listening, patience, and collaboration play a role. There is a focus on patients’ acceptance of the physical

aspects of their condition, while guiding them toward decisions that can help them take back control of their lives. Since the start of these initiatives, the physicians and therapists have seen a reduction in Keele STarT Back scores in patients that attend the classes and also those who do not. Data collected from January 2013 through June 2014 reveal significant improvement of Keele STarT Back scores at completion of the spinal rehabilitation program compared to initial scores. Of those who attended the classes and scored in the “high risk” or “medium risk” categories, 64.5 percent scored in the “low risk” category upon completion of the program. Interestingly, of those who did not attend classes and also initially scored in the “high risk” or “medium risk” categories, 75.3 percent scored in the “low risk” category upon completion of the program. This improvement is more significant in those patients that did not attend the classes (although they likely received coaching throughout the program in their interactions with the therapists and physicians). It should be noted that patients with more significant psychological barriers to therapy often are those most encouraged to attend the classes. The classes often are filled with the most challenging rehabilitation patients. Keele STarT Back scores also can be elevated initially with patients in significant acute pain or distress. This may not be associated with significant psychological barriers, and may only reflect the mental state they are in on that particular day while in significant pain. In these patients, as their pain improves through therapy, their outlook improves as well. These patients may not need cognitive behavioral coaching to the same degree as patients with true psychological barriers. These patients can generally be distinguished during the initial evaluation with the physician. CBC helps patients suffering from chronic pain problem solve, establish goals, and gradually regain control of their

lives. This helps the patient shift from “pain-focus” to “function-focus.” Reducing a patient’s focus on pain helps him or her return to activities, work, and prior level of function. Tackling the mental aspect of pain is the key to achieving a more complete recovery through the rehabilitation process. Conclusions The treatment of chronic pain patients has been continuously evolving over the years. Research has shown the benefits of a multidisciplinary approach for

patient management. Comprehensive rehabilitation programs can be an integral part in the care of these patients. Incorporating approaches that tackle both the physical along with the psychological factors of pain is our best chance to help these complex patients achieve long-lasting recoveries and improved quality of life. Deborah Friedman, MD, FAAPMR, is a board-certified physical medicine and rehabilitation physician specializing in spine rehabilitation. She practices at Physicians’ Diagnostics & Rehabilitation.

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“The child’s brain is the most complex ecosystem in the known universe and cannot be understood by reductionistic analysis. We must embrace the whole child as a dynamic and interactive reflection of his/her world.”

Integrative mental health strategies for kids Expanding the clinical toolkit By Timothy Culbert, MD, FAAP actually declined for those with physical disabilities, but for

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children with neurodevelopmental or mental health disabilities it increased by 20.9 percent! The

ates of neurodevelopmental/behavioral/emotional disorders in kids, including ADHD, autism spectrum disorders, anxiety, learning disorders, and depression, continue to rise in the United States. In fact, a 2014 study in Pediatrics that reviewed data from 2001 to 2011 concluded that childhood disability increased from 6.9 percent in 2001 to 7.9 percent in 2011. Childhood disability

reasons for this are complex and multifactorial, and likely include: • O ver-medicalizing common symptoms or misdiagnosis • Changes in DSM diagnostic criteria • Media exposure and parent education • A poor fit for a given child’s behavioral/learning style with his or her educational environment

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• A greater awareness of mental health disorders by health care clinicians in general, particularly primary care providers In addition, the argument exists that children in the last two to three decades have experienced increased exposure to additive biological and psychosocial “toxic stresses” that allow for, or facilitate, the phenotypic expression of an individual’s genetic predisposition for one of these mental health conditions. Many primary care doctors must see children with complex mental health challenges every day, but have less and less time to spend with them due to mounting pressures to be efficient and generate revenue. They may find it easier to prescribe a pill than take the time to counsel parents and patients on behavioral and other nonpharmacological options.

Conventional treatment The two most commonly used conventional tools to address neurodevelopmental or mental health issues have been psychotherapy and treatment with psychoactive medications. Medicines can be very helpful but as Sidney Wolfe, MD, (director of Public Citizen’s Health Research Group) points out, doctors often are far more knowledgeable about the benefits of drugs than they are about the risks that commonly lead to “medical over-optimism” and overprescribing. The rates of prescribing medications for children has at least tripled in the past 15 years with prescriptions for stimulants, antidepressants, and antipsychotics, even for younger children, leading the way. In my practice of developmental/behavioral pediatrics in the Twin Cities for over 25 years, I have found that parents clearly want more holistic treatment options for their children and

routinely ask, “Is there anything we can do instead of just putting our child or teenager on more medications?” They have become well-educated health care consumers on behalf of their kids, using the Internet and other resources as a way to better understand the risk-to-benefit balance of treatments. Parents’ questions and concerns about conventional medical treatments led me to pursue training in a number of unconventional areas. I began by learning about various mind/body skills such as biofeedback and medical hypnosis in the 1980s. I learned more about alternative medicine approaches like yoga, massage, aromatherapy, and meditation in the 1990s. I completed a Bush Fellowship in this area in 1999/2000 and The Kaiser Institute Program For Integrative Medicine in 2001. Recently, I have been training in functional medicine and nutrition. These experiences have led me to understand that there are a variety of safe, evidence-based, non-drug, holistic therapies that can treat children with a variety of behavioral/developmental disorders such as ADHD, autism, depression, and anxiety. This article will provide a brief introduction to some of these promising options.

Blended medicine: the best of both The truth is that parents have been far ahead of pediatric health care providers in trying alternative treatment options for many years. I believe we are obligated to partner with families in making sensible choices that consider all available options, both conventional and so-called “complementary.” We also need to work with patients and families in evaluating the balance of safety, efficacy, and cost for a given treatment option. All the usual tools of Western, allopathic mental health care such as psychotherapy, psychotropic medications, specialized school programs, and rehabilitative therapies such as occupational and speech/language therapy

are still necessary and valuable for many children. However, holistic approaches such as diet/ nutritional changes, supplements, meditation, yoga, biofeedback, expressive arts therapies, biomechanical approaches (such as

massage), acupuncture, exercise, and even new electronic healing technologies and mobile apps can all be helpful. An approach that combines the best of safe, evidence-based therapies from all traditions and that always considers the patient as a whole person, including their mind, body, and spirit is called integrative or holistic. Formal training in integrative medicine now is available in many medical schools, nursing schools, medical residencies, and fellowships. The Twin Cities is a hotbed of activity in integrative medicine training, practice, and research. Work is being done at the Minnesota Holistic Medical Association, The Penny George Institute for Health and Healing, and the Center for Spirituality and Healing at the University of Minnesota. The largest pediatric mental health provider in the region, PrairieCare, is launching a system-wide project to offer integrative options to all of its patients beginning in 2015.

Integrative approaches to mental health “Healing refers to the physical, mental and spiritual processes of recovery, repair and reintegration that increase order, coherence and holism in the individual, group and environment. Healing is not the same as curing.” University of Arizona Integrative Medicine Program, 1996

So what are some of these promising integrative approaches that offer nonpharmacologic benefits? Although the integrative approaches discussed in this article do have research backing them, they don’t yet have dozens of gold-standard studies behind them. The approaches are all very safe and reasonable as treatment alternatives or adjuncts. In addition, we should remember that the research studies on the risks/ benefits of psychiatric medications used in childhood are not perfect either. In fact, studies have called into question the efficacy of antidepressants as compared to placebo treatments, and recent studies also suggest that longterm stimulant use in ADHD may not be consistently beneficial. There also are concerns about the harmful effects that may develop in children’s developing central

nervous systems from long-term use of psychoactive medications. Research bias in published psychiatric studies sponsored by pharmaceutical companies also has been a concern.

Nutrition. Many parents ask about the effects of poor nutrition and behavior and wonder if their child eats too much junk food, particularly carbohydrates and refined sugars. New evidence does suggest that this can negatively affect attention and mood. A plethora of recent studies on the “second brain” located in the GI system suggests GI health and the microbiome (helpful bacteria) have important impacts on emotions and behavior. Key nutritional deficiencies may compromise the brain’s ability to make appropriate levels of neurotransmitters and perform other key neurological functions. Supplementation with therapeutic doses of key vitamins, minerals, and herbals sometimes can offer effective and better-tolerated alternatives to prescription medications (see the sidebar on this page). Diet changes (gluten-free, chemical-free, low-carbohydrate/ low-sugar are some examples) and an approach that involves healing the gastrointestinal tract (including probiotics) also can be very helpful for many kids with mental health challenges. Neurologist David Perlmutter, MD’s best-selling book “Grain Brain,” details some of the key interactions between the GI tract and the central nervous system.

Helpful supplements • Supplements that support healthy brain function: omega-3 fatty acids, B-complex, zinc, magnesium, folate, vitamin D3, probiotics, and prebiotics • Supplements that support depression: 5-HTP, St. John’s wort, rhodiola, S-adenosyl methionine • Supplements that support anxiety: inositol, L-theanine, GABA • Supplements that support sleep: valerian, melatonin, passionflower, lemon balm

Lifestyle activities. Basic lifestyle activities such as time spent in nature, exposure to sunlight, regular vigorous exercise, and certain animal assisted therapies such as hippotherapy (therapeutic horseback riding) can help kids with depression, autism spectrum disorders, and ADHD. Other integrative techniques. Techniques such as massage, acupuncture, and aromatherapy have less research to date for treatment of mental health disorders in children. However, promising adult research studies and expanding clinical experience with hundreds of children over the last several years suggests they can be helpful as well. The respected journal Pediatrics in

Healing technologies Kids love technology and although it is true that the American Academy of Pediatrics warns against the dangers of kids spending too much time using technology, it can be a tool for healing behavioral problems when utilized carefully. Integrative mental health strategies for kids to page 34

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Mindfulness meditation. Studies indicate that mindfulness meditation (also called mindfulness-based stress reduction or MBSR), along with other mind/ body techniques such as yoga and biofeedback, can improve symptoms of depression, anxiety, and ADHD. This method does require regular daily practice for several weeks to achieve benefits. It’s important that these techniques be presented to kids in ways that are developmentally appropriate and engaging. A new group therapy approach for teens with anxiety and depression that includes mindfulness practices, nutritional education, and yoga has been developed in the Twin Cities by Henry Emmons, MD, a pioneering holistic psychiatrist based on his successful adult model called “Resilience Training—Pathways to Joy” (see www.partnersinresilience.com).

Review (published by the American Academy of Pediatrics) has been running an ongoing series of articles on evidence-based use of complementary medicine for several years. Oxford University Press also has an entire series on integrative medicine, including volumes on integrative pediatrics and integrative psychiatry.

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February 2015 Minnesota Physician

POLICY

A long-term plan for long-term care

ndy Rooney, the 60 Minutes commentator, best summed up our greatest health care challenge when he said, “It’s paradoxical that the idea of living a long life appeals to everyone, but the idea of getting old doesn’t appeal to anyone.” Rooney’s comment is quite relevant when considering the aging demographic landscape in Minnesota. Workforce shortages In the year 2020, Minnesota will have more citizens over the age of 65 than it will have children entering kindergarten. In fact, the number of aging Minnesotans needing long-term care is expected to increase annually until the year 2035—a so-called silver tsunami—with the next generation’s workforce paying the bill. Already today, 15 percent of skilled nursing facilities consider closing their doors each year due to inadequate fund-

Addressing the growing crisis By Rep. Joe Schomacker

ing. Last year alone, one out of five Minnesota nursing homes reported turning seniors away due to a lack of staff to meet the demands of an increasingly

“The idea of living a long life appeals to everyone, but the idea of getting old doesn’t appeal to anyone.” Andy Rooney aging population. Minnesota is not alone in this conundrum, as baby boomers continue to age and retire. Each state must deal

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with long-term care issues. But statistics show that Minnesota has a larger elderly population than many other areas of the country.

Minnesota Physician February 2015

Addressing the crisis So how has the Legislature handled this oncoming crisis? Both Democrats and Republicans have done just enough over the years to be able to say they’ve begun addressing long-term care needs. That may work for the suits in St. Paul, but it doesn’t help the workforce in our care centers. I’ve seen the problems firsthand. Long-term care is the top employer in my Minnesota district whose counties border both South Dakota and Iowa. I have heard heart-wrenching stories concerning low reimbursement rates and the difficulty our long-term care facilities have attracting and retaining quality and experienced caregivers. Similar stories are shared with lawmakers from all corners of Minnesota, including the Twin Cities and surrounding metro area. This year, our new Minnesota House leadership has decided to address the long-term care dilemma with a sense of urgency. To this end, we created the Aging & Long-Term Care Policy Committee with the charge of making wholesale improvements to our senior care funding and long-term care

regulation problems. As a simple value statement, aging Minnesotans should receive the care they need to preserve their quality of life as long as possible in a place they can call home. Seniors should be able to live safely and independently as long as they can. Legislative leaders should respond by reforming our system to provide more flexibility and choices as we age. We have a duty to ensure that all aging Minnesotans receive safe and quality care from experienced caregivers, and a responsibility to be a guardian of quality care through funding and a fresh, bottom-up approach to regulations. Finally, we need to do more to encourage partnerships with seniors, their caregivers, and their families. In the past, the Minnesota Legislature has taken the approach of having health care issues debated in health care committees, taxes and estate bills debated in tax committees, and workforce initiatives debated in a jobs committee. No committee has ever had the sole focus of addressing aging and long-term care issues head on. As chairman of the Aging & Long-Term Care Policy Committee I eagerly look forward to working toward generational improvements in long-term care. Goals for reform The committee’s goals include funding reform for the care our senior citizens are receiving. A recent survey indicates that on average, facilities receive reimbursements that are more than $30 per bed per day short of the actual cost of care, which is clearly unsustainable. With the aging demographic shift we face over the next two decades, and the fact that 80 percent of all health care costs come during the final two years of life, we need to adopt a new service plan that ensures that our home health care workers, assisted living facilities, and nursing homes have adequate

reimbursement for the tasks and services they provide. We also need to strengthen the long-term care workforce. Those who take care of our elderly won’t get rich; in fact, they often are underpaid. Most people working in a nursing home do not view it as a career, but take the job either to help their family make ends meet or to use it as a stepping stone before taking another job in the health care field. The demand for long-term care is so great that we must make the profession desirable and worthwhile to those who seek a rewarding career opportunity. Those who plan on utilizing home health care options in the future should have the opportunity to set money aside for this purpose. Many adamantly oppose living in a nursing home, and it’s costly to have health care services provided in their homes. So why not let people plan ahead? Why not allow

them to save and take charge of their lives as they grow older? We should explore health-care savings account funds, or even 401K proceeds to help cover long-term care expenses.

icaid to pay for long-term care. Not only does that drive down more cost-effective solutions, but it also puts the burden on the state of Minnesota to pay for these costs.

In the year 2020, Minnesota will have more citizens over the age of 65 than it will have children entering kindergarten.

People would rather plan their own funeral than plan for their potential long-term care needs. A November 2014 study from the Center for Retirement Research at Boston College found that only 20 percent of Americans can afford and benefit from long-term care insurance and can make it work for them. Insurance will not work as the only solution. Neither will the recent recommendation that people should turn to Med-

The committee’s focus Not only will the Aging & LongTerm Care Policy Committee focus on long-term care solutions, but it will provide the information that all lawmakers need to know. More than $1 billion currently is spent on long-term care in Minnesota each year, and that could grow to $5 billion in the next decade. This means that our state needs to do what it can to help the greatest generation and upcoming baby boom-

ers in a way that’s efficient, effective, and sustainable. And that means lawmakers have to start planning now. When it comes to the impending challenges of elderly care, the Legislature has reflected the same values that Andy Rooney identified years ago. It is time to do what appeals to no one, but is imperative for everyone. Long-term care needs a long-term plan in Minnesota. Rep. Joe Schomacker (R-Luverne) is the chair of the Minnesota House Aging & Long-Term Care Policy Committee. He was recently elected to his third term in the Minnesota House of Representatives. During his time in St. Paul, Schomacker has served on House health and human services committees, as well as the workforce group of the Governor’s Health Care Reform Task Force, the Rural Health Advisory Committee, and the Legislature’s Health Care Workforce Commission. Schomacker is a small-business owner in Luverne.

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February 2015 Minnesota Physician

Practice Management

t goes without saying that patients can’t follow instructions they never receive. Unfortunately, it is just as true that patients can’t follow instructions they don’t understand or simply don’t remember. One way to improve the odds is to send them home with an after-visit summary. We all know that delivering patient-centered care doesn’t end when the 20-minute visit is over. As much as we would like to think that our patients understand what we’re saying and are ready to take the advice given during each appointment, research shows that patients are likely to forget half of what they are told by the time they get home. At Stillwater Medical Group, located in eastern Minnesota and western Wisconsin, our use of the after-visit summary to improve communication with patients is part of our effort to

Taking care beyond the office

communities across America. Together, MNCM and RWJF implemented measures that use questions from the Consumer Assessment of Healthcare Providers and Systems Clinician & Group Surveys (CG-CAHPS) program.

Why after-visit summary instructions work By Andrew Dorwart, MD improve patients’ experience of care, as measured by our patient experience surveys. These surveys allow patients to provide feedback on multiple aspects of their care, from the moment they walk into our offices until the end of the appointment, as well as their experience with office staff before and after appointments. The surveys also look at items such as access to care, whether the office followed up regarding a test result, and how well doctors communicate with patients.

The patient experience survey program Under Minnesota’s 2008 health reform law, all clinics in the state are required to participate in a statewide patient experience survey program. To develop an apples-to-apples comparison of physician clinics, the state partnered with MN Community Measurement (MNCM), which leads the local Aligning Forces for Quality effort. This is the Robert Wood Johnson Foundation’s (RWJF) signature effort to lift the overall quality of health care in 16

Three patients. Who is at risk for diabetes?

Stillwater Medical Group was one of nine medical groups participating in MNCM’s 2008 statewide pilot program to report this data. When we received the survey results, the scores on one particular question surprised and frustrated us: “During your most recent visit, did this doctor give you easy-to-understand instructions about taking care of these health problems or concerns?” We fell disappointingly below the national average. The results were met with skepticism, disbelief, and resistance. Across the group, physicians questioned the statistical significance and validity of

When there are no signs or symptoms, you may not know until it’s too late. Act now. Screen your patients for type 2 diabetes. It’s easy. It’s covered. It will reduce their risk. • Refer your at-risk patients to a proven lifestyle change program and help cut their risk of developing type 2 diabetes in half.

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• For patients who already have diabetes, send them to a quality diabetes self-management program to improve control and reduce complications. Find groups in Minnesota at www.health.mn.gov/diabetes/programs

Minnesota Department of Health DIABETES PROGRAM

Minnesota Physician February 2015

patient experience scores. Not only were the providers upset about their own individual scores, but we also were upset that friends or colleagues didn’t score well either. A universal sentiment surfaced that these survey scores didn’t prove if you were a good doctor or not. I shared this sentiment. While I scored okay in some areas, I consistently earned low ratings on the CG-CAHPS dimension about information and education. No one wants to believe negative results, but I also knew that this is what my patients were saying about me. Some colleagues and I decided that we needed to improve. EHR’s after-visit summary function To begin, I reconsidered how I gave my patients their treatment instructions. I realized it was not working for me to handwrite all of their notes on prescription pages or small

pieces of paper. Instead, I decided to tap into our clinic’s existing technology and use the after-visit summary function on our electronic health records (EHR) system. This feature allows us to print out a report with care instructions that can be given

a difference, I committed to giving a summary to every patient after every visit. Patients were thrilled The results were remarkable. In fact, it completely changed the way I practice medicine today.

When patients come to see me, I now walk them through their Research shows that patients are care instruclikely to forget half of what they tions as I type are told by the time they get home. them into the after-visit summary on to patients to take home. The the computer. I verbalize their report summarizes all of the isinstructions as I’m typing and sues addressed during the visit, then typically repeat them once including test results, medications prescribed, and important more before printing a hard copy. follow-up steps patients need to take. Although it already was part of our system, it was only being used after about 20 percent of all visits, including mine. Still feeling unsure if it would make

In addition to the patient medication and instruction list, I’m able to add patient education information, such as exercises they can do for low back pain. I also can copy and paste lab results into the report,

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so that patients don’t just hear, “Your labs were good,” but they actually get a printout of the items we tested along with the findings. The system also improves efficiency for providers, especially when dealing with common conditions such as upper respiratory infections, diabetes, and asthma, which have preprogrammed after-visit summary instructions so physicians don’t have to type everything freeform. The most important reaction I receive is from patients. Many times each week, patients tell me that they love the reports and how they provide one easy checklist to remind them what to do long after their visit to our office. Often, when patients come back to see me for their next appointment, they bring their previous after-visit summary instructions along with Taking care beyond the office to page 30

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February 2015 Minnesota Physician

Taking care beyond the office from page 29

their medications, and we check everything again. Practice-wide adoption Implementation of the after-visit summaries across the group was still met with skepticism and providers would say, “I don’t need that, it’s just a waste of paper. Patients understand and remember what I’m telling them.” But the truth is, they don’t always. After the initial months of adoption, my colleagues started to notice improvement with my patient experience scores and began considering the idea. I explained to them that even if there aren’t complex, multistep instructions, and the report simply lists patients’ allergies, medications, or vitals from today’s visit, it is valuable information for patients to have. And, it worked. With the implementation

of the after-visit summary tool and focus on patient experience in general, our clinic’s “rate your provider” CG-CAHPS scores increased from 74.2 percent in 2009 to 84.3 percent in the most recent quarter of 2014. Additionally, today, 100 percent of physicians in our practice use the tool and approximately 98 percent of patients receive after-visit summary instructions after each visit. What do you have to lose? For practices considering implementing the tool, my advice is to take heart and not to fear innovation that can improve outcomes. You may be a great communicator, but patients aren’t always going to remember what you say. They might be anxious about hearing test results or they might be new to your practice and haven’t had time to build a long-lasting relationship with you yet. All of these variables can decrease

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Family Medicine • Gastroenterology • General Surgery • Geriatrician • Outpatient Internal Medicine

• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery

• Pediatrics • Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Urgent Care

F O R M O R E I N F O R M AT I O N :

Kari Lenz, Physician Recruitment | karib@acmc.com | (320) 231-6366 www.acmc.com |

Minnesota Physician February 2015

retention, but seeing their diagnosis in black and white can be very powerful and create needed urgency for action to improve health. Beyond the creation of a tangible instruction list, educational guidelines, and medication checklist, using the after-visit summary function of our electronic health records system even served as the catalyst to change the way our group guides patients through the health care system. We improved our clinic’s entire discharge process and created a checkout area where patients can pick up their instructions. Not only did this alleviate providers’ concerns about printing and collecting the instructions for patients, but it also allows us to connect patients to their next point of care. In this area, we have staff who help patients make follow-up appointments or help

coordinate referrals to a specialist if needed. Health care and improving health for patients goes beyond just 20 minutes in the office. With technology, the possibilities for helping patients become more engaged partners in their care are endless. And by communicating with patients in ways that reflect their needs and preferences, we can improve outcomes. For Stillwater Medical Group, we’re looking expectantly toward the future and our next frontier with patient portals, the movement toward electronic after-visit summaries, and robust electronic health records to ensure patient understanding. Andrew Dorwart, MD, is board-certified in internal medicine. He is president of Stillwater Medical Group, medical director at HealthPartners St. Croix Valley, and chief medical officer at Lakeview Health.

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to page 10

Great Opportunities

• Immediate Openings • Casual weekend or evening shift coverage • Set your own hours • Competitive rates • Paid Malpractice

Join the top ranked clinic in the Twin Cities A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:

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We are independent physicianowned and operated primary clinic with three locations in the NW Minneapolis suburbs. Working here you will be part of an award winning team with partnership opportunities in just 2 years. We offer competitive salary and benefits. Please call to learn how you can contribute to our innovative new approaches to improving health care delivery.

Please contact or fax CV to:

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763-504-6600 Fax 763-504-6622

www.NWFPC.com February 2015 Minnesota Physician

Guidelines for managing asthma from page 15

can be greatly ameliorated and people with asthma can lead healthy normal lives. This can be accomplished only through a combination of coordinated public and private efforts. The Minnesota Asthma Program The MDH’s Asthma Program worked with a broad group of stakeholders to develop the first strategic plan to address the health and economic impacts of asthma in Minnesota and provide guidance for our collaborative work in 2001. That plan was updated in 2007 and 2014. The aim of this state plan is to provide a blueprint for collaborative action among those working across the range of health care, public health, and community settings in both private and public sectors. The plan also supports implementing asthma management practices that best align with quality asthma care and quality of life

for people who have asthma.

Asthma home visits

Four goals were identified by the Minnesota Asthma Program and its partners as important areas for action.

Asthma exacerbations are commonly triggered by exposure to allergens and irritants within the home. A systematic review was conducted to evaluate the effectiveness of home-based, multi-trigger, multicomponent interventions for the Guide to Community Preventive Services. It found that there was sufficient evidence to recommend these interventions provided by trained personnel. More information is available (www.thecommunityguide.org/asthma).

• Goal 1: Build on current data and monitoring systems to inform asthma intervention and management efforts and advance health equity in Minnesota. • Goal 2: Engage public health, health systems, and health care professionals in using the National Asthma Education and Prevention Program-based guidelines for asthma care to help people achieve and maintain optimal asthma control. • Goal 3: Build systems and capacity for asthma management and self-management for people who have asthma in Minnesota. • Goal 4: Continue to improve indoor and outdoor

The MDH Asthma Program has conducted several demonstration projects that addressed reducing environmental triggers in the home and provided asthma self-management education to families through home visits. These programs decreased the number of unscheduled clinic visits, decreased hospital visits, decreased the number of school days missed, and improved symptoms and quality of life. The estimated cost savings from these programs was almost $2,000 per child.

environments for all Minnesotans with asthma. Each goal has key objectives and strategies identified to point toward action to achieve the goals. The complete plan can be found online (www. health.state.mn.us/asthma). Reducing the impact of asthma in Minnesota remains a major public health challenge, even more so for populations disproportionately affected by asth-

ma. If you would like to know more about the Minnesota Asthma Program or opportunities for partnership, contact us at health.asthma@state.mn.us.

Wendy Brunner, MS, PhD, is an epidemiologist with the Minnesota Department of Health Asthma Program. Pamela Van Zyl York, MPH, PhD, RD, LN, is the program director for the Minnesota Department of Health Asthma Program.

Physician Practice Opportunities Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassionate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership.

Avera Marshall Regional Medical Center 300 S. Bruce St. Marshall, MN 56258

Currently we are seeking to add the following specialists:

• Family Practice

• OBGYN

• General Surgery

• Orthopedic Surgeon

• Internal Medicine

• Radiation Oncology

For details on these practice opportunities go to http://www.avera.org/marshall/physicians/ For more information, contact Dave Dertien, Physician Recruiter, at 605-322-7691 • Dave.Dertien@avera.org

www.averamarshall.org 32

Minnesota Physician February 2015

Family Medicine St. Cloud/Sartell, MN We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal. HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and beneﬁt package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE

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February 2015 Minnesota Physician

Integrative mental health strategies for kids from page 25

There are some new healing technologies that help kids understand mind/body connections more directly and make the therapy process more playful and engaging.

Biofeedback apps. Biofeedback involves visual or auditory information about a physical process such as muscle tension or breathing rate that kids can learn to control. Heart rate variability biofeedback involves using a small sensor (ear clip or finger pad) to measure the pattern of the heartbeat. Individuals can learn techniques combining paced breathing with positive mental imagery as a way to cultivate an optimal state of heart rate patterning, which has been called “resonant frequency” by some and “psychophysiological coherence” by others. In this state, individuals typically feel calm, happy, and attentive. Several different devices on the market make heart rate variability feedback fun, easy, portable, and cost-effective. The emWave Pro for computers (Mac or PC), and

its sister product for the iPad/ iPhone, Inner Balance, make it easy to take the device with you. Also, GPS for the Soul is a free download that uses your cell phone’s camera as a sensor.

Me Moves app. Many adults and kids find that traditional seated forms of mind/body skills training such as meditation, mental imagery, and breathing practice are boring and that to quiet their mind and body they prefer movement. Me Moves was developed by a mom to help calm her autistic child. It is based on research ideas that support the use of rhythmic visual patterns, music, and movement in engaging “whole brain” activities. With this app, the child moves his or her arms and hands in sync with geometric shapes, combined with music and visuals. Many teachers and special educators have seen improvements in anxiety and attention issues by utilizing this program.

The Adventures of Super Stretch. Another fun, movement-based app was developed by a Twin Cities yoga teacher, Jessica Rosenberg. Children

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watch an animated hero called “Super Stretch,” who teaches them basic yoga poses onscreen in developmentally appropriate language while they watch real kids demonstrate the poses.

Healing Buddies Comfort Kit. Children’s Hospitals and Clinics of Minnesota and Ridgeview Medical Center teamed up with local nonprofit DesignWise and created a mobile app that teaches kids of all ages self-regulation (mind/body) skills to manage pain, anxiety, insomnia, and nausea using a variety of scripted relaxation techniques as well as learning about acupressure and aromatherapy.

Conclusion Children, teenagers, and their families have been seeking out and experimenting with holistic therapies for many years, often out of frustration when conventional mental health treatments including rounds of psychiatric medications and/or “talk” therapies haven’t helped. It is incumbent on all pediatric health care providers to develop some foundational knowledge with regard to integrative approaches for kids

with ADHD, ASD, depression, and anxiety. Research supports that many of these approaches are safe and effective for certain patients. This will enable providers to partner with kids and their families to choose, prioritize, sequence, and make referrals for safe and effective therapies. Families should be given the chance to ask questions and be treated nonjudgmentally. We must learn to be careful, open-minded listeners and be honest about what we know and don’t know as we guide and treat our patients and their families. An integrative approach to mental health care can open new doors to healing for many of our patients and allow us to expand the mental health toolkit for children and adolescents.

Timothy Culbert, MD, FAAP, is an “integrative” developmental behavioral pediatrician in the Twin Cities with extensive training in holistic and functional medicine, hypnosis, meditation, biofeedback, nutrition, aromatherapy, and Reiki. He recently joined PrairieCare Medical Group, LLC, as medical director of Integrative Medicine.

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Minnesota Physician February 2015

AdvAnced PrActice Providers

(PA or NP) Our longstanding, independent, highly reputable clinic with busy schedule is recruiting: Health Care Team: Work collaboratively with 3 F/P physicians to care for our patients. 4 days/week – can flex up to 5 as a float to our satellite clinics. 8:30-5 weekdays, also added to Saturday rotation (8-noon) Ready Care and holiday rotation. Full benefits. Ready Care / Float: Work in our Ready Care either 8:30-5 to 11-7:30, depending on needs. Also added to Saturday rotation (8-noon) Ready Care and holiday rotation. This could be a 4- or 5-day position, depending on candidate’s needs. Full benefits. Applicants must be licensed to practice in Minnesota and certified and accredited by organizations recognized by the State of Minnesota. Tri-County Health Care s a private, not-for-profit corporation providing personalized care to patients in west central Minnesota since 1925. We have modern, state-of-the-art facilities and are committed to the highest standards of care.

For more information about these opportunities please call or e-mail:

Judy M. Erdahl, Provider Relations Coordinator Tri-County Health Care, 415 N. Jefferson St., Wadena, MN 56482 218-631-7462 • Fax 218-631-7503 • Email Judy.erdahl@tchc.org

Opportunities for full-time and part-time staff are available in the following positions: • Associate Chief of Staff • Dermatologist

• Medical Director Extended Care & Rehab (Geriatrics)

• Geriatrician/ Hospice/ • Ophthalmologist Palliative Care • Psychiatrist • Internal Medicine/ Family Practice Applicants must be BE/BC.

Olmsted Medical Center, a 160-clincian multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: Pain Medicine Rochester Northwest Clinic Psychiatrist – Child & Adolescence Rochester Southeast Clinic General Surgery Call Only – Hospital General Surgeon Hospital OB/GYN Hospital – New Women’s Health Pavilion Pathologist Hospital

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment

102 Elton Hills Drive NW, Rochester, MN 55901

email: dcardille@olmmed.org Phone: 507.529.6748 • Fax: 507.529.6622

www.olmstedmedicalcenter.org

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information: Visit www.USAJobs.gov or contact Nola Mattson, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301 February 2015 Minnesota Physician

Respiratory therapists from page 21

these qualifications under H.R. 2619. Another challenge is the struggle between advancing the profession and a projected need for a greater number of clinicians. To accommodate the expanding role of RTs, the AARC has recommended that by 2020, a baccalaureate degree be the minimum level of education needed to become a respiratory therapist and that passing the RRT exam be the credential for beginning respiratory care practice. It is strongly believed that an associate degree and passing the certified respiratory therapy (CRT) exam will no longer suffice. While these initiatives will ensure that RTs are prepared to respond to the profession’s increasing future demands, there are a limited number of schools that offer baccalaureate RT degrees. In fact, according to the AARC,

only 13 percent of RT programs offer a bachelor’s degree—most schools offer only an associate degree. Converting two-year programs and/or establishing new baccalaureate programs will be a major hurdle in the coming years.

Number of credentialed respiratory practitioners in Minnesota up to 2014

An additional barrier in today’s RT profession is the need for legislative changes that would allow RTs to take on a greater role (similar to a physician assistant or nurse practitioner), such as managing chronic diseases including COPD, asthma, and cystic fibrosis. This will take time and may face challenges from existing professional groups. However, with projected nursing and physician shortages and increasing patient needs, opposition may slowly decline.

care costs (especially those related to readmissions) along with a growing population of patients with chronic diseases, the future of RT seems secure. And since physician and nursing shortages are already being noted, it appears there is a more urgent need to allow RTs with the desire and skill to move into more self-directed patient management roles.

Conclusion With the renewed focus of health systems and payers to control and/or reduce health

To prevent RT workforce shortages, one could consider working toward a tiered system similar to nursing (licensed

Certified Respiratory Therapist (CRT)

2,757

Registered Respiratory Therapist (RRT)

1,705

Certified Pulmonary Function Technologist (CPFT)

254

Registered Pulmonary Function Technologist (RPFT)

Neonatal/Pediatric Specialty (NPS)

204

Sleep Disorders Specialty (SDS)

Adult Critical Care Specialty (ACCS)

Source: National Board for Respiratory Care (NBRC), 2014

practical nurse through nurse practitioner). This would allow two-year programs to graduate a base clinician and then offer staggered educational and credentialing levels/options for advancement and increased duties. However the future unfolds for this profession, it is apparent that the field of respiratory care is strong and growing. Derek Hustvet, BS, RRT-NPS, LRT, is a licensed respiratory therapist and neonatal/pediatric respiratory care specialist. He currently serves as the director of respiratory service at Pediatric Home Service, with whom he has worked for the past 10 years.

General Adult Psychiatry Be part of a broad-based mental health practice that is uniquely team-oriented! Hutchinson Health is seeking a sixth psychiatrist with a focus on general adult inpatient and outpatient care. Call responsibilities are 1 in 6. Compensation (salary plus productivity) and benefits are highly competitive. Our Mental Health services include a 12-bed inpatient unit and an outpatient clinic. The psychiatric staff includes two Fellowship-trained in child and adolescent, one Fellowship-trained in geriatrics, 10 other mental health professionals, and two chemical dependency professionals. Hutchinson Health, 50 miles west of the Twin Cities, includes a 66-bed acute care hospital, a 30-physician multi-specialty clinic, and several outpatient and specialty clinics. It serves 35,000 as the primary health care provider.

Hutchinson Health is an approved National Health Services site. Patient safety and evidence-based care are at the core of all clinical processes.

For further information, contact Hutchinson Health Human Resources (320) 484-4685 or hr@hutchhealth.com 36

Minnesota Physician February 2015

Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We are seeking BC/BE fullrange family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.com/careers and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

healthpar tners .com

Family or Internal Medicine Physician An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage available, but not required. GRHS is a progressive 19 bed Critical Access Hospital with two clinics. Glenwood is a family oriented community with an excellent school system. Recreational opportunities include boating, hiking, excellent fishing and hunting. We are halfway between Fargo and the Twin Cites. For more information Call Kirk Stensrud, CEO 320.634.4521 Mail CV to: Kirk Stensrud, CEO 10 Fourth Ave SE Glenwood, MN 56334 Email CV to: kirk.stensrud@glacialridge.org

www.glacialridge.org

MN Physician 4" x 5.25" 4-color

Fairview Health Services Opportunities to fit your life Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Be part of our nationally recognized, patient‑centered, evidence‑based care team. We currently have opportunities in the following areas:

• Dermatology • Allergy/ • Immunology Emergency

• Hospitalist • Geriatric • Medicine Hospice

• Dermatology

• Hospitalist • Internal Medicine

• Psychiatry • Orthopedic • Surgery Rheumatology

• Emergency • Medicine Family Medicine

• Med/Peds • Hospice

• Sports Medicine • Pain Medicine

Medicine

• Endocrinology

• Family Medicine General Surgery • • General Surgery Geriatric •

• Pediatrics • Ob/Gyn

• Ob/Gyn • Urgent Care • Internal Medicine • Psychiatry • Orthopedic • Med/Peds

Medicine

Surgery

• Vascular Surgery • Rheumatology

Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions in the following location.

Sioux Falls VA HCS, SD Cardiologist

Podiatrist

Endocrinologist

Primary Care (Family Practice or Internal Medicine)

Geriatrician (part-time) Hospitalist

Psychiatrist

Nephrologist

Pulmonologist

Oncologist

Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800‑842‑6469 or e-mail recruit1@fairview.org

Sorry, no J1 opportunities.

fairview.org/physicians TTY 612- 672-7300 EEO/AA Employer

Sioux Falls VA Health Care System

Physician Assistant (Mental Health)

Urologist

(605) 333-6852 www.siouxfalls.va.gov Applicants can apply online at www.USAJOBS.gov February 2015 Minnesota Physician

Reporting child maltreatment and abuse from page 11

hold on the child. The child may either then be admitted or put into foster care while awaiting the CPS/police investigation. Does patient confidentiality enter into reporting abuse? The Health Insurance Portability and Accountability Act (HIPAA) allows for the disclosure of protected health information without the consent of the child’s caregiver or legal guardian in situations where abuse or neglect is suspected. Ideally, the parent or guardian should be made aware of this disclosure unless the disclosure could place the child’s safety in jeopardy. Can the reporter of the abuse remain anonymous? Technically, yes—the reporter’s name is confidential unless she/he consents to be named; however, CPS and police will most likely need to receive additional historical and medical

information from the physician after the initial report and the physician can ultimately be subpoenaed to testify if the case goes to court. Caring for children who are suspected of being abused or neglected can be challenging even for experienced practitioners. Physicians should understand mandated reporting laws, know how to contact Child Protective Services, prioritize child safety, and when needed, seek consultation from a physician trained in child abuse pediatrics. A list of resources is provided in the sidebar. Alice Swenson, MD, FAAP, is board-certified in pediatrics and child abuse pediatrics and practices with Midwest Children’s Resource Center at Children’s Hospitals and Clinics of Minnesota. Chris Derauf, MD, FAAP, is board-certified in pediatrics and child abuse pediatrics and practices with Mayo Clinic. Sarah Lucken, MD, FAAP, is board-certified in pediatrics and practices with Hennepin County Medical Center.

Physician resources Below are resources for physicians if they suspect abuse but are unsure about the next steps to take in a medical workup for physical or sexual abuse or neglect. Currently, there is not one statewide number to call. The major metropolitan areas in the state all have resource numbers that can be called. • Midwest Children’s Resource Center (651) 220-6750 • University of Minnesota Masonic Children’s Hospital–Center for Safe and Healthy Children (612) 273-SAFE (7233) • Hennepin County Medical Center–Child Maltreatment Physician Consult Team (612) 873-3000 or (612) 873-2671 (ask for the on-call child maltreatment physician)

• Mayo Clinic Child and Family Advocacy Program; daytime: (507) 293-3411; after hours/weekend: (507) 284-2511 (ask for the on-call provider for MCFAP)

• The Children’s Hospital and Clinics; University of Minnesota Masonic Children’s Hospital; and the Mayo Eugenio Litta Children’s Hospital also have child maltreatment specialists available 24 hours per day for inpatient consultation on children who have possibly been maltreated. Other resources for physicians who suspect abuse: • Family Advocacy Center of Northern Minnesota (218) 333-6011 800 Bemidji Ave. N., Suite 4, Bemidji, MN 56601

• First Witness (218) 727-8353, 4 West 5th Street, Duluth, MN 55806 • Matty’s Place Children’s Advocacy Center (507) 453-9563 ext. 1106, 601 Franklin Street, Winona, MN 55987

• Red River Children’s Advocacy Center (701) 234-4583, 100 4th Street South, Suite 302, Fargo, ND 58103

• CornerHouse (612) 813-8300, 2502 10th Ave S., Mpls, MN 55404 • MN Depart. of Human Services, Reporting Child Abuse and Neglect, 2012. https://edocs.dhs.state.mn.us/lfserver/Public/DHS-2917-ENG

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Use your superpowers...

The lives you save could make you a hero. 38

Minnesota Physician February 2015

GET READY FOR

ICD-10

STAY ON THE ROAD TO 10 STEPS TO HELP YOU TRANSITION The ICD-10 transition will affect every part of your practice, from software upgrades, to patient registration and referrals, to clinical documentation and billing. CMS can help you prepare. Visit the CMS website at www.cms.gov/ICD10 and find out how to: •

Make a Plan—Look at the codes you use, develop a budget, and prepare your staff

•

Train Your Staff—Find options and resources to help your staff get ready for the transition

•

Update Your Processes—Review your policies, procedures, forms, and templates

•

Talk to Your Vendors and Payers—Talk to your software vendors, clearinghouses, and billing services

•

Test Your Systems and Processes—Test within your practice and with your vendors and payers

Now is the time to get ready. www.cms.gov/ICD10

Official CMS Industry Resources for the ICD-10 Transition

www.cms.gov/ICD10

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