Minnesota Physician November 2014 by Minnesota Physician Publishing

Vo l u m e X X V I I I , N o . 8

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The physician workforce in Minnesota Collecting and analyzing data By Teri Fritsma, PhD, and Nitika Moibi, MPP

he need for information on the health care workforce in general—and physicians in particular—has arguably never been greater than it now is. A combination of federal and state policy changes, demographic shifts in population, and growing primary and public health needs are working together to increase demand for health care services. For those with a mission to ensure that Minnesotans have access to quality health care and information about providers—who they are, where they are, and how they work—this information is critical.

Failure to communicate Addressing a systemic issue By Richard M. Frankel, PhD

here’s an old joke in medicine that goes, “What do you call someone who graduates last in their medical school class?” The answer is, “Doctor!” The implication of the joke is that, irrespective of other qualities that might differentiate members of this group (generalist vs. specialist, procedure driven vs.

non-procedure driven, inpatient vs. outpatient), being a doctor of any kind is the common denominator. If all doctors share the same basic qualities and characteristics, it would seem logical that communication between and among doctors would simply be a matFailure to communicate to page 10

Consider the changing health care landscape. The 2010 Affordable Care Act has reduced the number of uninsured Minnesotans to the lowest level ever: According to 2014 Minnesota Department of Health (MDH) data, fewer than 5 percent of Minnesotans currently are uninsured. At the same time, Minnesota’s population is aging—an estimated 285,000 Minnesotans will turn 65 this decade—more than the past four decades combined (Minnesota State Demographic Center). These two sweeping The physician workforce in Minnesota to page 14

Alcohol is more harmful to an unborn baby than cocaine, marijuana or heroin. Drinking during pregnancy can cause Fetal Alcohol Spectrum Disorders (FASD) which permanently harm the way your baby learns and behaves.

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November 2014 • Volume XXVIII, No. 8

Features Failure to communicate Addressing a systemic issue

MINNESOTA HEALTH CARE ROUNDTABLE

By Richard M. Frankel, PhD

The physician workforce in Minnesota 1 Collecting and analyzing data By Teri Fritsma, PhD, and Nitika Moibi, MPP

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

Robert Bösl, MD Starbuck Clinic

Culture and Health

Allergy and Immunology

Women’s Health

Allergy immunotherapy By Nancy Ott, MD

Advanced age pregnancy By Jillian Hallstrom, MD

Atherosclerotic cardiovascular disease By E lizabeth Tuohy, MD

Special focus: Rural Health 20

Community paramedics By A llen Smith

The New Face of Health Care Expanding medical professional relationships Thursday, April 23, 2015 • 1:00-4:00 PM Downtown Minneapolis Hilton and Towers

Professional Update: Cardiology

Creating a community partnership ynn Buckley, LPN, By L and Robin Weis

FORTy-THIRD SESSION

Collaborating with Indigenous communities By Melissa Walls, PhD, and Emily Onello, MD

Learning collaboratives 26 By R obert Payne, MD, Abe Jacob, MD, MHA, and Katherine Cairns, MPH, MBA

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 professionals 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. 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.

Publisher Mike Starnes | mstarnes@mppub.com Senior Editor Janet Cass | jcass@mppub.com Editor Lisa McGowan | lmcgowan@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.

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U of M Children’s Hospital Renamed After Donation The University of Minnesota has announced that it is renaming its children’s hospital the University of Minnesota Masonic Children’s Hospital after receiving a multimillion dollar donation. On Oct. 14, Minnesota Masonic Charities gifted the hospital $25 million to support pediatric research and care delivery. The group has donated a total of $125 million to the university over the last 60 years, $75 million of which has been donated since 2008 for cancer research and care. “We are proud of our long-standing partnership with the University of Minnesota,” said Eric Neetenbeek, president and CEO of Minnesota Masonic Charities. “The Masonic Fraternity is passionate about helping Minnesotans lead longer and healthier lives. By supporting the children’s hospital, we hope to facilitate new treatments and

cures that will benefit patients and families across the state and around the world.” “The University of Minnesota owes a great deal of thanks to Minnesota Masonic Charities for helping us develop leading academic medicine programs that are making a difference in people’s lives,” said Eric Kaler, president of the University of Minnesota. “Top quality health care is only possible when we have strong community support.” In March, Caroline Amplatz fulfilled her 2009 pledge of $50 million to the hospital ahead of schedule. She allowed the university to remove the previous name of University of Minnesota Amplatz Children’s Hospital and find another benefactor. The name change is effective immediately. The recent donation will be used to fund projects that will enhance the patient experience and advance research in several areas, including neurobehavioral development, rare and infectious disease, and stem cell therapies, according to univer-

Minnesota Physician November 2014

sity officials. “What we’re doing here is really all about training physicians, and looking at treatment modalities that will result in cures and better treatments,” said Neetenbeek. “They do wonderful things now. But with more money, you can always do more.”

Medicare Penalizes 36 Minnesota Hospitals Over the next year, Medicare is fining a record number of hospitals—2,610—an estimated $428 million for readmission rates. In Minnesota, 36 hospitals are being fined. Overall, readmission rates fell last year. However, almost one in five Medicare patients was readmitted to a hospital within 30 days, costing taxpayers an additional $26 billion, according to Medicare. The organization is penalizing 433 more hospitals than it did last

year, while 39 hospitals face the highest possible penalty. And, the average fine will be higher. Only 129 hospitals that were fined in the last round avoided penalties in this one. This is the third year since the 2010 implementation of the Affordable Care Act that hospitals have faced these penalties from Medicare. According to law, in the first year penalties could reach up to 1 percent of Medicare payments, rising to 2 percent in the second year. Now, potential fines can be up to 3 percent of Medicare bills, the highest possible percentage under federal law. Penalties are based on Medicare readmission scores from a three-year period ending June 2012. Therefore, more recent efforts at reducing readmissions may not be reflected in these scores. Medicare tracked two additional categories of patients for this round of penalties in addition to the previously tracked categories of patients with heart failure, heart attacks, or pneumonia. One additional category included patients with elective

hip or knee replacements; the other included lung ailments such as chronic bronchitis. Medicare determines appropriate readmission rates by taking into account the national rate of readmissions, so hospitals not only have to reduce their own rates, but also must do better than the industry overall in order to avoid fines.

Coverage Expansion Reduces ER Visits for Young Adults New research from the School of Public Health at the University of Minnesota has shown that the Affordable Care Act’s (ACA) young adult insurance expansion accompanied modest increases in use of inpatient mental health and inpatient substance abuse care, while emergency visits for the same disorders declined. In addition, researchers found that when young adults used these services, they were more likely to have health care coverage. “Our research is one of the first evaluations of the ACA’s coverage expansions that focuses on health services utilization,” said Ezra Golberstein, PhD, lead author and assistant professor of health policy and management at the University of Minnesota School of Public Health. “Mental health and substance use disorders peak among young adults at a time in life when health insurance coverage is low. We found that the coverage expansion was associated with modestly higher inpatient use for these disorders, along with decreases in emergency department use.” Researchers analyzed national trends in inpatient use and trends in emergency department use in California between 2005 and 2011. They focused on the dependent coverage provision enacted under the ACA that permits young adults to stay on their parents’ health insurance plan until age 26. They compared health care trends for 19- to 25-year-olds to trends for 26- to 29-year-olds who were not eligible under the ACA provision. The team, which included researchers at Yale University, Dartmouth College, and Har-

vard Medical School, found that the likelihood that inpatient visits were uninsured fell by 2.9 percent between 2005 and 2011. The likelihood that emergency department visits in California were uninsured fell by 3.9 percent. In addition, researchers found that both men and women showed increased rates of inpatient use, but that only women showed a decrease in emergency department use. “The fact that we see reductions in emergency department use strikes us [as] a good thing, suggesting that young adults were able to access mental health and substance use services in non-emergency settings,” Golberstein said. However, the authors noted that the data do not clearly show whether or not the increase in inpatient use has positive or negative ramifications. The study was meant to help understand how the ACA is affecting mental health and substance abuse treatment in the U.S.

Pediatric Orthopaedic Experts for 91 Years

Minneapolis VA to Study Pain Med Alternatives The Minneapolis VA Health Care System has been selected as one of 13 locations for a national initiative to explore nondrug approaches to manage pain and health conditions such as post-traumatic stress disorder, drug abuse, and sleep issues. The goal is to enhance options for U.S. military personnel and veterans that are dealing with these health concerns. The National Institutes of Health’s National Center for Complementary and Alternative Medicine (NCCAM), the National Institute on Drug Abuse (NIDA), and the U.S Department of Veterans Affairs Health Services Research & Development Division are providing $21.7 million over five years for the studies. “Pain is the most common reason Americans turn to complementary and integrative health practices,” said Josephine Briggs, MD, NCCAM director. “The need for nondrug treatment options is a

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Capsules to page 6 November 2014 Minnesota Physician

Capsules from page 5

significant and urgent public health imperative. We believe this research will provide much-needed information that will help our military and their family members, and ultimately anyone suffering from chronic pain and related conditions.” The Center for Investigative Reporting shows that VA physicians wrote more than 6.5 million prescriptions for hydrocodone, oxycodone, methadone, and morphine in 2012, which is a 270 percent increase from 2001. According to a JAMA Internal Medicine report released in June, 44 percent of the U.S. military reported experiencing chronic pain after combat deployment. Only 26 percent of the general population experience chronic pain. In addition, the report showed that pain is not the only problem causing the increase in opioid use. Fifteen percent of U.S. military members use opioids after deployment, while 4 percent of the general public uses them. This

increases the cause for concern as opioids are not consistently effective, have potential side effects, and often are misused. “Prescription opioids are important tools for managing pain, but their greater availability and increasing prescribing may contribute to their growing misuse,” said Nora Volkow, MD, NIDA director. “This body of research will add to the growing arsenal of pain management options to give relief while minimizing the potential for abuse, especially for those bravely serving our nation in the armed forces.”

Suicide Rates Jump, Officials Look for Answers The Minnesota Department of Health (MDH) is changing how data is collected on suicides in an effort to better understand sharply increasing rates of suicide in the state.

Minnesota Physician November 2014

According to the most recent data, the suicide rate in Minnesota jumped almost 29 percent from 2003 to 2011, more than double the national rate of increase. There were 496 deaths by suicide in 2003, and 684 in 2011, the highest number in Minnesota since the state began recording this information. Last year, there were 683 deaths by suicide. It now is the second-leading cause of death for Minnesotans ages 15 to 34 after accidents. Historically, suicide rates rise and fall with the economy and reach a peak when the economy is declining. However, Minnesota’s suicide rate showed a sharp increase as the economy began recovering after the severe downturn of 2008 to 2010, leaving health officials searching for answers. “Why are we becoming more suicidal in Minnesota?” asked Jon Roesler, MS, injury epidemiologist supervisor at the MDH. “The answer is that we don’t know. And that’s disconcerting.”

To investigate this unusual trend, Minnesota recently joined the National Violent Death Reporting System to start receiving data on suicides and other violent deaths from county coroners, law enforcement agencies, and other sources beginning in January 2015. This will reveal more information such as medical diagnoses, major life events such as job loss or divorce, and other reasons that could lead to someone committing suicide. Until now, MDH has relied primarily on the basic information provided on death certificates. “If we’re going to prevent suicides, we need to know the risk factors,” said Andrew Baker, MD, chief Hennepin County medical examiner. “Do we have a lot of untreated depression out there? Do we have people with bipolar [disorder] who are not taking their medications? That will be in the person’s [medical] file.”

Medicus Edwin Bogonko, MD, board-certified in internal medicine, has been named chair of the state’s Task Force on Immigrant International Medical Graduates in addition to serving as clinical director of medicine and lead hospitalist at St. Francis Regional Medical Center, Shakopee. He earned a medical degree from the University of Nairobi, Kenya, and graduated from Physician Leadership College, University of St. Thomas, St. Paul. The task force will develop strategies to Edwin Bogonko, MD integrate immigrant physicians into Minnesota’s health-care delivery system and make recommendations to the commissioner of health and the Legislature in January 2015. Maria del Pilar Hoenack-Cadavid, MD, board-certified in geriatric medicine and internal medicine, has joined Courage Kenny Rehabilitation Associates. She earned a medical degree from Juan N. Corpas Medical School in Bogota, Colombia, and served both an internal medicine residency and a fellowship in geriatric medicine Maria del Pilar at Hennepin County Medical Center (HCMC), Hoenack-Cadavid, Minneapolis. MD

Kristi Estabrook, MD, board-certified in psychiatry, has joined Essentia Health–St. Mary’s Medical Center, Duluth. She will be part of a new program offering comprehensive mental health consultation services to hospitalized patients and patients seen in the Emergency Department, and will care for both children and adults. Estabrook earned a medical degree from the Medical College of Wisconsin, Milwaukee, and completed both a residency in adult psychiatry and a Kristi Estabrook, MD psychosomatic medicine fellowship at the Medical College of Wisconsin Affiliated Hospitals, Milwaukee. David C. Herman, MD, MS, has been appointed CEO of Essentia Health effective early 2015, replacing retiring CEO Peter E. Person, MD, MBA. Herman, board-certified in ophthalmology, completed medical school and an ophthalmology residency at Mayo; a fellowship in ocular immunology and uveitis at the NIH’s National Eye Institute, Bethesda, Md.; and a master’s in David C. Herman, medical management at the University of Texas– MD, MS Dallas. He most recently served as president/ CEO of Vidant Health, an integrated health care system in North Carolina. Kenneth D. Holmen, MD, has been named president and CEO of CentraCare Health, St. Cloud, effective Jan. 1, 2015. He has served as vice president of physician strategies and business development for Bloomington-based HealthPartners since 2004. During that time, he also was chief medical officer and vice president for medical affairs at Regions Hospital, St. Paul. Holmen replaces Terry Pladson, MD, who will retire Dec. 31.

Kenneth D. Holmen, Andrew Schmidt, MD, board-certified in orMD

thopedic surgery and a fellow of the American Academy of Orthopedic Surgeons, has been named chief of orthopedics at HCMC. He is also a professor of orthopedic surgery at the University of Minnesota. Schmidt completed medical school at the University of California, San Diego; an orthopedics and rehabilitation residency at the Oregon Health Sciences University, Portland; and a fellowship in total joint replacement at HCMC.

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Interview

A commitment to care W hat are the biggest changes you have seen in the practice of medicine over your career? Perhaps the biggest change is the explosion in technology including diagnostic imaging such as CT and MRI, but also therapeutic technology changes such as laparoscopic and robotic surgery. Additionally, there are many more recognized diseases such as AIDS, Lyme disease, toxic shock syndrome, etc., that were unknown during my medical school tenure.

Robert Bösl, MD Starbuck Clinic Dr. Bösl is board-certified in family medicine and a fellow of the American Academy of Family Physicians. He also is a clinical assistant professor at the University of Minnesota–Morris. He practices the full range of family medicine at the Starbuck Clinic in Starbuck, Minn., which is part of the Stevens Community Medical Center in Morris. Dr. Bösl was awarded Staff Care’s 2013 Country Doctor of the Year Award and the 2014 University of Minnesota Distinguished Medical Alumni Award.

Y ou made a very unique commitment to your community when it was faced with the prospect of losing immediate access to care. Please tell us that story. The “Reader’s Digest” version is that the local hospital ended up closing, and the only clinic in town was part of that organization. When it became clear this was happening, I personally invested a million dollars in savings and loans into building, furnishing, and staffing a new clinic. I felt the community had supported the practice for many years and it appeared to be the only option in assuring long-term availability of health care in the community.

W hat is it about the practice of medicine in a rural setting that you find most rewarding? The lure and excitement of family medicine is being the first source of medical care for any medical problem indiscriminate of any limitation by age, sex, organ system, etc. “You just never know what’s behind door number two.” The uniqueness of practicing in During the autumn of 2004, I purchased two lots a rural setting is to accept this responsibility in the and personally removed numerous old trees, dilapicontext of a community wherein you also see your dated buildings and foundations, and cleaned up the patients frequently playing property. There were some in your men’s basketball delays due to zoning issues, league, in their workplace, at A physician no longer but I personally helped pour community events, and sothe clinic footings on Jan. 1, needs to feel like a martyr cially. You are better able to 2005 during a snow storm understand and treat patients practicing in a rural area. with the local cement purknowing their approach to veyor who felt strongly about life; their coping mechagetting the project going so nisms; and their work, family, and social stressors. he not only brought the cement during the middle Having cared for up to five generations in a given of winter, but also on a holiday. The clinic was built family, I know the family history as well as or better using local contractors who all felt an urgent need to than the patient. It is personally rewarding to see the get the clinic built. Eight clinic employees (my “Super positive results of my medical care throughout the 8”) were hired and began work on Feb. 14th learning community on a daily basis. a new electronic medical record system and getting W hat are some of the challenges facing medical practice in rural Minnesota? The medical practice challenges in a rural practice are not dissimilar from those in a metro area: increasing government and insurer “meddling” in the practice of medicine often with no patient benefit and increasing physician time requirements associated with the bureaucratic aspects of health care delivery rather than direct patient care. H ow does practicing medicine in a metro area differ from a rural practice? Economically, it is perhaps more difficult in a rural area, though few rural doctors go into medicine for financial rewards anyhow. Each office needs an ECG machine, for instance, whether the office has one doctor or 12, so the cost of practice is higher per physician. Each office is responsible for all of the insurer/ government “quality” studies, the cost of which is the same for a single doctor office or one with 12 physicians. Emotionally, it may be more rewarding to practice in a rural area because you can see the outcomes of your work in the community. It’s gratifying to see the

kid whose appendix you removed two weeks earlier lead his basketball team to victory.

Minnesota Physician November 2014

the clinic ready to open for business on April 1, 2005. By then, all clinic, lab, and X-ray equipment was in place, staff and physician were EMR computer literate, all insurance contracts and licensing were in place, and soon the new Starbuck Clinic was inundated with patients. W hat have been the biggest rewards of this investment? The practice has thrived over the last 10 years since the clinic was built. It has provided jobs and local health care. Since the community has many elderly citizens, travel to other communities for health care in Minnesota weather can be difficult. It also has provided a measure of stability for the local nursing home and the local pharmacy. N ow that you are looking at retirement, what are some of the challenges in essentially replacing yourself? Without trying to come across as egotistical, the shoes may be tough to fill; but this is true not just here but throughout rural Minnesota. Nurses have indicated that I need to be cloned, and perhaps the University of Minnesota would be up to that challenge. (It would

actually be ironic if a person from Starbuck were to be the first human clone as the first bovine clone born in 2000 was a Canadian bull named Starbuck!) On a more realistic note, a physician no longer needs to feel like a martyr practicing in a rural area. Although I am the only physician physically present in Starbuck, I do have a superb physician’s assistant as well. The hospital at Stevens Community Medical Center in Morris has 24-hour emergency room physician coverage alleviating the vast majority of after-hour calls (except of course for the privilege of delivering babies). There are presently seven family physicians that rotate weekend hospital call, which is certainly reasonable. There are many dedicated caring family physicians and many places in rural Minnesota looking for another family physician. I think that many family physicians might consider joining a rural practice, but their spouse may be in a profession that does not have jobs in rural areas. There is an innate fear in some physicians about rural practice due to the fact that rural medicine in the past did often demand a 24-hour/seven-day-a-week commitment. This is no longer the case and rural practices generally provide significant flexibility in obtaining the lifestyle a physician desires.

A s a doctor in a small community, there must be some unique issues around the relationships you develop with your patients. What can you share with us about this? Nothing, it is all prohibited by HIPAA (just kidding)! The longitudinal relationship between family physicians and their patients is sacred even without HIPAA. We share both the ecstasy of life (such as delivering babies) as well as the agonies (cancer, death, etc.) with our patients and their families. Our relationship cannot evolve without mutual trust and respect. Together, we can work to optimize their health on their terms. hat do you see in the future for rural W health care? I think it will continue to be strong in Minnesota. Minnesotans have a tendency to be hard-working, caring individuals, which is the ideal combination of attributes needed to care for our rural citizens. I had the opportunity and pleasure to precept a medical student this summer (Whitney Bertram) who has a clear understanding of rural health care and a dedication to the principles of rural health care delivery. She is intelligent (both academically and interpersonally), inquisitive, empathetic, and caring. As she likely is representative of the quality of students entering

our medical schools, the future of Minnesota rural health is in good hands. D o you have any special plans heading into retirement? I haven’t asked my wife yet what my plans are! I had contemplated going back to the University of Minnesota to take some more classes so I could try out for the Gopher basketball team, but Norwood Teague indicated that my NCAA eligibility had expired more than four decades ago. I also checked with the Senior PGA Tour, but they indicated they had no interest in someone with a 24 handicap. I may continue work on my novel, although thus far I’ve only gotten to the title page. I understand that Lake Minnewaska has become infested with oversize walleyes so I may try to help the DNR with that problem. I have some chainsaw expertise (certainly a great deal of experience), so might consider consulting work with the forestry service. More honestly, those of us who have truly enjoyed the intellectual stimulation of rural health, and the pleasure derived from serving our patients, will find it difficult to replace the unique stimuli we found in our practices. Fortunately, we will accept retirement as a new challenge. I will embrace retirement when it arrives with the same vigor that I embraced medicine.

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ter of mechanically exchanging information based on a shared understanding of the medical facts and the best available evidence for treatment. Such is not the case, and in this short article I will explore three reasons why: power and prestige (generalist vs. specialist); lack of training in communication and conflict management skills (teach-back and talkback, polarity management); and emphasis on individual performance (relational coordination). Power and prestige A long time ago, in a galaxy far away … The Sept. 20, 1948 issue of Life Magazine featured a groundbreaking photo essay about Dr. Ernest Ceriani, a general practitioner from Kremmling, a small town in northern Colorado. Dr. Ceriani, and the photographs taken by the famed photographer W. Eugene Smith were remarkable in several ways.

First, they were the inspiration for several radio and television shows, most notably, Young Dr. Malone; Marcus Welby, M.D.; and Dr. Kildare. The three doc-

Unresolved conflict among colleagues constitutes a significant risk to patient safety.

tors who starred in these shows (all males) were portrayed as rugged, individual decision-makers. Their formula for success lay in making difficult diagnoses, often without the aid of technology; one way physician-centered communication that consisted of telling patients and family members what to do; and more times than not, bringing about a miraculous cure. Today, of course, most

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physicians work in teams; more than 50 percent of all entering medical students are female, and over-reliance on technology (think EMR, diagnostic testing,

Minnesota Physician November 2014

etc.) has been cited by experts as a significant barrier to empathy and compassionate care. Second, the Life magazine photos call attention to the predominant mode of care delivery in the United States during the mid-20th century, which was solo practice. Most physicians in solo practice did their own billing, kept their own books and, for patients who were paying out of their own pock-

Telephone Equipment Distribution (TED) Program

Failure to communicate from cover

et, set their own fee schedules. Due to rapid growth in private insurance markets from the 1940s onward, and the advent of Medicare and Medicaid in 1965, most physicians’ fees now are set by third parties, thereby limiting physicians’ decision-making authority. Further challenging physicians’ sense of autonomy was the rise of health maintenance organizations (HMOs) and capitated payments in the 1980s and the transfer of risk for medical expenses from insurance companies to physicians. Large-scale changes in practice style and reimbursement patterns did not affect doctors equally. For example, in the written commentary accompanying the Life Magazine photos it was pointed out that in 1948

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idents as a training tool. Since that time scholarship about the impact of communication on processes and outcomes of care has blossomed and several systematic reviews have demonstrated the benefits of good communication between doctors and patients. In one particularly important report, the Institute of Medicine in 2001 asserted that patient-centered communication, i.e., care that takes into account the attitudes, beliefs, and values of the patient in all aspects of decision-making, was one of six domains that define quality in health care. Today, most schools of medicine have a required course on communicating with patients but few, if any, focus on effectiveness in physician-to-phyMost schools of medicine sician communihave a required course cation. One area that on communicating with has received a patients but few … focus on good deal of atten… physician-to-physician tion and concern lately is end-ofcommunication. shift hospital handoffs, in which one doctor transfers the care of of another’s, questions of worth his or her patients to another. and value are bound to emerge. The Joint Commission estiSuch questions are only remates that 80 percent of all adinforced by the perception of verse outcomes in hospitals can status and hierarchy that exist be traced back to breakdowns in medical school culture. One might put the logic here crudely in communication during handoffs. Of note, according to as, “The person to graduate last a recent study only 8 percent in their medical school class of medical schools teach the may be a doctor but she or he handoff as part of their formal also is very unlikely to get into curriculum. Instead, students a surgical residency, therefore typically learn from observing the person who does go into surgery is better and more valu- residents and attending physiable!” A solution to this problem cians conduct handoffs. This essentially means that handis dialogue among generalists offs are done according to the and specialists in which issues norms and idiosyncrasies of of economic disparities and intellectual gifts can be discussed each service and each provider; the result is a great deal of openly and respectfully. unwanted variation in style and practice that is a threat to paLack of training in tient safety and quality of care. conflict management “Don’t take this personally but…” There are three communithe average general practitioner made about $10,000 whereas the average specialist made about $14,000, a difference of about 40 percent. A Merritt Hawkins & Associates’ Review of Physician Recruiting Incentives in 2012 showed that primary care physicians (PCPs) were offered an average of $189,000 whereas specialists in orthopedics, cardiology, and urology were offered an average of $461,000, a difference of almost 250 percent! Without going into detail about what created such disparities, I suggest that their very existence is a fundamental barrier to effective communication. If one doctor’s time is worth 2.5

Communication has always played an important role in medical care from the Greek physicians onward. The “modern” era of communication research dates to the late 1930s when medical educators started making wire recordings of res-

cation strategies that have been found to be helpful in conducting handoffs. The first is preparation and readiness for the handoff. Lack of preparation on the part of an outgoing resident can lead to limited anticipatory management information being given to the incoming resident.

Without an overall sense of the tasks to be accomplished and in what order, delays in care may follow thereby increasing patients already at risk in terms of the intensity and timing of their care. Second, addressing readiness to initiate a sequence of handoffs also is helpful in aligning the giver and receiver of information. Simply asking, “Are you ready to receive my handing off of my patients to you?” can go a long way toward creating a smooth transition of information. Third, asking if there are any more questions or whether it is okay to move on to the next patient creates a temporal frame that is useful. Finally, from studies of communication across an authority gradient among crews on nuclear submarines comes SBAR (Situation, Background, Assessment, Recommendation). SBAR is a structured communication tool that allows subordinates to communicate information to superiors in a logical, mutually understood

way. The tool, based on teachback and talkback methods has been used in hospitals to help bedside nurses communicate their concerns and questions to attending physicians who are not onsite, and at times that may not be optimal. Although there has been limited uptake of the tool to date, research indicates that it is an efficient and effective way of transmitting information where differences in power exist. Conflict is an inevitable part of everyday medical life. For many adults, managing conflict effectively is challenging, especially in complex social groups with high-performance standards, weighty responsibilities, and significant risks of harm arising from errors and lapses in judgment. Because medicine is not an exact science and differences of opinion exist among colleagues and experts about optimal treatment approaches for various conditions, conflict and strong differences of opinFailure to communicate to page 12

November 2014 Minnesota Physician

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Failure to communicate from page 11

ion are bound to arise. My colleagues and I recently undertook a study of work-life narratives in a large health care organization in which we asked 150 nurses and 55 physicians to tell us a story about when they were at their best and one where they felt challenged by conflicting values. Certain topics like humanism clustered in the positive stories of both groups, while conflict-laden topics like respect clustered among the challenging stories. Interestingly, more than 80 percent of the conflict-laden stories did not contain any description of attempted or completed resolution. For example: There was a transgendered individual on our unit. Two staff members weren’t tolerant of the situation and in return I was pretty adamant about how I felt that they became very judgmental. I guess I was trying to be supportive of this person … The other staff member made a comment about Jesus and fags, and I was just like, “Oh, we don’t use that word.” And she thought it was very acceptable to say that about a patient … [and] refuse to address that patient as whatever gender they had decided that they were. We concluded from this and other similar stories that the “residue” from unresolved conflict among colleagues constitutes a significant risk to patient safety and quality precisely because it is likely to become amplified and more difficult to manage over time. One suggestion for dealing with such underlying conflicts is to adopt tools such as polarity management into day-to-day operations. Developed by Barry Johnson in the early 1990s, polarity management is a conceptual and practical framework for resolving difficult issues. For example, one physician may claim that, “We physicians are dedicated to providing quality care to patients irrespective of their ability to pay,” while another physician insists, “That’s all well and good, but our goal is not to solve societal problems

Minnesota Physician November 2014

but to stay solvent and make our payroll each month.” The first physician is focusing on the ethical principle of beneficence and ignoring, at least in principle, the question of cost; the second physician is doing the opposite by focusing on cost without considering social responsibility. Research has shown that focusing on one pole to the exclusion of the other inevitably exposes the downside of that pole. Polarity management seeks a balance and focuses on the upside potential of both poles while minimizing their downsides. A new book by Johnson entitled, “Polarity Management: Identifying and Managing Unsolvable Problems” (2014), may be useful in addressing hidden as well as explicit conflicts among colleagues. Likewise, the American Academy on Communication in Healthcare (AACH), (www.aachonline.org), offers a variety of courses for physicians in patient interviewing, creating relationship-centered organizations and culture, and managing conflict and strong emotion. AACH uses principles of adult learning to work with course participants to identify “hot spots” in practice, such as how to engage with colleagues to solve conflicts. Participants work in small group with national experts in communication to hone their skills. In its third decade, AACH has trained hundreds of physicians and health care leaders to communicate in conflict situations more effectively, efficiently, and with greater empathy. Emphasis on individual performance “It’s my way or the highway, or is it?” Despite the recent emphasis on learning interpersonal skills and communicating effectively, doctors are still primarily judged on their individual performance, whether it’s in terms of productivity and throughput, or the number of first-authored publications needed for promotion and tenure. In an era of “team

science” and interprofessional teamwork, the fact still remains that individual doctors will be named in medical malpractice law suits, are still individually licensed, and are paid on the basis of the number and type of patients they see. Against this backdrop is a framework recently developed by Jody Gittell and her colleagues known as relational coordination. Gittell originally developed the approach by studying Southwest Airlines and their approach to customer service and corporate culture. What she noticed was that, as a company, Southwest employees had shared goals, shared knowledge, and mutual respect for one another, regardless of rank in the organization. Applying the relational coordination framework to postoperative pain and functioning and length of stay in nine hospitals, she found that those with a high degree of relational coordination had significantly better outcomes than their counterparts with low-relation-

al coordination. Several tools for increasing relational coordination including Team STEPPS have been shown to be effective in shifting the emphasis from individual to team performance.

Historically, doctors have received very little formal training in communication. Concluding thoughts In this short article I have tried to articulate some of the biggest challenges to effective

physician-to-physician communication. Economic disparities between types of physicians and (untested) inferences about intellect, motives, and effort can contribute to limited conflict-laden communication. Testing these inferences with colleagues from different disciplines and specialties can go a long way to improving communication. Historically, doctors have received very little formal training in communication and it has occupied a quaint, but unscientific position, as “bedside manner” in the medical school curriculum. Research has documented the importance and impact of communication and conflict resolution skills on processes and outcomes of patient care and we are beginning to understand the importance of these skills for physician-to-physician communication. Finally, despite the fact that incentives and responsibilities focus on individual performance, there is growing evidence that shared mental

models, knowledge, and respect all contribute to the health and well-being of patients and organizations. Instead of jokes that deride being last in one’s medical school class and inferences about how that will limit one’s earning potential, perhaps we should be asking what members of a still noble profession share in common rather than characteristics and qualities that divide them. Respectful dialogue might just be a useful recipe for improving communication. Richard M. Frankel, PhD, is professor of Medicine and Geriatrics at Indiana University School of Medicine, Indianapolis and the director of the Mary Margaret Walther Program in Palliative Care at the IU/Simon Cancer Center, Indianapolis. He is also the associate director of the VA Center for Healthcare Information and Communication (CHIC) at the Richard L. Roudebush Veteran’s Administration Medical Center, Indianapolis. Dr. Frankel has published more than 225 research papers in the area of physician-patient communication.

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The physician workforce in Minnesota from cover

2% 4%

Figure 1. Licensed physicians by race

72%

White

Asian

Black

Other

14%

Unknown race - No survey response

Approximately 50 percent, or 10,860 licensed physicians completed the survey. Among those, 86 percent answered the question about race. Source: 2013 Minnesota Department of Health Physician Workforce Survey

changes alone are enough to substantially increase the demand for health care. But shifts in the racial and ethnic composition of Minnesota’s population, as well as the uneven distribution of Minnesota’s population around the state,

call for not just more, but also different modes of health-care service delivery. Newer models, such as health care homes and team-based approaches through accountable care organizations (ACOs); telemedicine; changes in scopes of practice

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such as those for advanced practice registered nurses (APRN); and collaborative agreements; all will have an impact on the number, type, and distribution of health care providers needed. To respond appropriately, Minnesota policymakers, health systems, educational institutions, and workforce development professionals need current, comprehensive, and accurate state-level health-care workforce data.

Partnering to collect data How do we track Minnesota’s physician workforce? According to administrative records from the Board of Medical Practice (BMP), approximately 15,000 licensed physicians practice medicine in Minnesota, with another 6,000 licensed in Minnesota but practicing out of state. What do we know about them? Who are they, where are they, and what kind of medicine do they practice? Are there enough of them in the right places to meet our state’s health care needs? Thanks to a longstanding partnership between the BMP and the MDH, state-level data are available to answer many of these questions. As part of the license application and annual license renewal, the BMP requires physicians to provide

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Minnesota Physician November 2014

• Where and when they graduated from medical school • Post-graduate training information • Current specialty board certifications • Primary business address State law also requires MDH to collect (and physicians to provide) additional information, including: • Work status information (average hours worked, future intent to practice, practice settings, and services provided) • Demographic information • Languages used to communicate for clinical purposes The BMP/MDH partnership enables MDH to collect this information unobtrusively at the time a physician renews his or her medical license with the BMP. Workforce and labor market researchers at MDH then merge the MDH and relevant BMP datasets, allowing them to analyze all the workforce data available on the entire population of Minnesota physicians. MDH issues its reports and shares the findings with health licensing boards, policymakers, educators, employers, associations, and the public. In addition to the BMP, MDH also collaborates with boards

Table 1. N umber and share of Minnesota physicians by specialty certification

General Pediatrics

Patient-friendly early morning, evening, and Saturday hours. Appointments:

information such as:

Number of Minnesota Physicians

Share of Minnesota Physicians

2,758 2,020 862 552 502 1,622 449 2,457 745

12.7% 9.3% 4.0% 2.5% 2.3% 7.5% 2.1% 11.3% 3.4%

4,238

19.6%

5,464 21,669

25.2% 100%

Source: Minnesota Board of Medical Practice, May 2014 data

Figure 2. Population per every one physician, by Minnesota region

Micropolitan/ Large Rural

519

Small Town/ Small Rural

500

1000

1500

2000

2500

Source: Minnesota Board of Medical Practice, May 2014 data

that oversee licensing for most health care professionals, including nursing, mental health, dentistry, and physical therapy. How does data help? At the most basic level, stakeholders need counts of health care providers, particularly by specialty type. We can’t know if supply meets demand unless we can quantify both. Table 1 on page 20 provides basic counts of the 21,699 physicians who hold active licenses issued by the BMP. But with growing immigrant and minority populations in Minnesota, counting providers is only the beginning: it also is important to be able to characterize their demographic makeup. Members of ethnic or racial minority groups may be more likely to seek care and have better outcomes with physicians who have specialized knowledge about health concerns common to their background. According to data compiled by the Minnesota Compass Project, an estimated 85.7 percent of Minnesota’s population is white (estimates are for 2010–2012), whereas just over 72 percent of physicians in Minnesota are white, reflecting a diversifying provider workforce (see Figure 1 on page 20). Finally, beyond counting and characterizing providers, it is becoming increasingly important to have information on

31.8%

Rural/Isolated

2,043

Rural/Isolated

23.2%

Small Town/ Small Rural

674

24.7%

Metropolitan

297

Metropolitan

Figure 3. S hare of physicians who supervise a physician assistant

both where and how they work. To ensure that the supply of providers can meet the demand for services—both today and in the future—stakeholders must have a clear understanding of the regional distribution of the physician workforce. The majority of physicians work in metropolitan areas of the state. What does this mean for access to care in more rural regions? As one indicator of access to care, the data in Table 1 on page 20 includes all physicians with active licenses who report a Minnesota business address. (Note that only about 26 percent of these are primary care physicians. Also included are other specialists, subspecialists, facility-based physicians, and physicians without a specialty certification.) The lowest population-to-physician ratio is in the metropolitan areas of the state, with higher ratios in the more rural areas (see Figure 2 on this page). In rural areas, there are over 2,000 patients for every physician. The distribution of physicians around the state only tells part of the story, however. When grappling with questions of supply and demand in rural Minnesota, stakeholders need a contextualized picture of how care is provided. Figure 3 on this page provides a glimpse into one way that Minnesota’s health care system adjusts to the relative shortage of physicians in rural areas. Rural

46.6% 0

Source: Minnesota Board of Medical Practice, May 2014 data

physicians are far more likely than metro-based physicians to supervise a physician assistant, which can reduce the demand for physicians. (Similarly, though not shown here, MDH survey findings indicate that rural physicians are much more likely to have a prescrib-

ing agreement with one or more nurse practitioners or APRNs, and, before 2014 legislative changes eliminated the need, were more likely to supervise at least one APRN through a collaborative agreement.) These The physician workforce in Minnesota to page 38

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November 2014 Minnesota Physician

CULTURE AND HEALTH

he importance and complexity of culture in the human experience is widely appreciated across diverse academic disciplines. Most definitions of culture focus on collective beliefs, customs, behaviors, and ways of life common to a particular group or society in place and time. But how does “culture” relate to a person’s physical well-being and mental health? And more important, can we better address the vast health disparities in our nation by considering cultural factors as a critical component of health? This article explores an emerging body of research evidencing the importance of culture for health in American Indian communities. Indigenous health disparities The descendants of the First Americans include over 5 million American Indian and Alaska Native (hereafter Indigenous) people who endure among the highest rates of

Collaborating with Indigenous communities Considering culture for promoting health By Melissa Walls, PhD, and Emily Onello, MD health disparities in the United States. Indigenous people live an average of 4.2 fewer years than all other Americans and cope with significantly higher infant mortality rates than do whites. Relative to all other U.S. racial groups, Indigenous people are more likely to experience diabetes mellitus, tuberculosis, and certain cancers. Indigenous communities are disproportionately affected by suicide, substance abuse, mental health problems, and violence. These comparisons repre-

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Minnesota Physician November 2014

sent overall generalizations and do not capture significant diversity across the nation’s 560+ federally recognized tribes. Unfortunately, a closer look at our own region reveals that Indigenous people in the Upper Midwest experience even greater disease burden than many of those in other areas of the country. The Indian Health Service (IHS) is the primary federal provider of health care for Indigenous people and is divided into 12 physical service administrative areas. Tribes in the state of Minnesota are included in the “Bemidji Area” sector, which also includes Wisconsin, Michigan, Illinois, and Indiana. Most recent data from the IHS publication, “Regional Differences in Indian Health” reveals that in the Bemidji Area, rates of deaths due to unintentional injuries, diabetes mellitus, heart disease, lung cancer, female breast cancer, cervical cancer, and numerous other health problems are above average in comparison to IHS coverage areas overall. Furthermore, the Bemidji Area age-adjusted death rate is second highest at 1,470 deaths per 100,000 compared to 1,059/100,000 for IHS overall. The rate for the U.S. general population during the same time period was 872/100,000. These alarming trends parallel those found across Indigenous populations globally and reflect the very real and lasting consequences of colonization. In the United States, this includes systematic attacks on culture and lifestyle, removal of children, separation of families, social and geographic dislocation and isolation, and ongoing economic and sociopolitical marginal-

ization, including heightened poverty and barriers to accessing health care. Sources of strength Despite these significant factors, Indigenous communities maintain unique cultural resources, including the support of extended kin relationships, knowledge of Indigenous healing practices, traditional medicines, cultural involvement, and a sense of belonging that promote holistic wellbeing. There are increasing numbers of health care facilities across North America that provide both “Western” medical treatment and traditional Indigenous options, including integration with traditional healers, ceremonies, and healing gardens (Alaska’s Southcentral Foundation is an excellent example). Countless grassroots cultural and language preservation efforts including culturally centered health interventions and substance abuse prevention programs have proliferated across Indigenous reservations and urban institutes. At a minimum, these programs work to culturally adapt existing general population “evidence-based” programs to ensure a better cultural fit. Other programs are completely structured around very specific Indigenous value systems and accompanying activities, including traditional storytelling, ceremonies, language immersion, and connecting generations. Inherent in these approaches is recognition of the power of cultural reclamation and positive Indigenous identity. As one woman (an Indigenous elder) told our research team, “When you talk in your language, you do feel it, and your body feels it.” Until recently, Indigenous cultural strengths have been largely ignored in a research landscape where deficits and pathology permeate the literature. Scholarly evidence of the protective effects of culture on health lags behind what communities have articulated for decades, though researchers, policy makers, and practitioners are starting to take notice. A now-classic study by

Chandler and Lalonde (1998) explored the extreme heterogeneity in suicide rates across Indigenous reserves in British Columbia. They found that communities that made active efforts to reclaim and repair their traditional cultures had dramatically lower rates of suicides than those that did not. In short, cultural continuity was a protective factor against suicide. Cessation of alcohol use among Indigenous adults has been empirically associated with traditional spirituality, even after controlling for the effects of inpatient treatment (Torres Stone et al., 2005). Other researchers have shown involvement in traditional cultural activities to be correlated with better mental health, and a positive cultural identity associated with less bodily pain. Numerous qualitative studies explore Indigenous perspectives on resilience in terms of strong collective identity, extended kinship patterns, feelings of connectedness, and specific traditional teachings. These generalized findings are but an overview of a steady rise in systematic investigation of cultural factors as community-based mechanisms for health promotion. Researchers still have much to learn in terms of effectively conceptualizing and measuring “culture” and the protective mechanisms through which culture operates. Nonetheless, these findings are promising and demonstrate the critical need to engage and respect community perspectives and wisdom in the ongoing battle against health disparities. Community ownership and collaboration For researchers involved in studies with Tribal Nations, community-based participatory research (CBPR) and more specifically, tribally based participatory research (TBPR) are now standard protocol for ethical collaboration. CBPR and TBPR are orientations that set methodologies and shift the role of the “researched” away from passive subjects toward active participants engaged in research planning, data collec-

tion, dissemination, and implementation. This orientation is especially critical given tribal sovereignty and past exploitation of communities in the name of research. Underlying these models are principles of mutual respect, efforts to equalize power differentials, and the acknowledgement and respect for community sovereignty and ownership in the research process. Implications for physicians and medical educators What does all of this mean to the practicing physician? A possible parallel to CBPR/ TBPR in clinical encounters is patient-centered care, where providers make the effort to understand illness through each individual’s lived experiences in a safe, empathetic environment. Like CBPR, Indigenous patients are collaborators whose viewpoints are valued as critical to understanding health and healing. A skilled practitioner can explore the patient’s health beliefs in a cultural context by using (for example) questions outlined in Kleinman and Benson’s, “Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It.” Cultural perspectives are revealed when physicians take the time to ask questions like, “What do you believe is the cause of this problem? What do you think this problem does inside your body? How does it affect your body and your mind? What do you most fear about this condition? What do you most fear about the treatment?” Thus, the patient is free to share the degree to which culture may or may not impact her or his meaning of health and illness. How might we train the next generation of physicians to practice in a manner that encourages trust and cultural appreciation? At medical schools across the country, including the University of Minnesota Medical School–Duluth, faculty members are asking this particular question. The Liaison Committee on Medical Collaborating with Indigenous communities to page 23

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Professional Update: Cardiology

he principal approach to reducing atherosclerotic cardiovascular disease (ASCVD) risk due to dyslipidemia changed significantly with the publication of the American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Treatment Guidelines in November 2013. The guidelines were created by an expert panel from the National Heart, Lung, and Blood Institute in collaboration with the ACC/AHA based on extensive review of the medical literature. They contain several key differences compared to the 2001 National Cholesterol Education Program Adult Treatment Panel Third Report on the Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III), including: • A focus on ASCVD risk reduction in those shown to benefit most • Use of the Pooled Cohort Equations Cardiovascular Risk Calculator for risk

Atherosclerotic cardiovascular disease New guidelines for reducing risk By Elizabeth Tuohy, MD assessment in primary prevention • A new perspective on LDL-C treatment goals • Recommendations regarding statin safety The new Cholesterol Treatment Guidelines highlight that adherence to a heart healthy diet, routine physical activity, avoidance of tobacco products, and maintenance of a healthy weight remain key to overall health and ASCVD risk reduction.

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Focus on ASCVD risk reduction An extensive body of randomized controlled trial (RCT) data demonstrated a significant reduction in ASCVD events, such as coronary heart disease, cardiovascular deaths, and fatal and nonfatal strokes, with a good margin of safety from statin therapy for four groups: • Individuals with clinical ASCVD, including acute coronary syndrome, stable angina, coronary or other arterial revascularization, stroke, TIA, or atherosclerotic peripheral arterial disease • Individuals with primary elevations of low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dl • Individuals 40 to 75 years of age with diabetes and LDL-C 70 to 189 mg/dl without clinical ASCVD • Individuals without clinical ASCVD or diabetes, 40 to 75 years of age, LDL-C 70 to 189 mg/dl, and estimated 10-year ASCVD risk of 7.5 percent or more, identified with the new Pooled Cohort Equations Risk Calculator No recommendations were made regarding cholesterol treatment in individuals not in these four groups. Instead, it is recommended that physicians use clinical judgment and consider other risk factors, such as family history of premature heart disease; moderate hyperlipidemia (LDL-C >160 mg/ dl); high-sensitivity C-reactive protein ≥ 2 mg/dl; ankle-brachial index <0.9; coronary calcium score ≥300 Agatston

units or ≥75th percentile for age, sex, and ethnicity; or an elevated lifetime risk of ASCVD. No recommendations were made regarding cholesterol treatment in patients with New York Heart Association (NYHA) Class II-IV ischemic cardiomyopathy, end-stage renal disease on hemodialysis, HIV, or solid-organ transplantation. Global risk assessment for primary prevention The 2013 ACC/AHA Cholesterol Treatment Guidelines recommend the use of the Pooled Cohort Equations Cardiovascular Risk Calculator to estimate 10-year ASCVD risk. The calculator estimates risk using data from multiple community-based populations and is applicable to African American and non-Hispanic Caucasian men and women 40 to 79 years of age. For other ethnic groups, the equation for non-Hispanic Caucasians is recommended, although the calculator may underestimate or overestimate risk for other ethnic groups. This is a major change from the ATP III recommendations, which advised using the Framingham Risk Calculator for assessment of 10-year risk. Framingham estimated risk based on study populations rather than community-based populations, did not include race as a variable, and did not include stroke as a clinical endpoint. By more accurately identifying higher-risk individuals for statin therapy, the Pooled Cohort Equations Cardiovascular Risk Calculator focuses statin therapy on those most likely to benefit. A new perspective on LDL-C treatment goals Evidence from RCTs does not support the continued use of specific LDL-C tagets. Although treating to an LDL target has been common practice for many years, there are several problems with this approach. First, no clinical trials have titrated statin therapy to a certain LDL goal. Instead, fixed-dose statin strategies were used. Second, using LDL-C targets may result in undertreatment, such as using a low-intensity statin in a

patient with significant clinical ASCVD, or overtreatment with nonstatin drugs that have not been shown to reduce ASCVD when used in addition to optimal statin treatment, even though the drug may lower LDL-C. Third, treating with multiple cholesterol-lowering agents increases the risk for adverse effects without additional ASCVD risk reduction.

tensity. (To see a table on statin intensities, find Table 5 in the ACC/AHA Cholesterol Guidelines at: www.circ.ahajournals. org/content/early/2013/11/11/01. cir.0000437738.63853.7a)

Instead, the 2013 ACC/AHA Cholesterol Treatment Guidelines recommend choosing the appropriate intensity of statin based on an individual’s risk. High-intensity statin therapy is defined as a daily dose that lowers LDL-C by 50 percent or more. Moderate-intensity statins are expected to lower LDL-C by 30 percent to less than 50 percent. Low-intensity statins are expected to lower LDL by less than 30 percent.

Safety recommendations The ACC/AHA Cholesterol Treatment Guidelines provide safety recommendations for individuals receiving statins to reduce ASCVD risk. Prior to initiating statin therapy, physicians should assess a patient’s baseline fasting lipid panel and ALT and obtain a clinical history of any current muscle symptoms. It is reasonable to check a baseline creatine kinase (CK) for individuals believed to be at increased risk of muscle symptoms based on a personal history of statin intolerance, muscle disease, or use of other drugs that might increase the risk of myopathy. During statin treatment, it is reasonable to measure CK in individuals with muscle symptoms, but routine assessment of CK is not recommended. Similarly, it is reasonable to measure hepatic function if hepatotoxicity is suspected, but routine ALT assessment is not recommended.

Statin intensities High-intensity statin treatment is recommended for individuals with the greatest level of risk, including those 75 or younger with clinical ASCVD; those 21 or older with a primary elevation in LDL-C 190 mg/dl or greater; and those 40 to 75 years of age with diabetes with an estimated 10-year ASCVD risk of 7.5 percent or more. Moderate- to high-intensity statin treatment is recommended for individuals with clinical ASCVD who are older than 75 and individuals 40 to 75 years of age without diabetes or clinical ASCVD, but who have an estimated 10-year ASCVD risk greater than 7.5 percent. Moderate-intensity statin therapy is recommended for individuals with diabetes who have a 10year risk of less than 7.5 percent or those who are not able to take high-intensity statin therapy due to a history of intolerance; impaired renal or hepatic function; unexplained alanine aminotransferase (ALT) elevation more than three times the upper limit of normal; or concomitant use of drugs affecting statin metabolism. Similarly, low-intensity statin therapy may be considered in those unable to tolerate statins of greater in-

new-onset diabetes, particularly in individuals at increased risk for diabetes, such as those with impaired glucose tolerance or metabolic syndrome. The likelihood of statin therapy causing diabetes varies by statin inten-

These guidelines help to direct the choice of appropriate statin intensity.

Statin-induced myopathy and rhabdomyolysis are quite rare; however, statin-induced myalgias are not. If unexplained severe muscle symptoms develop during statin treatment, physicians should discontinue the statin and assess for the possibility of rhabdomyolysis. If mild to moderate muscle symptoms occur, statin therapy should be discontinued, and physicians should evaluate for other conditions that may have predisposed the patient to muscle symptoms, such as hypothyroidism, reduced renal or hepatic function, rheumatologic disorders, steroid myopathy, vitamin D deficiency, or primary muscle diseases.

sity. Moderate-intensity statins cause diabetes in one out of 1,000 statin-treated patients per year. High-intensity statins cause diabetes in three out of 1,000 statin-treated patients per year. Overall, however, the benefit in ASCVD risk reduction from statin therapy outweighs the risk of developing statin-associated diabetes. In summary While the ACC/AHA Cholesterol Treatment Guidelines do not address all topics relevant to cholesterol treatment, they help identify patients most likely to benefit from statin therapy for

the reduction of ASCVD. This guideline moves us away from treating to an arbitrary LDL target and helps us assess patients’ global ASCVD risk using information from the medical evidence to date and a more accurate risk calculator that also incorporates the important clinical endpoint of stroke. These guidelines help to direct the choice of appropriate statin intensity to match a patient’s risk. Appropriately, much is still left to clinical judgment and individualized care through provider-patient discussions. Reference: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Stone NJ, Robinson J, Lichtenstein AH, et al. J Am Coll Cardiol 2013; Nov 12

Elizabeth Tuohy, MD, is a board-certified cardiologist at United Heart & Vascular Clinic (UHVC), where she serves as medical director of the Heart Disease Prevention Clinic.

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Review of the statin RCTs show that statin therapy is associated with an increased risk of November 2014 Minnesota Physician

SPECIAL FOCUS: RURAL HEALTH

ometimes the easiest way to bring about change is simply to ask for it. That’s what happened in Redwood Falls, Minn. The physicians at Affiliated Community Medical Center (ACMC) needed help. They watched their newly diagnosed dementia patients walk out of their office feeling scared and unsure as to what would happen next. So, physicians reached out to the community’s aging-services organizations for a resource guide and to see if there were alternatives to long-term care. They needed something to bridge the gap between clinical and nonclinical care. Calls were made, leaders were gathered, and in the midst of a simple call for help, relationships developed into something much bigger. What started as a request for a resource brochure turned into a partnership and a rich network of resources created for an aging community that reached beyond the traditional health care system.

Creating a community partnership Providing memory care in rural Redwood County By Lynn Buckley, LPN, and Robin Weis Building a network The clinic administrator at ACMC met with the Minnesota River Area Agency on Aging and began discussions about a resource directory. This conversation later led to a written commitment to improve services for those being diagnosed with dementia. In order to achieve that goal, all the providers in Redwood County that served dementia patients and their families were asked to meet and begin figuring out what needed to be done. Instead of reinventing the wheel, we thought it would be a good idea to research other community partnerships. Our

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network replicated models from nearby dementia networks in Olivia and Willmar. We knew these networks were a success and looking at their models helped us set the goals that we wanted to pursue in Redwood County. The Redwood Area Dementia Awareness Network was formed in 2009. Currently, individuals from Redwood area nursing homes; assisted living facilities; memory care units; adult day health; the Minnesota Association of Area Agencies on Aging; ACE of SW Minnesota–Redwood County; and area clinics

and hospitals are represented in the network, which meets monthly. Other agencies such as public health, transportation, hospital discharge planners, and a personal care attendant (PCA) agency are available as needed. Each group in the network played an important role and brought their particular expertise to the table. All of these unique points of view ensured that the network provided the best solutions and care for dementia patients in the area. We were beginning to see how each member of the collaborative was instrumental in making the network a success. By meeting and talking through struggles or gaps in care, the network was able to find the best solutions for patients and their families. For example, at one meeting the director of an assisted living residence asked for help addressing the struggles of a married couple living at her facility. The husband’s dementia needs were exhausting his wife

and the assisted living facility was struggling to care for the couple. Through discussions, it was suggested that putting the husband into adult day services two or three times a week would not only give his wife a break from caregiving, but would allow the couple to stay together longer.

The Redwood Area Dementia Network was recently selected to become part of the ACT on Alzheimer’s action team. ACT on Alzheimer’s is a volunteer driven, statewide collaboration preparing Minnesota for the impact of Alzheimer’s disease and related dementias.

Ultimately, we wanted to help memory loss patients and their families find alternatives to long-term care, allowing them to live outside of the health care system, at least during the early stages of the illness. To do this successfully, the network had to implement or enhance assessment, education, support, and assistance to patients and their family caregivers. By educating patients about the services that are available to them, they can confidently choose the type of care that fits their needs. This actually reduces the cost of long-term care because people only enter these facilities when it becomes absolutely necessary.

Responding with resources One of the first projects that the dementia awareness network completed was a dementia resource guide for physicians. This involved organizing all the formal and informal resources available in the community and making them accessible on ACMC’s computer system so physicians had the information readily available. Over 88,000 Minnesotans age 65 and older live with Alzheimer’s and the number is growing. The organizations involved in the Redwood Area Dementia Awareness Network created a variety of resources in the Redwood Falls area for people with Alzheimer’s or other

dementias. Many conditions can cause memory loss and memory often improves when the condition causing the problem is treated. There are things that can be done even if the diagnosis is Alzheimer’s or a related dementia. The Redwood County memory care coordinator position was created in 2009 and is the first point of contact for dementia patients and their caregivers. The coordinator guides them through all of the available resources, and discusses community-based care options such as home care and adult day services. By connecting dementia patients and caregivers with the memory care coordinator as early as possible, patients and their caregivers are encouraged to take advantage of these resources when appropriate. The memory care coordinator also encourages patients and their families to visit memory care centers, adult day services, and

long-term care facilities, and to discuss home care services early on so caregivers are prepared and receptive to tapping into these services when needed. Memory care resources in Redwood County The Healthy Aging Education Series is designed for older adults with the goal of enhancing the aging process and reducing stress. The series is held in conjunction with the Redwood Area Hospital’s education program. Session topics include a heart-healthy diet, driving in later life, vision loss, health care directives, sleep, and the importance of respite care. Powerful Tools for Caregivers helps family members become more comfortable with their role as caregiver. This program is a series of six 90-minute classes, held once a week. Respite care is provided by Redwood Area Hospital’s adult day health program. Creating a community partnership to page 22

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November 2014 Minnesota Physician

Creating a community partnership from page 21

Caregiver Coaching is available for caregivers who need to find balance in their lives and look at their situation with fresh eyes. Caregiver consultants that offer coaching attend a two-day training course offered by the Minnesota Board on Aging and Minnesota Association of Area Agencies on Aging. The Virtual Dementia Tour is a hands-on experience that enables people to become sensitized to what dementia or Alzheimer’s disease might feel like. The Redwood Area Dementia Awareness Network offers the tours locally two to three times per year. Local long-term care and assisted living facilities, as well as police and fire departments have requested virtual dementia tours to educate their staff so they better understand their clients. A Matter of Balance is an ideal program for people who have fallen, are concerned about

falling, and have restricted their activities. It also helps those interested in improving flexibility, balance, and strength. Participants should be over age 60, ambulatory, and able to problem-solve. Two trained coaches lead the classes, which are two hours long and can be offered once a week for eight weeks or twice a week for four weeks. The curriculum includes a guest therapist from Redwood Area Hospital’s rehab department. Live Well at Home helps older adults live at home longer as they age. It’s an overarching philosophy of keeping communities together by offering the services and programs needed to mitigate the risk factors that are most likely to move elders out of their homes. A standard quiz called Rapid Screen identifies at-risk older adults. Rapid Screen is available at Live Well at Home’s website (mnlivewellathome.org) and as a mobile app. The next step is to offer Live Well at Home training for

providers to expand the referral base throughout Redwood County. The sooner older adults or their caregivers are able to reach us, the sooner we are able to mitigate risks before a crisis happens. Creating community trust Physicians know that the work of the Redwood Area Dementia Network and the memory care coordinator has helped to break down the barriers and fear surrounding a dementia diagnosis. When the network first started, the initial reaction by patients was to decline meeting with the memory care coordinator after being diagnosed with dementia. But as the public has become more aware of the network’s mission to become a dementia-friendly community, the physicians have seen greater acceptance and trust of the diagnosis and referral to the memory care coordinator. The partner organizations within the network are also seeing the added benefits of our

Three patients. Who is at risk for diabetes?

work together. While we were all working to develop a rich and varied set of solutions for the older adults in our community, we discovered that we also have a collective voice to bring change—especially when it comes to policy and communicating with our elected officials. Members advocate for other members, all with the same goal: the health and well-being of older adults in our community. By breaking down the silos of aging services and allowing the organizations to support each other throughout the care path, resources can grow and flourish. Lynn Buckley, LPN, is certified in gerontology and has been the coordinator of the Redwood Area Hospital Adult Day Services program for the past 23 years. She is the past president of the Minnesota Adult Day Services. Robin Weis is the Aging Program director for the Slayton office of the Minnesota River Area Agency on Aging, Inc. She works closely with Senior LinkAge Line and Minnesota Help Network.

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Minnesota Physician November 2014

Collaborating with Indigenous communities from page 17

Education (LCME) has charged our nation’s medical schools with providing training in cultural competency, also known as cultural humility or cultural safety. Such an ability to engage with all patients, and in particular with cross-cultural patients develops in several ways. First, medical learners gain knowledge about what culture means (and how it differs from race and ethnicity). Next, students explore their own attitudes about race, ethnicity, and culture. Simultaneously, medical learners practice real-world skills with patients. (In fact, developing focused knowledge, skills, and attitudes around cultural competence is one of the stated objectives of “Cultural Competence Education for Students in Medicine and Public Health,” a July 2012 report by an expert panel from the Association of American Medical Colleges and the Association of Schools of Public Health.

Too often, our medical literature simplifies cross-cultural encounters in a “cookbook” fashion, familiarizing the reader with common beliefs and customs of a certain cultural group. Though historical background about certain cultural beliefs and customs can be informative, physicians should be mindful that, “It should be understood that there is no one way to treat any racial and ethnic group, given the great sociocultural diversity within these broad classifications. We need instead to have a framework of interventions that can be individualized and applied in a patient- and family-centered fashion,” according to “A Physician’s Practical Guide to Culturally Competent Care” from the U.S. Health & Human Services Office of Minority Health. As Epner and Baile explain in their 2012 article in Annals of Oncology, “Patient-centered care: the key to cultural competence,” both physician and patient are better served by de-

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veloping foundational communication skills and awareness of health beliefs inherent across all cultures, rather than amassing superficial and potentially stereotyping categorizations about culture, beliefs, and expectations. Development of the knowledge, skills, and attitudes to provide culturally competent care is a lifelong process and extends well beyond medical school. An additional educational resource for physicians with an interest in enhancing these skills is “A Physician’s Practical Guide to Culturally Competent Care” mentioned earlier, which also grants free continuing medical education (CME) credit for completion. Conclusion Just as tribally-based participatory researchers have partnered with tribal communities to study health issues, medical students and physicians are encouraged to partner with their patients. Indeed, the patient-centered care model develops around the goals and at-

titudes of the patient. Historical attacks on Indigenous culture and ongoing marginalization of Indigenous knowledge are root social determinants of growing health inequities. Tribes have long articulated the protective and healing power of culture, and are owners and promoters of their community-based strengths. It is essential that researchers and physicians appreciate the impact that culture and Indigenous local knowledge can have on individual and community health. Melissa Walls, PhD (Bois Forte and Couchiching First Nation Ojibwe), is an associate professor in the Department of Biobehavioral Health & Population Sciences at the University of Minnesota Medical School– Duluth. Emily Onello, MD, is an assistant professor in the Department of Family Medicine & Community Health at the University of Minnesota Medical School–Duluth. She is board-certified in family medicine and practices at the Lake Superior Community Health Center in Duluth.

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Special Focus: Rural Health

he Affordable Care Act (ACA) is forcing health care systems to alter how they deliver services. This is not just a concern for large health care systems, but it impacts delivery methods at critical access hospitals as well. These changes have even affected local emergency medical services (EMS). High-deductible insurance coverage has resulted in a general decrease in transports per year for some EMS providers due to patients seeking alternate forms of transport.

As change occurs, TriCounty Health Care (TCHC), a 25-bed critical access hospital in Wadena, Minn., has looked for ways to reduce costs and readmission rates, and increase meaningful use and patient satisfaction scores in the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. Rural hospitals need to show their community that they are interested in quality care and, at the

Community paramedics Bridging gaps in rural health care By Allen Smith same time, find ways to improve so they remain competitive. Patients are customers, and as customers, they have the right to choose where to go for their medical care. Patients will seek care where they feel their needs are being met and will remain with local providers if that care exceeds their expectations. Rural areas often have gaps in their health care for various reasons. Gaps exist if patients have access issues or feel disconnected from health care. Upon discharge, patients often don’t understand their treatment plans and feel that their only option for clarification is a return visit to the emergency

Federal Funding for Broadband Available Qualifying health care providers may apply to receive 65% discounts on equipment and connections. The Healthcare Connect Fund was created by the FCC especially for providers in rural areas to: • Increase access to specialists through telemedicine • Enhance exchange of electronic medical records • Improve coordination of patient care

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Minnesota Physician November 2014

department (ED). Community paramedics (CPs) can educate patients about their treatment plans and the health services available to them, which could help avoid unnecessary visits to the ED. CPs also can help patients remain in their homes instead of being placed elsewhere. Ultimately, rural areas often have underserved patients with underutilized resources. A new EMS program called mobile integrated health care (community paramedic program) hopes to bridge these gaps. Community paramedics: A new EMS program A community paramedic is a state-certified paramedic who has completed a formal educational program through an accredited college and has shown competence in providing health education, monitoring, and services beyond the traditional roles of emergency care. The specific services CPs provide are organic and determined by local health needs and in collaboration with a physician. The program serves to increase patient access to primary and preventive care. In the summer of 2013, TCHC initiated a community paramedic program to meet the health care needs of rural Wadena. We wanted to address the gaps found in rural health care in a new way that was obtainable, sustainable, and that fit with our mission statement of being committed to improving the health of the communities we serve. The introduction of a community paramedic program, a top trend in EMS, fit well with TCHC goals. According to John Pate, MD, the medical director at TCHC EMS, a CP using a mobile integrative health care approach can help decrease emergency room visits

and health care costs, and increase patient outcomes. In addition to a critical access hospital in Wadena, TCHC has five rural clinics, two outpatient rehabilitation clinics, and a full-time multicounty advanced life support (ALS) ambulance service. Our service area incorporates approximately 25,000 people. CPs can educate patients and connect them to health care services that allow patients to manage their health care better. TCHC uses their CPs to assist with medication reconciliation, help elderly patients access their electronic patient records, and arrange for home health needs and durable medical equipment (DME). According to Pate, positive results already are being seen. In 2013, TCHC conducted a community health needs assessment as part of Minnesota Medical Assistance’s meaningful use requirements and found that 27 percent of residents had not gotten medical or mental health care when they felt it was needed. Our strategy moving forward was to help those patients with heart disease, stroke, diabetes, high cholesterol, high blood pressure, alcohol use, drug use, and cancer, and to alter unhealthy behavior. We wanted to reduce readmissions and help the numerous mental health patients in our service area. We felt it was important that the community paramedic be the eyes and ears of our providers and look for solutions to improve care. First steps: Partnering for success TCHC partnered with Wadena County Public Health as part of a Minnesota statewide health improvement program (SHIP) and received a community transformation grant (CTG). The SHIP and the CTG were tied to the Wadena County community health survey and TCHC’s health needs assessment. Wadena County Public Health, along with TCHC, would periodically evaluate the program using a scorecard method. These evalu-

ations would help us assess and improve the program and uncover other gaps that could be filled. These partnerships were important because all local stakeholders were involved in providing a solution to the community’s health needs. During initial meetings with our partners, we divided into two workgroups based on the participants’ expertise. The first group looked at aligning our eventual process with the Minnesota Department of Health, local providers, Wadena County public health, and the community. The second group addressed reimbursement barriers, facilitated knowledge sharing, and identified best practices. Both groups decided that the first people the CPs would target were noncompliant patients and those patients who had not qualified for or agreed to other services, such as home care. CPs are not long-term home care providers but they can help a patient adjust to the need for home care. We realized that patients often jump to the conclusion that applying for home health care means that long-term care is the next step. CPs could educate these patients about the true benefits of long-term home health care and once patients felt comfortable, the appropriate referrals could be made and received positively. We decided to also work with patients who had frequent hospital readmissions for acute myocardial infarction, heart failure, or pneumonia. We decided that behavioral health patients also would benefit from the CP program. At a later point, we decided to include patients who had three or more ED visits in less than four months. Both workgroups wanted to strive for higher patient satisfaction scores. Studies have shown that a post-discharge phone call will increase patient satisfaction scores to “always recommend.” The groups felt that a visit from a CP should further increase those scores by showing an investment in the

patient experience and his or her well-being. Program development We wanted to choose the right mix of paramedics to become CPs, so we focused on tenured paramedics who demonstrated excellent patient care skills and were tactful, enthusiastic, and results-oriented. We also chose paramedics who were high performers in the EMS system. Training to become a certified CP was conducted at an accredited local community college, and involved completing a total of 112 hours of classroom training, as well as 196 hours of clinical training at various hospitals, ultimately earning 12 college credits. The cost of the course was covered by a SHIP grant and involved five TCHC paramedics.

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Since the community paramedic program was new for TCHC, new processes had to be developed. For example: • How would CPs receive orders from clinics, the ED, or hospital once a patient was discharged and needed further services? • How would a CP request referrals or order items such as sleep studies, DMEs, physical therapy, or home health care? • Would CPs be able to bill for services? How would this billing meet the legal requirements of Minnesota Medical Assistance?

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November 2014 Minnesota Physician

Special Focus: Rural Health

n 2013, medical directors from Children’s Hospitals and Clinics of Minnesota, University of Minnesota Children’s Hospital, Gillette Children’s Specialty HealthCare, and Mayo Children’s Hospital began meeting informally to exchange ideas and share best practices for reducing preventable complications, readmissions, and serious safety events. They met to learn from one another and to improve the quality and safety of care in an “All teach, all learn” environment. Although each of the four organizations already had robust quality and safety improvement programs, they agreed that joining together and participating in the collaborative would accelerate their quality improvement efforts. The fact that the collaborators were competitors did not stop them from partnering with each other. They felt that when it came to safety and quality of care, working together to share their data, findings, and exper-

Learning collaboratives

representatives of: • Children’s Hospitals and Clinics of Minnesota • Gillette Children’s Hospital

An innovative improvement in pediatric care By Robert Payne, MD; Abe Jacob, MD, MHA; and Katherine Cairns, MPH, MBA tise was the best way to improve pediatric health care for every child in Minnesota. These initial meetings were the start of the Minnesota Hospitals’ Solutions for Pediat-

to build a statewide collaborative improvement model. The Ohio collaborative was later expanded and grew to include a network of over 80 pediatric hospitals nationwide.

That the collaborators were competitors did not stop them from partnering. ric Patient Safety Collaborative (hereafter called the Collaborative). The model was the Ohio Children’s Hospitals’ Solutions for Patient Safety that incorporated eight Ohio pediatric hospitals that worked together

Expanding the Collaborative In 2013, The Minnesota Collaborative expanded to include other hospitals and organizations with an interest in and commitment to pediatric health care. Participants now include

• Hennepin County Medical Center • Mayo Children’s Hospital • St. Cloud Hospital • University of Minnesota Children’s Hospital • Minnesota Chapter of the American Academy of Pediatrics • Minnesota Hospital Association Expanding from the initial group of pediatric hospitals has broadened the work and reach of the Collaborative. The original organizing medical directors recognized an opportunity for additional collaboration and sought funds to further their efforts. In the fall of 2013, the Minnesota Department of Health (MDH), as part of its health reform initiative,

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Why use a learning collaborative approach … especially in a rural area? Learning collaboratives for health care homes in Minnesota engage hospital and clinic-level leadership in quality improvement, practice redesign, and work toward the Institute of Health Improvement’s (IHI) Triple Aim objectives. The IHI Triple Aim is a national initiative to achieve the following goals: • Improve the individual experience of care • Improve the health of the population • Improve affordability by containing the per capita cost of providing care A learning collaborative builds leadership capacity to sustain patient-centered care and supports change through a team approach. It engages patients/families, clinicians, and other stakeholders in the learning collaborative as drivers of change and quality improvement. Minnesota has over 770 primary care clinics statewide. An estimated 40 percent of these clinics provide pediatric services. Transportation and time barriers make in-person meetings of the larger learning collaborative problematic. However, statewide and rural collaboratives have utilized team meetings/conference calls at the local level and statewide/regional updates via conference call and/or in-person meetings. This makes it easier for rural physicians and teams to participate. Training and updates on the project can be recorded and available as an online webinar for team members regardless of their location. Maintenance of Certification for physicians also can be available for participants with online access and feedback. sought proposals for health care homes and other clinics interested in patient-centered care. The Collaborative saw this as an opportunity to engage affiliated, primary care clinics with a focus on patient/family involvement in patient safety initiatives. The Collaborative received grant funds in 2014 from the MDH allowing it to incorporate outpatient facilities in this effort. Each of the four pediatric hospitals partnered with a primary care clinic to develop a universal patient safety education card (similar to an airline safety card) aimed at reducing adverse events for clinic visits and hospital admits. Some of the messages on the safety card are as simple as verifying patient ID before every dose of medication. Another example lets parents know it’s okay to ask providers whether they’ve washed their hands before touching their child. The safety card will be pictorial, so families of all languages and literacy levels will understand its message. Parent and family involvement The MDH, as part of its grant requirements, included a strong parent involvement component for each grant awarded. Thus, each hospital/clinic team included at least one parent partner/family advisor as an integral component in the quality improvement planning. Each hospital and clinic

team chose at least one parent or family member to provide input and feedback on the Hospital-Clinic Safety Card, which was the common selected safety project. Parents were so interested in working with the Collaborative that many had to be turned away, but received regular updates on the project despite not being involved. Erin Knoebel, MD, of Mayo Clinic, highlighted the parent role at a recent presentation, “We want you to ask us/tell us because you—the patients and the families—are part of our care team too.” What makes this collaborative unique is the focus on “transitions” between place of care and the parent/family as key members of the health care team. By improving communication with parents, patients, and clinic/hospital caregivers the Collaborative is aiming to reduce preventable complications and hospital-acquired infections; injuries in the clinic; preventable readmissions; and adverse drug events. Learning collaboratives, with parent/family involvement, are a natural adjunct to pediatric practice since parent and family involvement is key for preventive, episodic, and inpatient care. Increasing partners and collaborative projects Additionally, representatives of Medica, the MDH, the Department of Human Services, the Minnesota chapter of the Amer-

ican Academy of Pediatrics (MNAAP), the Minnesota Hospital Association, and others have contributed substantively to the Collaborative. Each of these partners brings a unique perspective to safety and quality in pediatric care. For example, one of the Collaborative’s projects is to focus on outpatient medication compounding.

Many pharmacies compound unusual or infrequently used medications, but there is no standard for the resulting formulation. Thus, a family might receive a medication with one concentration from one pharmacy and another concentration from another pharmacy, increasing the risk of accidental Learning collaboratives to page 34

ENGAN ASSOCIATES Creating Healing Environments for 35 Years Knowledgeable • Creative • Experienced

“We wouldn’t hesitate to work with Engan Associates again.” (Matt Reinertson, Heartland Orthopedic Specialists)

Allergy and Immunology

ass the Kleenex! It’s ragweed pollen season in most of the U.S. and your nose knows. Commonly called hayfever, it’s also known as allergic rhinoconjunctivitis and it affects 20 percent or more of the American population. Patients call or visit your office complaining of sneezing, runny nose, congestion, and itching caused by pollen. Other allergens such as animal dander, mold spores, and dust mites also are potent triggers of this IgE-mast-cell-driven condition. Many patients also will develop allergic asthma. Avoiding allergens is the best way to avoid symptoms but this is not always possible. Nasal saline rinses used with a neti pot or squeeze bottle are a nonpharmacologic way to help wash away allergens and inflammatory mediators. There are many good over-thecounter medications available such as nonsedating antihista-

Allergy immunotherapy What’s new? By Nancy Ott, MD mines, nasal steroid sprays, and ketotifen eye drops to control allergic rhinoconjunctivitis, so prescription medication often is not needed. Too often these measures don’t successfully control allergy symptoms.

There are new treatments now available to allergy patients. Patients will complain about side effects from medication or don’t want to take medication for long periods of time. If IgE skin or blood tests confirm an allergy, then subcutaneous

BC/BE Family Practice Mercy Family Clinic – Lake Mills, Iowa (Outpatient only) Manage your own outpatient practice This outstanding practice opportunity provides approximately 75-100 outpatient visits per week. Become part of a 9-hospital and 43-clinic Mercy Health Network–North Iowa. Services include: Primary Care–for men, women and children of all ages, Laboratory, X-ray, EKG, Podiatry Clinic, Behavioral Services-Individual and Family Counseling Lake Mills is a family oriented community of approximately 2,000 people. Located just 35 miles from Mason City, Iowa and 117 miles from Minneapolis, MN, it is home to many high quality businesses, an industrious labor force, excellent municipal facilities and an equitable tax structure. An abundance of amenities include a new aquatic center, a beautiful golf and country club, and four city parks. Outdoor activities abound and the excellent school system was one of 64 nationwide to be named a “Service Learning Leader.”

Practice where your skills are appreciated, where physicians are highly respected members of the community, where you and yours will flourish as you become rooted in a lifestyle second to none.

Send CV to: scottcl@mercyhealth.com (888) 877-5551 or (641) 428-5551 www.mercynorthiowa.com Mercy Medical Center–North Iowa

1000 4th Street SW, Mason City, IA 50401

immunotherapy (SCIT) can be given over weeks, months, and years. SCIT was the only FDA-approved immune-modulating treatment available for allergies until recently. There are new treatments now available to allergy patients.

Minnesota Physician November 2014

Jonna Quinn, D.O., OB/GYN, joined Mercy 2013 Mark Lloyd, D.O., Family Medicine, joined Mercy 2014

Subcutaneous immunotherapy More commonly called allergy shots, SCIT is available for allergy sufferers age 5 and older. SCIT induces tolerance to allergens. This sustained decrease or resolution of allergy symptoms, even after cessation of immunotherapy, is caused by a number of immune changes including down-regulating the T-helper-2 cells’ allergy-inducing cytokines such as IL4 and IL5. IgG4 blocking antibodies also play a role in tolerance as well as up-regulating other cytokines such as IFN-gamma and the decrease of eosinophil number and activity. IgE levels often decline as well. SCIT also has been found to prevent the onset of asthma and new allergy sensitization in children. Tried and true, this century-old treatment of inducing tolerance has a couple of new twists: 1) Rush SCIT can help build up tolerance faster than the traditional method, and 2) newly FDA-approved sublingual immunotherapy (SLIT) uses tablets under the tongue, not shots. SCIT dates back to the early 1900s when Leonard Noon, MD, took mixtures of pollen and injected the extract into hayfever patients, reporting the resulting decrease of allergic symptoms in Lancet in 1911. Since that time, specific allergens from dust mites, cat,

grass, ragweed, and stinging insects (i.e., bees) have been identified and isolated, making specific standardized allergen extracts available. Tree pollen, mold, and dog extracts have not yet been standardized, but extracts are available. Attempts to standardize mold extracts have failed because each batch grows different allergens. Allergy shots are started at 1/100 or 1/1000 of the top therapeutic dose (or maintenance dose). After initial allergy extract buildup occurs over three to six months in a physician’s office, six to 20 micrograms of a specific allergen at top dose is injected subcutaneously every four weeks for a total of three to five years, which should sustain tolerance. The major drawbacks of this therapy include the risk of anaphylaxis, the time commitment of weekly and then monthly visits that include a 30-minute reaction waiting period after receiving the shot(s), and a potential 30 percent failure rate. In order to get shots, patients must be healthy, have controlled asthma, and should carry an epinephrine device in case a reaction occurs after the 30-minute wait. Any reaction beyond local itching at the injection site could herald the onset of anaphylaxis and therefore epinephrine should be given with any systemic reaction no matter how mild. Rush immunotherapy For patients that can’t invest the time-intense weekly buildup or who have to reach top dose quickly, rush immunotherapy is a very effective method. Rush involves injecting the majority of buildup doses (27 total for aeroallergens and 17 for venom) in one to three days. Preparation for this intensive buildup includes vigorous premedication with histamine blockers, leukotriene blockers, and corticosteroids. In select patients, rush immunotherapy using omalizumab, an anti-IgE biologic that is FDA-approved for asthma and chronic urti-

caria, has been given off-label for three months prior to SCIT combined with the premedication plan. Sublingual immunotherapy In addition to SCIT, the FDA approved sublingual immunotherapy (SLIT) for grass and ragweed pollen in early 2014. Instead of an injection, this therapy involves placing a pill under the tongue to dissolve. Patients have to be monitored by a physician the first time they take the pill, but can be dosed at home thereafter. There is less risk of a serious reaction such as anaphylaxis with SLIT, however we recommend that patients keep an epinephrine injectable on hand just in case. Twenty percent to 30 percent of patients will have side effects consisting of an itchy mouth and throat. Although the symptoms that occur in the oropharynx are mostly local, a rare case of anaphylaxis has been reported. Unlike SCIT, which can be started any time of the year, SLIT must be started three to four months prior to the pollen allergy season and continued throughout the season. SLIT is done seasonally each year, whereas SCIT can be discontinued after three to five years. SLIT should not be given to patients with unstable asthma, eosinophilic esophagitis (EoE), or to those taking beta-blockers. Patients who are hypersensitive to inactive ingredients such as fish-source gelatin, mannitol, and cellulose should not take SLIT. SLIT has been available in Europe longer than in the U.S. because Europeans have a different system for measuring allergens and the FDA requires a rigorous approval process for new treatments. A number of randomized placebo-controlled Phase III trials for grass and ragweed pollen SLIT in adults and children inadequately controlled by medications have been studied over the last two decades in the U.S. In the

Journal of Allergy and Clinical Immunology in 2010, a European grass pollen SLIT study was reported. The treatment phase lasted three years and a follow-up study of subjects one year after treatment was completed. The study looked at symptoms, medication scores, quality of life, percentages of symptoms, and medication-free days. The study reported that the active group had significant sustained benefit in all areas during treatment as well as one year after SLIT was stopped as compared to placebo. Symptom scores and medication scores dropped 26 percent and 29 percent respectively. Similar studies have been conducted for ragweed pollen and dust mites. U.S. randomized-placebo-controlled studies have not assessed SLIT’s affect on asthma. In Italy in 2009, J. Walter Canonica, MD, conducted a meta-analysis regarding the efficacy of SLIT for asthma. In one study of 397 adults and children, he found a significant reduction in asthma medication for house dust mite SLIT compared to placebo (p=.02). Three products currently are available for SLIT in the U.S.: Ragweed Ragwitek for ages 18 to 65, 5-Grass mix Oralair for ages 10 to 65, and Timothy grass GRASTEK for ages 5 to 65. These products currently are licensed for patients who have allergic rhinitis with or without allergic conjunctivitis symptoms and IgE-antibody-proven allergy. Treatment must start three to four months before the season starts. GRASTEK can be extended year-round to complete a threeyear program for sustained effectiveness. Twenty percent to 30 percent of patients will have side effects consisting of an itchy mouth and throat. Although the symptoms that occur in the oropharynx are mostly local, anaphylaxis has occasionally been reported. Final thoughts Allergic rhinoconjunctivitis can range from a minor irrita-

tion to a severe problem with comorbidities such as sinusitis, otitis media, reflux, polyps, and asthma. Control of this common problem should be easily attainable for most with current medications and advice from your primary care provider. Severe cases of allergic rhinoconjunctivitis should be evaluated by an allergist for treatment of comorbidities. SCIT with traditional or rush buildup can provide symptom relief with long-term immunologic change. SCIT can be used for dust mite, pollen, animal,

and mold allergy. For pollen allergy sufferers, SLIT is now available for two of the three pollen seasons and is available for those patients who don’t have the time to visit a doctor’s office for allergy shots. These successful treatments can help our patients cope, feel better, and put the Kleenex box away! Nancy Ott, MD, is board-certified in allergy and immunology and has practiced this specialty for 22 years. She practices at the Mayo Clinic in Rochester. Special interests include asthma, food allergies, and atopic dermatitis.

e f i L l u f r e d A Live n o It’s A W Radio Play

– Adapted for stage by Joe Landry

LUNCH AND DINNER PERFORMANCES DECEMBER 11 – 21, 2014 This beloved American holiday classic comes to captivating life as a live 1940s radio broadcast. $65 for matinee and $85 for evening performance. Per person price includes a three-course lunch or dinner, coat check, taxes and service charge.

Book online at saintpaulhotel.com or call 651-228-3860 for more information.

350 Market Street, Saint Paul, MN 55102 | 800-292-9292 | saintpaulhotel.com

November 2014 Minnesota Physician

Women’s Health

hen it comes to having children, some say that 40 is the new 20. Is this true? Maybe, if statistics about older mothers are to be believed. Career-minded women increasingly have postponed childbearing until later maternal ages. Over the last 20 years in the United States, the number of live births to women of advanced maternal age (AMA) has increased. AMA is defined as 35 years and older. Since 1990, delayed childbearing rates in women aged 35 to 39 increased by 50 percent. Rates in women aged 40 or older grew by 70 percent in the same timeframe (Hamilton et al., 2013; Martin et al., 2011; Matthews and Hamilton, 2009). Many of these were first births. Trends to delay childbearing and first births are not unique to the U.S., and also are observed in other developed countries that include Western Europe and Canada. They are largely attributed to factors that reflect advances in women’s

Advanced age pregnancy

functional labor and Cesarean delivery, intrauterine growth restriction, decreased birth weight, and stillborn babies (especially if other risk factors are present and in first-time AMA mothers).

Assessing risks and outcomes Jillian Hallstrom, MD health and societal status: more effective and greater access to birth control, advanced fertility/ reproductive technology, higher education, women in the workforce, and delayed marital age. AMA risks Delaying childbearing is not without risk. According to the American Society for Reproductive Medicine, the probability of attaining pregnancy begins to decline at about age 32 and increases quickly after age 37. This further increases the time to achieve pregnancy. The likelihood of miscarriage increases with age. Numerous studies show miscarriage rates

as a function of maternal age at 25 percent for women aged 30 to 39, and 50 percent for women aged 40 to 45. Coexisting medical conditions become more prevalent, which can increase the rate of pregnancy complications. Other adverse pregnancy and perinatal outcomes associated with AMA are well documented (per UpToDate and the American Congress of Obstetricians and Gynecologists). Older mothers are at greater risk for gestational diabetes, gestational hypertension, preeclampsia, placental abruption, placenta previa, preterm delivery, dys-

The rate of twins and higher-level multiples also increases with maternal age, which poses additional risk beyond even a singleton pregnancy. Many, due to declining fertility, are likely to require reproductive assistance, to great expense and physical and emotional hardship. Increased miscarriage rates are largely associated with chromosomal abnormalities, most notably Down syndrome, but also with trisomies of 13 and 18, and sex chromosome abnormalities. Given trends toward delayed motherhood, it’s good news that today’s obstetric providers are better equipped than ever to clinically counsel and medically assess and manage AMA patients, increasing the likelihood

It’s your life. Live it well.

Family Practice with OB Family Medicine

Stevens Community Medical Center’s Starbuck Clinic is looking for a family medicine physician. Enjoy the beautiful area lakes, quiet atmosphere and all that West Central Minnesota has to offer. Starbuck Clinic is home to Staff Care’s 2013 Country Doctor of the Year. Dr. Bösl and Greg Rapp, PA provide full clinic services in the picturesque town of Starbuck, MN on Lake Minnewaska. Dr. Bösl would like to transition into retirement. If you would enjoy the serenity of a rural lake community plus the comfort of an independent practice, this is your opportunity!

For more information, contact John Rau, CEO or Dr. Robert Bösl. Morris location

Starbuck location

320.589.7655 jrau@scmcinc.org

320.239.3939 rbosl@hcinet.net

John Rau, CEO

Dr. Robert Bösl

www.scmcinc.org

Visit us on Facebook and Twitter.

Minnesota Physician November 2014

EOE

Our independent, physician-owned clinic is seeking a BC/BE physician with OB for our family practice facility. 1:9 Calls. Competitive salary/benefits, with opportunity for ownership within 1 year. Paid malpractice, health and dental insurance, 401(k), CME and more. Cloquet is an historic, vibrant community just 15 minutes from Duluth and 10 minutes from Jay Cooke State Park. Adjacent to the St. Louis River, Cloquet has hiking, biking and ATV trails; skiing; boating; fishing; parks; and the only white water rafting in Minnesota. Residents enjoy locally performed plays, concerts and the arts; community festivals; dining and more.

Send CV to: jturonie@raiterclinic.com 218.879.1271 • www.raiterclinic.com 417 Skyline Blvd. • Cloquet, MN 55720

of positive outcomes for both mother and baby. Preconception counseling All women contemplating pregnancy, especially those of advanced age, should receive preconception counseling. Older mothers present complexities that are not as prevalent in their younger counterparts. Women of AMA often are at greater risk for coexisting medical conditions due to age and/or lifestyle, including hypertension (preexisting and gestational); diabetes (preexisting and gestational); medical illness that includes cardiovascular disease and cancer; decreased fertility; and high follicle stimulating hormone (FSH) levels. Preconception counseling is warranted in this population and presents good insight into AMA baseline health status so that obstetrical management protocols can be adjusted to assure best outcomes for older mothers and babies.

Preconception counseling should include discussion of lifestyle concerns such as exercise, nutrition, and environmental exposures; review of family and individual health history; risk assessment; evaluation and diagnostic screening for genetic conditions and preexisting medical conditions; updated immunizations; and mammogram screening when indicated. Open discussion about fertility changes in both parents should be addressed at this time. Frank discussion about risks of chromosomal abnormalities based on maternal age, and consideration of how the parents would wish to proceed if an abnormality is found, should be addressed. Improved screening innovations Today, AMA patients have more options for screening and diagnostic tests during pregnancy to evaluate for chromosomal abnormalities and birth defects. These women still are offered

more invasive diagnostic tests such as amniocentesis or chorionic villus sampling (CVS) (which carry a risk of miscarriage in a small percentage of patients), but also have options for more reliable noninvasive screening tests. The diagnostic accuracy of noninvasive prenatal screening tests has improved in recent years. Noninvasive screening tests in first and second trimesters to assess age-related risks include nuchal translucency (NT) screening ultrasound with PAPP-A and the quadruple screening test respectively. Both use maternal blood serum markers that are put into a mathematical equation to calculate the risk for the current pregnancy. The NT-PAPP-A test factors ultrasound findings and the quad screen factors in maternal age. Using maternal age, however, often triggers a positive screen, necessitating additional testing for definitive answers. These tests also screen for nonchromosomal birth

defects (neural tube defects, cardiac defects, etc.) and chromosomal aneuploidy, characterized by extra or missing chromosomes. Aneuploidy is commonly linked to significant genetic disorders such as Down syndrome and trisomy 13 and 18, and, thereby, higher rates of miscarriage. Specifically, these tests pick up approximately 80 percent to 87 percent of Down syndrome with an estimated 5 percent false positive rate. Additionally, they can detect trisomies 13 and 18. Since about 2012, new noninvasive screening tests to detect fetal genetic defects have been developed. They involve using cell-free fetal DNA and technology using genomic sequencing from maternal plasma to detect fetal aneuploidy. These tests have detection rates in the 98 percent range for trisomies 13, 18, and 21, and can be done as early as nine to 10 weeks of gestation. One test currentAdvanced age pregnancy to page 32

Urgent Care We have part-time and on-call positions available at a variety of Twin Citiesâ&#x20AC;&#x2122; 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.

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 Fellowshiptrained in geriatrics, 10 other mental health professionals, and two chemical dependency professionals.

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

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

MN Physician 4" x 5.25" 4-color

November 2014 Minnesota Physician

Advanced age pregnancy from page 31

lyavailable also has detection rates for sex chromosome aneuploidies and trisomies 16 and 22. Currently, these tests only are offered as screening to high-risk individuals and women of AMA. They have not been tested in low-risk patients or women with multiple-gestation pregnancies. Targeted/Level II ultrasound also should be recommended to all women of AMA. Any patient with a positive screen on any noninvasive screening test or an abnormal targeted ultrasound is considered at risk, and should be offered invasive diagnostic tests such as amniocentesis or CVS, and genetic counseling. Patient monitoring Close monitoring during pregnancy with a high index of suspicion is warranted for all patients, but especially those women of AMA, watching for signs of a pregnancy complica-

tion. Early ultrasound should be considered for evaluating viability and fetal number (increased rate of multiple gestation). Regular care needs to be stressed, with evaluation for hypertension or preeclampsia, testing for gestational diabetes, and assessing fetal movement and fetal growth. Because women age 40 and older are at even greater risk of stillbirth, additional antenatal testing is recommended near term. Based on more recently developed UpToDate recommendations, our practice initiates antenatal testing at 37 weeks gestation and we recommend delivery at 39 weeks gestation (one week prior to the due date), possibly earlier with additional maternal comorbidities. AMA women aged 35 to 39 with additional risk factors (African American race or obesity) also should have antenatal monitoring and consideration of delivery at 39 weeks gestation. In women aged 35 to 39 with no

additional risk factors, we recommend delivery at 40 weeks. Labor and delivery in older mothers typically takes longer and may prove more difficult. Cesarean deliveries are more likely in older mothers and recovery following delivery can be delayed. Postpartum concerns Mothers of AMA are at no greater risk than their younger counterparts for postpartum depression, weight management, or lactation. However, perimenopausal or menopause-related changes may impact breast milk production, induce fatigue, and pose different needs in these patients. Postpartum birth control needs for women of AMA may differ compared to younger women. Conclusion Pregnancy in older women is becoming more common and it is important for providers to be familiar with the higher

risks present in this population of women. Pregnancy in this population can be very rewarding and lifestyle-changing, and presents with unique challenges. Patients need to be counseled appropriately and offered testing available to maintain their safety and that of their babies. For many who have delayed childbearing until later ages, stillbirth can be an even more devastating consequence of pregnancy complications, given the decreased rate of fertility and declining chances of successful pregnancy for the future. Maintaining good health in pregnancy helps to reduce the risk of longterm medical problems. With close monitoring, we can help maximize chances for a healthy pregnancy and minimize risks to the future health of our patients. Jillian Hallstrom, MD, is boardcertified in obstetrics and gynecology, and practices at Oakdale Obstetrics & Gynecology, with clinics in Maple Grove, Plymouth, and Crystal.

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

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

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 • General Surgery • Geriatrician • Outpatient Internal Medicine

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

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 November 2014

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

Join the Leader in Correctional Health Care FEDERAL BUREAU OF PRISONS

Full-Time Psychiatrist – FMC Rochester, MN Full Time Clinical Director – FCI Sandstone, MN Learn more at: www.bop.gov

November 2014 Minnesota Physician

Learning collaboratives from page 27

and possibly a health plan?

incorrect dosing by parents. The Collaborative is convening pediatric pharmacists from around Minnesota to examine the feasibility of standard concentrations for pediatric medicines that are individually compounded.

• Are you interested in adding parents/family members to your quality improvement team, parent advisory council, or teen advisory council? • Do you want to hear about successful pediatric learning collaboratives from the St. Cloud, Duluth, and Rochester areas that report improved immunization rates, decreased hospitalizations, improved care coordination for children/teens/young adults with chronic health conditions, and improvements in access to care for diverse patient groups?

Joining the Collaborative The Collaborative seeks to improve the safety and quality of care for every child in Minnesota. Many children receive care outside a hospital or even a hospital-affiliated clinic. Despite the size of the hospital or clinic, or the nature of the organization, the Collaborative wants to encourage more rural hospitals and pediatric clinics to participate. Consider how the Collaborative could benefit your hospital or clinic, especially if you are in a rural area:

• Do you have parents or patients interested in helping with a clinic or hospital project?

• Could you use this opportunity to work on a project that jointly benefits your affiliated hospital, clinic,

• Do you have one or two hours per month to work on a learning collaborative in your clinic or hospital?

Sioux Falls VA Health Care System

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 Primary Care (Family Practice or Internal Medicine) Psychiatrist Endocrinology

Pulmonologist Oncologist Cardiologist (part time) Physician Assistant (Mental Health)

Sioux Falls VA HCS (605) 333-6852 www.siouxfalls.va.gov

• Do you have two or more clinic or hospital staff interested in working on a pediatric quality improvement project in cooperation with parents/patients? • Has your clinic considered Minnesota health care home (HCH) certification or Minnesota Department of Human Services Health Home (a behavioral health care home and primary care) certification? Do you need help figuring out how to make it happen? Competition can be useful in health care, but when it comes to safety and preventing injuries, collaboration among health professionals with the patient as the focus is far better. The Minnesota Hospitals’ Solutions for Pediatric Patient Safety Collaborative welcomes additional hospital/clinic teams who want to join. Together we will continue to improve safety and quality of pediatric care for every child in Minnesota.

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

Minnesota Physician November 2014

Robert Payne, MD, is board-certified in neonatal-perinatal medicine and pediatrics and is the medical director for the Departments of Quality and Research at Children’s Hospitals and Clinics of Minnesota. Abe Jacob, MD, MHA, is board-certified in pediatrics and internal medicine. He is the chief medical officer at the University of Minnesota Children’s Hospital and an assistant professor of pediatrics and internal medicine at the University of Minnesota Medical School. Katherine Cairns, MPH, MBA, is executive director of the Minnesota chapter of the American Academy of Pediatrics and project manager/facilitator for six other national and state medical home learning collaboratives.

Family or Internal Medicine Physician

Applicants can apply online at www.USAJOBS.gov

If your hospital and an affiliated primary care clinic are interested in more information on this pediatric learning collaborative, contact Dr. Abe Jacob at akj@umn.edu or Dr. Rob Payne at Rob.Payne@childrensmn.org. We meet on the second Tuesday of every other month (November, January, etc.) at 6 pm. Teleconference options also are available.

WE CHOSE MERCY FOR THE PRACTICE; WE’RE STAYING FOR THE COMMUNITY! Mercy and North Iowa offer: • Premier

Olmsted Medical Center, a 160-clincian multispecialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth.

Opportunities available in the following specialties:

Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere.

Family Medicine Pine Island Clinic

The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Cardiologist Rochester Southeast Clinic Child Psychiatrist Rochester Southeast Clinic

General Surgery Call Only – Rochester Hospital

rural health care network in northern Iowa and southern Minnesota; • Centers of Excellence: Bariatric, Breast Imaging; • Family-friendly communities with plenty of parks, great schools and activities; • Culture: museums, nature centers, The Legendary Surf Ballroom; • Half-way between Des Moines and Mpls/St. Paul

Family Medicine (with and without OB) Opportunities in the following North Iowa communities: • Ackley/Iowa • Emmetsburg Falls • Hampton • Algona • Lake Mills • Britt • Mason City • Clear Lake • Osage • Cresco

For more information: Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 102 Elton Hills Drive NW Rochester, MN 55901

Cindy Scott: 641-428-5551, scottcl@mercyhealth.com www.mercynorthiowa.com

Jonna Quinn, D.O., OB/GYN, joined Mercy 2013 Mark Lloyd, D.O., Family Medicine, joined Mercy 2014

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

www.olmstedmedicalcenter.org

Family Medicine & Physician Assistant

Family Medicine

Great Opportunity

St. Cloud/Sartell, MN

In a St. Cloud area URGENCY CENTER

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.

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

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

763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

MN Physician 4" x 5.25" 4-color

November 2014 Minnesota Physician

Community paramedics from page 25

A partial list of services provided by TCHC’s community paramedics • L ab draws on long-term care patients and home-bound patients

• Twelve-lead EKGs for longterm care patients

• Tracheal tube stoma care

• IV restarts for long-term care patients

• Bladder scans

• Wound care

• Medication compliance of mentally ill patients

• Pre-orthopedic surgery home visits to assess falling hazards

• Medication education

• Post-surgery follow-up to assess sepsis potential

resources; and coordination of care between providers, social services, and ancillary health care departments. When needed, additional training for CP staff was provided to ensure that interactions with patients remained positive and exceeded the patient’s needs. Eventually, the CP program was ramped up to full speed. Meetings were held with local stakeholders to identify other gaps in the health care system that CPs could help bridge and this led to increased patient

satisfaction and health care savings. The program had some of its best moments when serving the high number of mental health patients. There often are long ED wait times for patients who have to be medically cleared before being placed in a mental health facility. Evaluation of this process showed that it made more sense for the crisis intervention team to start the placement process, and send the nonrisk patient home where a CP then could do the lab

draws instead of making them wait for the lab draws and results at the hospital. The patient could return to the ED after the lab results were in. It’s not uncommon for a patient waiting for medical clearance in the ED to become anxious and have a violent outburst aimed at the staff. These patients often feel more at ease at home. Sustainability Everyone is concerned about sustainability. Although we’ve started to see some changes with Minnesota Medical Assistance reimbursing for some services, there will be a need to pursue legislation to get Medicare to reimburse for non-transports. This will take time and showing carriers the value-based savings that can occur will facilitate the change. Our own experience has shown that after implementing the CP program, we documented health care savings of $43,000 per month during the first quarter, and $22,000 per month

during the second quarter. We arrived at these calculations by taking into account the total cost of transporting a patient to the ED and the cost of services while there. We then compared these charges to the cost of the services provided by a CP, which should prevent unnecessary trips to the ED. As the ACA implemented the federal incentive for hospitals to reduce readmission rates or incur penalties, these federal regulations have opened the door for CPs to bridge rural health care gaps and work with hospitals to both increase patient access/outcomes and reduce cost. With this change, EMS will need to take an active role in the coordination of patient services and show that the profession adds value to the system. Allen Smith is the EMS manager at Tri-County Health Care, a critical access hospital in Wadena, Minn.

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

Currently we are seeking to add the following specialists:

300 S. Bruce St. Marshall, MN 56258

• General Surgery

• Internal Medicine

• Radiation Oncology

• Family Practice

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 36

Minnesota Physician November 2014

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

• Medical DirectorExtended Care & Rehab • Geriatrician/ Hospice/ (Geriatrics) Palliative Care • Ophthalmologist • Internal Medicine/ Family Practice

• Psychiatrist

Applicants must be BE/BC.

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:

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.

• Family Practice • Urgent Care 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.

Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible. Please contact or fax CV to:

Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429

763-504-6600 Fax 763-504-6622

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 www.NWFPC.com November 2014 Minnesota Physician

The physician workforce in Minnesota from page 15

data can provide much-needed insight on how the balance between supply and demand is being constantly shaped and reshaped by evolving practice models. How are these data used? In addition to summary reports available on the MDH website (www.health.state.mn.us/divs/ orhpc/workforce/data.html), these data help the MDH respond to legislative, policy, and workforce development requests for information. Some examples include: • MDH provided data on Minnesota’s practicing psychiatrists and other licensed mental health professionals to a legislatively convened mental health workforce workgroup charged with increasing the number of mental health providers in the state.

• MDH provided physician workforce data to a legislative task force working to address barriers faced by immigrant international medical graduates to attain state licensure and integrate into Minnesota’s workforce. • MDH and BMP partnered with the Federation of State Medical Boards (FSMB) on a pilot project to develop a minimum dataset on physicians to inform state and federal physician workforce policies. • The Rural Health Advisory Committee (RHAC) has used physician workforce data to inform its decision-making; for example, RHAC used this data in reports on general surgeons and obstetric services in rural areas. • MDH data have informed current and past workforce policy discussions

such as the Legislative Health Care Workforce Commission (2014–2016); the National Governor’s Association Workforce Policy Academy (2014– 2015); the University of Minnesota Medical School Blue Ribbon Commission (2014); the Foreign Trained Physician Task Force (2014); and the Governor’s Health Care Reform Task Force–Workforce Work Group efforts (2011). In addition to these activities, MDH routinely responds to data requests from state and federal agencies, universities, research centers, associations, legislators, and the public. How can you help? State law requires physicians to provide occupational data to MDH. Upon completing the online application to renew your medical license, you will be directed to answer a brief set of workforce questions.

Simply respond to these questions accurately and fully. The process is meant to be seamless and efficient, and should take you five to seven minutes to complete. Your responses help develop a comprehensive picture of the physician workforce and support health workforce planning efforts in Minnesota and nationally. Want to know more? To learn more about healthcare workforce data, check out the MDH website at www. health.state.mn.us/divs/orhpc/ workforce/ or call (651) 2013838 for data requests or questions. Watch for an updated physician workforce report this fall! Teri Fritsma, PhD, is a senior workforce analyst at the Minnesota Department of Health. Nitika Moibi, MPP, supervises the health workforce data collection, planning and analysis, and policy work at the Minnesota Department of Health, Office of Rural Health and Primary Care.

Behavioral Health Assistant Medical Director – Outpatient Care Minneapolis/St. Paul, Minnesota HealthPartners Medical Group is a large, successful, award-winning multispecialty physician practice in Minneapolis/St. Paul, Minnesota. Our Behavioral Health Division seeks a high-energy, visionary psychiatric leader for all HealthPartners Behavioral Health outpatient sites and services throughout the Twin Cities metropolitan area. Our ideal candidate is an engaging, adaptable, forward-thinking leader who focuses on collaboration and creativity while effectively analyzing our internal data in order to achieve national benchmarks for quality of care, patient satisfaction and affordability. In partnership with the Director of Outpatient Professional Services, you will ensure excellence in the care, patient satisfaction and stewardship of mentally ill and substance abuse patients while continuously improving our systems, encouraging the professional growth, satisfaction and interdisciplinary teamwork of our providers and staff, and promoting integration and collaboration efforts with HealthPartners’ primary and specialty care divisions and the community. You will be responsible for the clinical quality, productivity and efficient use of outpatient clinical care resources, performance improvement processes and outcomes, and documentation/billing/compliance for our clinicians. As liaison with our outpatient primary and specialty care physicians, we will rely on you for communication and networking, as well as mentoring and professional consultation to our clinical directors. Board certification in psychiatry with at least two (2) years of administrative and five (5) years of clinical experience is strongly preferred; Minnesota medical licensure and unrestricted credentialing eligibility are required. Forward your CV and cover letter to lori.m.fake@healthpartners.com, or apply online at www.healthpartners.com/careers. Call (800) 472-4695 x1 for more information. EOE

Minnesota Physician 38 Minnesota Physician November 2014 8.5" x 5.25" B&W

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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The more we get together, the happier and healthier we’ll be.

At MMIC, we believe patients get the best care when doctors, staff and administrators are humming the same tune. So we put our energy into creating risk solutions that help everyone feel conﬁdent and supported. Solutions such as medical liability insurance, physician well-being, health IT support and patient safety consulting. It’s our own quiet way of revolutionizing health care. To join the Peace of Mind Movement, give us a call at 1.800.328.5532 or visit MMICgroup.com.