MN Physician Dec 2015 by Minnesota Physician Publishing

Vo l u m e X X I X , N o . 9 D e c e m b e r 2 015

Improving health care delivery Patient and family engagement By Lisa Juliar; Nora Vernon, MS, RN; and Rahul Koranne, MD

Positive psychiatry A new approach to mental health By Dilip V. Jeste, MD

edical practice has traditionally focused on determining the causes of illnesses, developing and using safe and effective treatments, and reducing the associated suffering and disability. These components are, however, not sufficient to fulfill the enormous potential of medicine to promote human welfare. The World Health Organization has defined health, not as an absence of disease or infirmity, but as a state of complete physical, mental, and social well-being. Research shows that higher levels of positive psychosocial characteristics such as resilience, optimism,

and social engagement are associated with objectively measured better health outcomes including greater longevity. While physicians are experts in health, most of the fieldâ&#x20AC;&#x2122;s attention has been devoted to managing disorders. Positive psychosocial characteristics are rarely addressed in our textbooks or journals. The health care system is changing rapidly for several reasons. These include the rapidly growing older population with greater health care needs, the decreasing number of available Positive psychiatry to page 16

ffective delivery of health care is inherently dependent on health care providers whose mindset is that of a highly-trained expert. Can we improve health care delivery by supplementing the provider perspective with greater and more structured input from patients and families? For the past two years, the Minnesota Hospital Association (MHA) has made it a strategic goal to answer that question. By inviting several patients and families, including co-author Lisa Juliar, to partner with them as patient advisors, MHA has learned much about how to authentically include patients and families as experts in their care. The results are early, but unambiguous: patient and family involvement improves health care delivery. Hence, MHA has developed an evolving model of authentic inclusion of patients called Include Always. Background Recent years have brought a major shift in the way health care operates. Patients and families are becoming integrated as meaningful, respected partners in the systems that provide care to them and their communities. MHAâ&#x20AC;&#x2122;s efforts recognize that true patient and family Improving health care delivery to page 18

Physicians, are you SIcK of: Feeling like you work for insurance companies instead of patients? Declining reimbursements while your patients pay higher premiums? Hospitals dictating where you refer patients? Patients delaying or avoiding much needed care because of high deductibles?

is looking for primary and specialty physicians who want to help create a cure for the common coverage.

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December 2015 • Volume XXIX, No. 9

MINNESOTA HEALTH CARE ROUNDTABLE

Features Positive psychiatry A new approach to mental health

By Dilip V. Jeste, MD

Improving health care delivery 1 Patient and family engagement By Lisa Juliar; Nora Vernon, MS, RN; and Rahul Koranne, MD

FORTY-FIFTH SESSION

DEPARTMENTS CAPSULES

10 Orthopedic Surgery 28

MEDICUS

INTERVIEW

The future of post-acute care

Osteochondritis dissecans By Jeffrey Macalena, MD, and Bradley Nelson, MD

Behavioral Health 30

Renae Peterson, RN Good Samaritan Society

Building spiritual strength By Cory D. Voecks, MA; Lucas P. Hansen; and J. Irene Harris, PhD, LP

Practice Management

Transforming care By L. Read Sulik, MD, and Todd Archbold, LSW, MBA

Medical Innovation vs. Medical Economics When payment policies limit quality of life

Thursday, April 21, 2016 • 1:00-4:00 PM Downtown Minneapolis Hilton and Towers

Professional Update: Neurology Anti-NMDA receptor encephalitis By Ryan P. Williams, MD, EdM

Special Focus: Senior and Long-Term Care Family advocates in long-term care By Suzanne M. Scheller, JD

Personal health records 26 22 By Tom Gossett, MM, PMP, and Rolf Hage

The pre-admission screening process 24 By Stephanie Minor, MPP

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Publisher Mike Starnes | mstarnes@mppub.com Editor Lisa McGowan | lmcgowan@mppub.com Associate Editor Richard Ericson | rericson@mppub.com Acquisitions Editor Patricia Mata Starnes | tmata@mppub.com Art Director Joe Pfahl | joe@mppub.com Office Administrator Amanda Marlow | amarlow@mppub.com Account Executive Stacey Bush | sbush@mppub.com Account Executive Kylie Engle | kengle@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.

background and focus: The pace of innovation in medical science is rapidly escalating. From more accurate diagnostic equipment, to the use of genomic data, to better surgical techniques and medical devices, to new and more efficacious pharmaceuticals, breakthroughs occur nearly every day. These advances face many challenges when incorporated into medical practice. Several significant factors limit this adoption, including the economic models around how patient use of new science will be utilized. Twentieth century health insurance, medical risk management, and reimbursement models are controlling 21st century medical care and patients are the losers. objectives: We will review examples of recent scientific advances and the difficulties they face when becoming part of best medical practice, despite their clear superiority over existing norms. We will look at prevailing thinking behind economic models that govern how health care is paid for today. Our panel of industry experts will explore potential solutions to these problems. We will look at ways to create balance between payment models, new technology, and increased quality of life. Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub. com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable. Name Company Address City, State, ZIP Telephone/FAX Card #  Check enclosed  Bill me

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December 2015 Minnesota Physician

Minnesota Physician December 2015

It clicked when my doctor and I discussed Trulicity 速1,2

Trulicity is a GLP-1 RA therapy that offers proven glycemic control, once-weekly dosing, and the Trulicity pen.*1 If you have patients who struggle with the idea of adding an injectable, consider Trulicity as an option for the next step in their care.1,3 Recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg for additional A1C reduction. * In clinical studies, the range of A1C reduction from baseline was 0.7% to 1.6% for the 0.75 mg dose and 0.8% to 1.6% for the 1.5 mg dose; the percentage of patients achieving A1C <7% ranged from 37% to 69% for 0.75 mg and 53% to 78% for 1.5 mg.1,4-7

Trulicity is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes. Limitations of Use: Not recommended as first-line therapy for patients inadequately controlled on diet and exercise because of the uncertain relevance of rodent C-cell tumor findings to humans. Prescribe only if potential benefits outweigh potential risks. Has not been studied in patients with a history of pancreatitis; consider another antidiabetic therapy. Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not for patients with pre-existing severe gastrointestinal disease. Has not been studied in combination with basal insulin.

Select Important Safety Information WARNING: RISK OF THYROID C-CELL TUMORS In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk of MTC with use of Trulicity and inform them of symptoms of thyroid tumors (eg, mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity.

Please see Important Safety Information for Trulicity, including Boxed Warning about possible thyroid tumors including thyroid cancer, on next page and accompanying Brief Summary of Prescribing Information. Please see Instructions for Use included with the pen.

Learn about proven glycemic control with fewer injections at Trulicity.com

December 2015 Minnesota Physician

Trulicity® is an injectable option that may click with your patients

1,2

A GLP-1 RA therapy that offers:

Proven glycemic control*1

Once-weekly dosing

The Trulicity pen

* In clinical studies, the range of A1C reduction from baseline was 0.7% to 1.6% for the 0.75 mg dose and 0.8% to 1.6% for the 1.5 mg dose; the percentage of patients achieving A1C <7% ranged from 37% to 69% for 0.75 mg and 53% to 78% for 1.5 mg.1,4-7 Recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg.

Once-weekly Trulicity delivered results across clinical trials A1C from baseline A1Creduction reduction from baseline Add-on to metformin (26 weeks)

Add-on to metformin (52 weeks)

Add-on to metformin and Actos® (26 weeks)

Add-on to metformin and Amaryl® (52 weeks)

Compared to Victoza®4

Compared to Januvia®1,8,9

Compared to Byetta®1,10

Compared to Lantus®1,6,11,12

MeanA1C A1Cchange change from from baseline Mean baseline(%) (%)

0.0 -0.2 -0.4

-0.39

-0.6

-0.46

-1.0

-0.87

-1.2

-0.99

-1.10

-1.4

-1.08 -1.51

Victoza (1.8 mg) (n=300; Baseline A1C: 8.1%)

Januvia (100 mg) (n=273; Baseline A1C: 8.0%)

Placebo (n=141; Baseline A1C: 8.1%)

Trulicity® (1.5 mg) (n=299; Baseline A1C: 8.1%)

Trulicity® (0.75 mg) (n=281; Baseline A1C: 8.2%)

Byetta (10 mcg BID) (n=276; Baseline A1C: 8.1%)

Trulicity (0.75 mg) (n=272; Baseline A1C: 8.1%)

Trulicity (1.5 mg) (n=279; Baseline A1C: 8.1%)

Trulicity (0.75 mg) (n=280; Baseline A1C: 8.1%)

Trulicity (1.5 mg) (n=273; Baseline A1C: 8.2%)

26-week, randomized, open-label comparator phase 3 study

•

104-week, randomized, placebo-controlled, double-blind

• 104-week, randomized, placebo-controlled, 26-week, randomized, open-label phase 3 study of adult patients with type 2 diabetes treated of adult patients with type 2 diabetes treated with metformin with metformin mg/dayof adult patients mg/day comparator≥1500 phase 3 study of adult double-blind phase≥1500 3 study • Primary objective was to demonstrate noninferiority of • Primary objective was to demonstrate noninferiority of patients with type 2 diabetes treated with type 2 diabetes treated with metformin Trulicity 1.5 mg vs Januvia on A1C change from baseline at Trulicity 1.5 mg vs Victoza 1.8 mg on A1C change from baseline with metformin ≥1500 52 weeks (-1.1% vs -0.4%, respectively; difference of -0.7%; at 26 weeks (-1.42% mg/day vs -1.36%, respectively; difference of ≥1500 -0.06%; mg/day 95% CI [-0.19, 0.07]; 2-sided alpha level of 0.05 for noninferiority

95% CI [-0.9, -0.5]; multiplicity-adjusted 1-sided alpha level

•

52-week, randomized, placebo-controlled phase 3 study

5. Wysham C, Blevins T, Arakaki R, et al. Efficacy and safety of dulaglutide added onto pioglitazone and metformin versus exenatide in type 2 diabetes in a randomized controlled trial (AWARD-1)

endpoint of[published superiority was notin met correction appears Diabetes Care. 2014;37:2895]. Diabetes Care. 2014;37:2159-2167.

6. Giorgino F, Benroubi M, Sun JH, et al. Efficacy and safety of once-weekly dulaglutide versus insulin glargine in patients with type 2 diabetes on metformin and glimepiride (AWARD-2) [published online ahead of print June 18, 2015]. Diabetes Care. doi:10.2337/dc14-1625. 7. Data on file, Lilly USA, LLC. TRU20140912A. 8. Data on file, Lilly USA, LLC. TRU20150313A.

•

78-week, randomized, open-label comparator phase 3 study

• 78-week, randomized, open-label comparator 52-week, randomized, placebo-controlled (open-label assignment to Byetta or blinded assignment to (double-blind with respect to Trulicity dose assignment) of adult Trulicity or adult patients with type 2 diabetes to patientsphase with type3 2 diabetes with maximally tolerated phase 3 placebo) studyof(open-label assignment studytreated (double-blind with respect to treated with maximally tolerated metformin (≥1500 mg/day) metformin (≥1500 mg/day) and Amaryl (≥4 mg/day) Byetta assignment to Trulicity or Trulicity dose assignment) of adult patients and Actosor (upblinded to 45 mg/day) • Lantus titration was based on self-measured fasting plasma of adult typeof2 diabetes glucosewith 2 diabetes treated with24% maximally •placebo) Primary objective was topatients demonstratewith superiority utilizingtype an algorithm with a target of <100 mg/dL; Trulicity 1.5with mg vsmaximally placebo on change in A1C from metformin baseline of patients were titratedmetformin to goal at the 52-week primarymg/day) endpoint and treated tolerated tolerated (≥1500 at 26 weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; objective was to demonstrate (≥1500 mg/day) and Actos1-sided (up toalpha 45level mg/day)• Primary Amaryl (≥4 mg/day)noninferiority of Trulicity 95% CI [-1.2, -0.9]; multiplicity-adjusted 1.5 mg vs Lantus titrated to target on A1C change from baseline at

• Primaryofobjective Primary objective was to model demonstrate was towith demonstrate 0.025 for noninferiority 0.25% margin; analysis of margin 0.4%; mixed repeated measures analysis) covariance of using last observation [LOCF]); noninferiority ofobjective Trulicity 1.5 mg for vsA1C reduction wasnoninferiority Trulicity 1.5 carried mg vsforward Januvia • Primary of noninferiority met; primary objective met of 0.025; analysis of covariance using LOCF); primary of superiority was not met • Primary Victoza 1.8secondary mg onendpoint A1C change from on A1C change from baseline at 52 weeks objective was to demonstrate objective met baseline at 26 weeks (-1.42% vs -1.36%, (-1.1% vs -0.4%, respectively; difference of superiority of Trulicity 1.5 mg vs placebo on respectively; difference of -0.06%; 95% CI -0.7%; 95% CI [-0.9, -0.5]; multiplicitychange in A1C from baseline at 26 weeks References [-0.19, 0.07]; 2-sided alphaST,level ofal.0.05 adjusted 1-sided of 0.025 for -0.5%,a respectively; difference 1. Dungan KM, Povedano Forst T, et Once-weekly dulaglutide versus once-dailyalpha liraglutidelevel in metformin-treated patients with type (-1.5% 2 diabetesvs (AWARD-6): randomised, open-label, phase 3, non-inferiority trial [published 2014;384:1348]. Lancet. for noninferiority margin 0.4%;correction mixedappears in Lancet. noninferiority with 2014;384:1349-1357. 0.25% margin; analysis of -1.1%; 95% CI [-1.2, -0.9]; multiplicity2. Trulicity [Prescribing Information]. Indianapolis, IN: Lillyof USA, LLC; 2015. model repeated measures analysis) covariance using last observation carried adjusted 1-sided alpha level of 0.025; 3. Data on file, Lilly USA, LLC. TRU20150203A. forward [LOCF]); primary objective met analysis of covariance using LOCF); primary • Primary objective of noninferiority for 4. Data on file, Lilly USA, LLC. TRU20150203B. objective met A1C reduction was met; secondary •

Lantus (n=262; Baseline A1C: 8.1%)

Trulicity (1.5 mg) (n=279; Baseline A1C: 8.1%)

Data represent least-squares mean ± standard error.

•

-0.76

-1.30

-1.36 -1.42

-1.6 -1.8

•

-0.63

-0.8

52 weeks (-1.1% vs -0.6%, respectively; 1-sided • Lantus titration wasmultiplicity-adjusted based on self-measured alpha level of 0.025 for noninferiority with 0.4% margin; analysis of fasting plasma covariance using LOCF); primaryglucose objective metutilizing an

algorithm with a target of <100 mg/dL; 24% of patients were titrated to goal at the 52-week primary endpoint

• Primary objective was to demonstrate

noninferiority of Trulicity 1.5 mg vs Lantus titrated to target on A1C change from baseline at 52 weeks (-1.1% vs -0.6%, respectively; multiplicity-adjusted 1-sided alpha level of 0.025 for noninferiority with 0.4% margin; analysis of covariance using LOCF); primary objective met

Please see Important Safety Information for Trulicity, including Boxed Warning about possible thyroid tumors including thyroid cancer, on the following page and accompanying Brief Summary of Prescribing Information. Please see Instructions for Use included with the pen.

Minnesota Physician December 2015

Important Safety Information WARNING: RISK OF THYROID C-CELL TUMORS

In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk of MTC with use of Trulicity and inform them of symptoms of thyroid tumors (eg, mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity. Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to dulaglutide or any of the product components. Risk of Thyroid C-cell Tumors: Cases of MTC in patients treated with liraglutide, another GLP-1 receptor agonist (GLP-1 RA), have been reported in the postmarketing period; the data in these reports are insufﬁcient to establish or exclude a causal relationship between MTC and GLP-1 RA use in humans. If serum calcitonin is measured and found to be elevated or thyroid nodules are noted on physical examination or neck imaging, the patient should be further evaluated. Pancreatitis: Has been reported in clinical trials. Observe patients for signs and symptoms including persistent severe abdominal pain. If pancreatitis is suspected, discontinue Trulicity promptly. Do not restart if pancreatitis is conﬁrmed. Consider other antidiabetic therapies in patients with a history of pancreatitis. Hypoglycemia: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of the sulfonylurea or insulin to reduce the risk of hypoglycemia. Hypersensitivity Reactions: Systemic reactions were observed in patients receiving Trulicity in clinical trials. Instruct patients who experience symptoms to discontinue Trulicity and promptly seek medical advice. Renal Impairment: In patients treated with GLP-1 RAs, there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, sometimes requiring hemodialysis. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. In patients with renal impairment, use caution when initiating or escalating doses of Trulicity and monitor renal function in patients experiencing severe adverse gastrointestinal reactions. Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug.

0.75 mg, and Trulicity 1.5 mg) were nausea (5.3%, 12.4%, 21.1%), diarrhea (6.7%, 8.9%, 12.6%), vomiting (2.3%, 6.0%, 12.7%), abdominal pain (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), and fatigue (2.6%, 4.2%, 5.6%). Gastric emptying is slowed by Trulicity, which may impact absorption of concomitantly administered oral medications. Use caution when oral medications are used with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to a clinically relevant degree. Pregnancy: There are no adequate and well-controlled studies of Trulicity in pregnant women. Use only if potential beneﬁt outweighs potential risk to fetus. Nursing Mothers: It is not known whether Trulicity is excreted in human milk. A decision should be made whether to discontinue nursing or to discontinue Trulicity, taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of Trulicity have not been established and use is not recommended in patients less than 18 years of age. Please see Brief Summary of Prescribing Information, including Boxed Warning about possible thyroid tumors including thyroid cancer, on following pages. Please see Instructions for Use included with the pen. DG HCP ISI 20APR2015 Trulicity® is a registered trademark owned or licensed by Eli Lilly and Company, its subsidiaries, or affiliates. Trulicity is available by prescription only. Actos® is a registered trademark of Takeda Pharmaceutical Company Limited. Byetta® is a registered trademark of the AstraZeneca group of companies. Amaryl® and Lantus® are registered trademarks of Sanofi-Aventis. Januvia® is a registered trademark of Merck & Co., Inc. Victoza® is a registered trademark of Novo Nordisk A/S. Other product/company names mentioned herein are the trademarks of their respective owners. References 1. Trulicity [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC; 2015. 2. Trulicity [Instructions for Use]. Indianapolis, IN: Lilly USA, LLC; 2014. 3. Polonsky WH, Hajos TR, Dain MP, Snoek FJ. Are patients with type 2 diabetes reluctant to start insulin therapy? An examination of the scope and underpinnings of psychological insulin resistance in a large, international population. Curr Med Res Opin. 2011;27(6):1169-74. doi: 10.1185/03007995.2011.573623. Epub Apr 6, 2011. 4. Dungan KM, Povedano ST, Forst T, et al. Once-weekly dulaglutide versus once-daily liraglutide in metformin-treated patients with type 2 diabetes (AWARD-6): a randomised, open-label, phase 3, non-inferiority trial [published correction appears in Lancet. 2014;384:1348]. Lancet. 2014;384:1349-1357. 5. Umpierrez G, Tofé Povedano S, Pérez Manghi F, et al. Efficacy and safety of dulaglutide monotherapy versus metformin in type 2 diabetes in a randomized controlled trial (AWARD-3). Diabetes Care. 2014;37:2168-2176. 6. Giorgino F, Benroubi M, Sun JH, et al. Efficacy and safety of once-weekly dulaglutide versus insulin glargine in patients with type 2 diabetes on metformin and glimepiride (AWARD-2) [published online ahead of print June 18, 2015]. Diabetes Care. doi:10.2337/dc14-1625. 7. Blonde L, Jendle J, Gross J, et al. Once-weekly dulaglutide versus bedtime insulin glargine, both in combination with prandial insulin lispro, in patients with type 2 diabetes (AWARD-4): a randomised, open-label, phase 3, non-inferiority study. Lancet. 2015;385:2057-2066. 8. Data on file, Lilly USA, LLC. TRU20150203A. 9. Data on file, Lilly USA, LLC. TRU20150203B. 10. Wysham C, Blevins T, Arakaki R, et al. Efficacy and safety of dulaglutide added onto pioglitazone and metformin versus exenatide in type 2 diabetes in a randomized controlled trial (AWARD-1) [published correction appears in Diabetes Care. 2014;37:2895]. Diabetes Care. 2014;37:2159-2167. 11. Data on file, Lilly USA, LLC. TRU20140912A. 12. Data on file, Lilly USA, LLC. TRU20150313A.

The most common adverse reactions reported in ≥5% of Trulicitytreated patients in placebo-controlled trials (placebo, Trulicity

PP-DG-US-0359

10/2015 PRINTED IN USA

December 2015 Minnesota Physician

TrulicityTM (dulaglutide) Brief Summary: Consult the package insert for complete prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS • In male and female rats, dulaglutide causes a dose-related and treatmentduration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. • Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk of MTC with use of Trulicity and inform them of symptoms of thyroid tumors (eg, mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity.

insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of sulfonylurea or insulin to reduce the risk of hypoglycemia in this setting. Hypersensitivity Reactions: Systemic hypersensitivity reactions were observed in patients receiving Trulicity in clinical trials. If a hypersensitivity reaction occurs, the patient should discontinue Trulicity and promptly seek medical advice. Renal Impairment: In patients treated with GLP-1 receptor agonists, there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis. Some of these events were reported in patients without known underlying renal disease. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Because these reactions may worsen renal failure, use caution when initiating or escalating doses of Trulicity in patients with renal impairment. Monitor renal function in patients with renal impairment reporting severe adverse gastrointestinal reactions. Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug. ADVERSE REACTIONS

INDICATIONS AND USAGE Trulicity™ is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Risk of Thyroid C-cell Tumors: In male and female rats, dulaglutide causes a doserelated and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. Glucagon-like peptide (GLP-1) receptor agonists have induced thyroid C-cell adenomas and carcinomas in mice and rats at clinically relevant exposures. It is unknown whether Trulicity will cause thyroid C-cell tumors, including MTC, in humans, as the human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined. One case of MTC was reported in a patient treated with Trulicity. This patient had pretreatment calcitonin levels approximately 8 times the upper limit of normal (ULN). Cases of MTC in patients treated with liraglutide, another GLP-1 receptor agonist, have been reported in the postmarketing period; the data in these reports are insufficient to establish or exclude a causal relationship between MTC and GLP-1 receptor agonist use in humans. Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2. Counsel patients regarding the potential risk for MTC with the use of Trulicity and inform them of symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Trulicity. Such monitoring may increase the risk of unnecessary procedures, due to the low test specificity for serum calcitonin and a high background incidence of thyroid disease. Significantly elevated serum calcitonin value may indicate MTC and patients with MTC usually have calcitonin values >50 ng/L. If serum calcitonin is measured and found to be elevated, the patient should be further evaluated. Patients with thyroid nodules noted on physical examination or neck imaging should also be further evaluated. Pancreatitis: In Phase 2 and Phase 3 clinical studies, 12 (3.4 cases per 1000 patient years) pancreatitis-related adverse reactions were reported in patients exposed to Trulicity versus 3 in non-incretin comparators (2.7 cases per 1000 patient years). An analysis of adjudicated events revealed 5 cases of confirmed pancreatitis in patients exposed to Trulicity (1.4 cases per 1000 patient years) versus 1 case in non-incretin comparators (0.88 cases per 1000 patient years). After initiation of Trulicity, observe patients carefully for signs and symptoms of pancreatitis, including persistent severe abdominal pain. If pancreatitis is suspected, promptly discontinue Trulicity. If pancreatitis is confirmed, Trulicity should not be restarted. Trulicity has not been evaluated in patients with a prior history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Hypoglycemia with Concomitant Use of Insulin Secretagogues or Insulin: The risk of hypoglycemia is increased when Trulicity is used in combination with

Clinical Studies Experience: Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice. Pool of Placebo-controlled Trials: These data reflect exposure of 1670 patients to Trulicity and a mean duration of exposure to Trulicity of 23.8 weeks. Across the treatment arms, the mean age of patients was 56 years, 1% were 75 years or older and 53% were male. The population in these studies was 69% White, 7% Black or African American, 13% Asian; 30% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.0 years and had a mean HbA1c of 8.0%. At baseline, 2.5% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60mL/min/1.73 m2) in 96.0% of the pooled study populations. Adverse Reactions in Placebo-Controlled Trials Reported in ≥5% of Trulicity-Treated Patients: Placebo (N=568), Trulicity 0.75mg (N=836), Trulicity 1.5 mg (N=834) (listed as placebo, 0.75 mg, 1.5 mg): nausea (5.3%, 12.4%, 21.1%), diarrheaa (6.7%, 8.9%, 12.6%), vomitingb (2.3%, 6.0%, 12.7%), abdominal painc (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), fatigued (2.6%, 4.2%, 5.6%). (a Includes diarrhea, fecal volume increased, frequent bowel movements. b Includes retching, vomiting, vomiting projectile. c Includes abdominal discomfort, abdominal pain, abdominal pain lower, abdominal pain upper, abdominal tenderness, gastrointestinal pain. d Includes fatigue, asthenia, malaise.) Note: Percentages reflect the number of patients that reported at least 1 treatment-emergent occurrence of the adverse reaction. Gastrointestinal Adverse Reactions: In the pool of placebo-controlled trials, gastrointestinal adverse reactions occurred more frequently among patients receiving Trulicity than placebo (placebo 21.3%, 0.75 mg 31.6%, 1.5 mg 41.0%). More patients receiving Trulicity 0.75 mg (1.3%) and Trulicity 1.5 mg (3.5%) discontinued treatment due to gastrointestinal adverse reactions than patients receiving placebo (0.2%). Investigators graded the severity of gastrointestinal adverse reactions occurring on 0.75 mg and 1.5 mg of Trulicity as “mild” in 58% and 48% of cases, respectively, “moderate” in 35% and 42% of cases, respectively, or “severe” in 7% and 11% of cases, respectively. In addition to the adverse reactions ≥5% listed above, the following adverse reactions were reported more frequently in Trulicity-treated patients than placebo (frequencies listed, respectively, as: placebo; 0.75 mg; 1.5 mg): constipation (0.7%; 3.9%; 3.7%), flatulence (1.4%; 1.4%; 3.4%), abdominal distension (0.7%; 2.9%; 2.3%), gastroesophageal reflux disease (0.5%; 1.7%; 2.0%), and eructation (0.2%; 0.6%; 1.6%). Pool of Placebo- and Active-Controlled Trials: The occurrence of adverse reactions was also evaluated in a larger pool of patients with type 2 diabetes participating in 6 placebo- and active-controlled trials evaluating the use of Trulicity as monotherapy and add-on therapy to oral medications or insulin. In this pool, a total of 3342 patients with type 2 diabetes were treated with Trulicity for a mean duration 52 weeks. The mean age of patients was 56 years, 2% were 75 years or older and 51% were male. The population in these studies was 71% White, 7% Black or African American, 11% Asian; 32% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.2 years and had a mean HbA1c of 7.6-8.5%. At baseline, 5.2% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60 ml/min/1.73 m2) in 95.7% of the Trulicity population. In the pool of placebo- and active-controlled trials, the types and frequency of common adverse reactions, excluding hypoglycemia, were similar to those listed as ≥5% above. Other Adverse Reactions: Hypoglycemia: Incidence (%) of Documented Symptomatic (≤70 mg/dL Glucose Threshold) and Severe Hypoglycemia in Placebo-Controlled Trials: Add-on to Metformin at 26 weeks, Placebo (N=177), Trulicity 0.75 mg (N=302), Trulicity 1.5 mg (N=304), Documented symptomatic: Placebo: 1.1%, 0.75 mg: 2.6%, 1.5 mg: 5.6%; Severe: all 0. Add-on to Metformin + Pioglitazone at 26 weeks, Placebo (N=141), Trulicity 0.75 mg (N=280), Trulicity 1.5 mg (N=279), Documented symptomatic: Placebo: 1.4%, 0.75 mg: 4.6%, 1.5 mg: 5.0%; Severe: all 0. Hypoglycemia was more frequent when Trulicity was used in combination with a sulfonylurea or insulin. Documented symptomatic hypoglycemia occurred in 39% and 40% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Severe hypoglycemia occurred in 0% and 0.7% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Documented symptomatic hypoglycemia occurred in 85% and 80% of patients when Trulicity 0.75 mg

TrulicityTM (dulaglutide)

Limitations of Use: Not recommended as a first-line therapy for patients who have inadequate glycemic control on diet and exercise because of the uncertain relevance of rodent C-cell tumor findings to humans. Prescribe Trulicity only to patients for whom the potential benefits outweigh the potential risk. Has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. It is not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not recommended in patients with pre-existing severe gastrointestinal disease. The concurrent use of Trulicity and basal insulin has not been studied. CONTRAINDICATIONS Do not use in patients with a personal or family history of MTC or in patients with MEN 2. Do not use in patients with a prior serious hypersensitivity reaction to dulaglutide or to any of the product components. WARNINGS AND PRECAUTIONS

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and 1.5 mg, respectively, was co-administered with prandial insulin. Severe hypoglycemia occurred in 2.4% and 3.4% of patients when Trulicity 0.75 mg, and 1.5 mg, respectively, was co-administered with prandial insulin. Heart Rate Increase and Tachycardia Related Adverse Reactions: Trulicity 0.75 mg and 1.5 mg resulted in a mean increase in heart rate (HR) of 2-4 beats per minute (bpm). The long-term clinical effects of the increase in HR have not been established. Adverse reactions of sinus tachycardia were reported more frequently in patients exposed to Trulicity. Sinus tachycardia was reported in 3.0%, 2.8%, and 5.6% of patients treated with placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg, respectively. Persistence of sinus tachycardia (reported at more than 2 visits) was reported in 0.2%, 0.4%, and 1.6% of patients treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Episodes of sinus tachycardia, associated with a concomitant increase from baseline in heart rate of ≥15 beats per minute, were reported in 0.7%, 1.3%, and 2.2% of patients treated with placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg, respectively. Immunogenicity : Across four Phase 2 and five Phase 3 clinical studies, 64 (1.6%) Trulicitytreated patients developed anti-drug antibodies (ADAs) to the active ingredient in Trulicity (ie, dulaglutide). Of the 64 dulaglutide-treated patients that developed dulaglutide ADAs, 34 patients (0.9% of the overall population) had dulaglutide-neutralizing antibodies, and 36 patients (0.9% of the overall population) developed antibodies against native GLP-1. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, the incidence of antibodies to dulaglutide cannot be directly compared with the incidence of antibodies of other products. Hypersensitivity : Systemic hypersensitivity adverse reactions sometimes severe (eg, severe urticaria, systemic rash, facial edema, lip swelling) occurred in 0.5% of patients on Trulicity in the four Phase 2 and Phase 3 studies. Injection-site Reactions: In the placebo-controlled studies, injection-site reactions (eg, injection-site rash, erythema) were reported in 0.5% of Trulicity-treated patients and in 0.0% of placebo-treated patients. PR Interval Prolongation and Adverse Reactions of First Degree Atrioventricular (AV) Block: A mean increase from baseline in PR interval of 2-3 milliseconds was observed in Trulicity-treated patients in contrast to a mean decrease of 0.9 millisecond in placebo-treated patients. The adverse reaction of first degree AV block occurred more frequently in patients treated with Trulicity than placebo (0.9%, 1.7%, and 2.3% for placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg, respectively). On electrocardiograms, a PR interval increase to at least 220 milliseconds was observed in 0.7%, 2.5%, and 3.2% of patients treated with placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg, respectively. Amylase and Lipase Increase: Patients exposed to Trulicity had mean increases from baseline in lipase and/or pancreatic amylase of 14% to 20%, while placebotreated patients had mean increases of up to 3%. DRUG INTERACTIONS Trulicity slows gastric emptying and thus has the potential to reduce the rate of absorption of concomitantly administered oral medications. Caution should be exercised when oral medications are concomitantly administered with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to any clinically relevant degree. USE IN SPECIFIC POPULATIONS Pregnancy - Pregnancy Category C: There are no adequate and well-controlled studies of Trulicity in pregnant women. The risk of birth defects, loss, or other adverse outcomes is increased in pregnancies complicated by hyperglycemia and may be decreased with good metabolic control. It is essential for patients with diabetes to maintain good metabolic control before conception and throughout pregnancy. Trulicity should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. In rats and rabbits, dulaglutide administered during the major period of organogenesis produced fetal growth reductions and/or skeletal anomalies and ossification deficits in association with decreased maternal weight and food consumption attributed to the pharmacology of dulaglutide. Nursing Mothers: It is not known whether Trulicity is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for clinical adverse reactions from Trulicity in nursing infants, a decision should be made whether to discontinue nursing or to discontinue Trulicity, taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of Trulicity have not been established in pediatric patients. Trulicity is not recommended for use in pediatric patients younger than 18 years. Geriatric Use: In the pool of placebo- and active-controlled trials, 620 (18.6%) Trulicity-treated patients were 65 years of age and over and 65 Trulicity-treated patients (1.9%) were 75 years of age and over. No overall differences in safety or efficacy were detected between these patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Hepatic Impairment: There is limited clinical experience in patients with mild, moderate, or severe hepatic impairment. Therefore, Trulicity should be used with caution in these patient populations. In a clinical pharmacology study in subjects with varying degrees of hepatic impairment, no clinically relevant change in dulaglutide pharmacokinetics (PK) was observed. Renal Impairment: In the four Phase 2 and five Phase 3 randomized clinical studies, at baseline, 50 (1.2%) Trulicity-treated patients had mild renal impairment (eGFR ≥60 but <90 mL/min/1.73 m2), 171 (4.3%) Trulicitytreated patients had moderate renal impairment (eGFR ≥30 but <60 mL/min/1.73 m2) and no Trulicity-treated patients had severe renal impairment (eGFR <30 mL/min/1.73 m2). TrulicityTM (dulaglutide)

Trulicity DG HCP BS 20APR2015 Brief Summary 7 x 9.75

DG HCP BS 20APR2015

No overall differences in safety or effectiveness were observed relative to patients with normal renal function, though conclusions are limited due to small numbers. In a clinical pharmacology study in subjects with renal impairment including end-stage renal disease (ESRD), no clinically relevant change in dulaglutide PK was observed. There is limited clinical experience in patients with severe renal impairment or ESRD. Trulicity should be used with caution, and if these patients experience adverse gastrointestinal side effects, renal function should be closely monitored. Gastroparesis: Dulaglutide slows gastric emptying. Trulicity has not been studied in patients with pre-existing gastroparesis. OVERDOSAGE Overdoses have been reported in clinical studies. Effects associated with these overdoses were primarily mild or moderate gastrointestinal events (eg, nausea, vomiting) and nonsevere hypoglycemia. In the event of overdose, appropriate supportive care (including frequent plasma glucose monitoring) should be initiated according to the patient’s clinical signs and symptoms. PATIENT COUNSELING INFORMATION See FDA-approved Medication Guide • Inform patients that Trulicity causes benign and malignant thyroid C-cell tumors in rats and that the human relevance of this finding has not been determined. Counsel patients to report symptoms of thyroid tumors (eg, a lump in the neck, persistent hoarseness, dysphagia, or dyspnea) to their physician. • Inform patients that persistent severe abdominal pain, that may radiate to the back and which may (or may not) be accompanied by vomiting, is the hallmark symptom of acute pancreatitis. Instruct patients to discontinue Trulicity promptly, and to contact their physician, if persistent severe abdominal pain occurs. • The risk of hypoglycemia may be increased when Trulicity is used in combination with a medicine that can cause hypoglycemia, such as a sulfonylurea or insulin. Review and reinforce instructions for hypoglycemia management when initiating Trulicity therapy, particularly when concomitantly administered with a sulfonylurea or insulin. • Patients treated with Trulicity should be advised of the potential risk of dehydration due to gastrointestinal adverse reactions and take precautions to avoid fluid depletion. Inform patients treated with Trulicity of the potential risk for worsening renal function and explain the associated signs and symptoms of renal impairment, as well as the possibility of dialysis as a medical intervention if renal failure occurs. • Inform patients that serious hypersensitivity reactions have been reported during postmarketing use of GLP-1 receptor agonists. If symptoms of hypersensitivity reactions occur, patients must stop taking Trulicity and seek medical advice promptly. • Advise patients to inform their healthcare provider if they are pregnant or intend to become pregnant. • Prior to initiation of Trulicity, train patients on proper injection technique to ensure a full dose is delivered. Refer to the accompanying Instructions for Use for complete administration instructions with illustrations. • Inform patients of the potential risks and benefits of Trulicity and of alternative modes of therapy. Inform patients about the importance of adherence to dietary instructions, regular physical activity, periodic blood glucose monitoring and HbA1c testing, recognition and management of hypoglycemia and hyperglycemia, and assessment for diabetes complications. During periods of stress such as fever, trauma, infection, or surgery, medication requirements may change and advise patients to seek medical advice promptly. • Each weekly dose of Trulicity can be administered at any time of day, with or without food. The day of once-weekly administration can be changed if necessary, as long as the last dose was administered 3 or more days before. If a dose is missed and there are at least 3 days (72 hours) until the next scheduled dose, it should be administered as soon as possible. Thereafter, patients can resume their usual once-weekly dosing schedule. If a dose is missed and the next regularly scheduled dose is due in 1 or 2 days, the patient should not administer the missed dose and instead resume Trulicity with the next regularly scheduled dose. • Advise patients treated with Trulicity of the potential risk of gastrointestinal side effects. • Instruct patients to read the Medication Guide and the Instructions for Use before starting Trulicity therapy and review them each time the prescription is refilled. • Instruct patients to inform their doctor or pharmacist if they develop any unusual symptom, or if any known symptom persists or worsens. • Inform patients that response to all diabetic therapies should be monitored by periodic measurements of blood glucose and HbA1c levels, with a goal of decreasing these levels towards the normal range. HbA1c is especially useful for evaluating long-term glycemic control.

Eli Lilly and Company, Indianapolis, IN 46285, USA US License Number 1891 Copyright © 2014, 2015, Eli Lilly and Company. All rights reserved. Additional information can be found at www.trulicity.com DG HCP BS 20APR2015 TrulicityTM (dulaglutide)

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Community Clinical Oncology Program Changes Name Twin Cities-based nonprofit cancer research group Community Clinical Oncology Program has changed its name to the Metro-Minnesota Community Oncology Research Consortium (MMCORC). It says that the new name better reflects its mission of cooperation among clinical research organizations in the area. The consortium, which is funded by the National Cancer Institute (NCI), works to give patients with cancer access to the newest therapies, symptom management, and cancer prevention. It has helped to enroll an average of 500 patients in clinical trials in Minnesota per year. It was formed in 1979 and recently received a $11.5 million grant from NCI to conduct clinical trials and research studies aimed at improving patient outcomes and reducing health disparities. “The MMCORC is an incredibly valuable resource for the cancer patients in our communities,” said Joseph Leach, MD, principal investigator for

MMCORC and medical oncologist at Minnesota Oncology. “Many of the life-saving treatments now available are due to the research conducted by this consortium.”

Minnesota Leads Scores on Physician Quality Information Minnesota continues to be one of very few states to receive high marks for providing publicly available information on the quality of physician care. For the third year in a row, Minnesota received an “A” grade on the State Report Card on Transparency of Physician Quality Information from the Health Care Incentives Improvement Institute. It was one of only three states to receive the highest letter grade, and it is attributed to the state’s Minnesota HealthScores website. Washington also maintained its “A” grade from last year, and California improved its performance from a “B” in 2014 to an “A.” Only one other state received a different letter grade from 2014: Oregon, which improved its performance from a “D” in 2014 to a “C” this year.

Minnesota Physician December 2015

Maine was the only state to receive a “B.” Massachusetts and Wisconsin received a “C” and Missouri, New Mexico, and Ohio received “D” grades. The remaining 40 states received a failing grade. “While there is some progress, all of the states with a failing grade last year received the same this year,” said Francois de Brantes, executive director of the Health Care Incentives Improvement Institute. “That means the vast majority of Americans simply don’t have access to local information on the quality of physician care. There is, however, the potential for significant progress in the next year and we’re doing our part to make it happen.” The grades are based on the number of primary care and specialty care physicians for whom health care quality information is publicly available and the ease by which a consumer can find the information. Analysts used the Robert Wood Johnson Foundation’s national directory for comparing health care quality as a starting point for the review. The report notes some exceptions, which are the same as they were in 2014. “The community-wide programs in

Detroit, Cincinnati, Cleveland, and Kansas City continue their hard work of providing physician quality of care information,” the report says. “And the same is true for the statewide efforts in Maine, Massachusetts, California, Colorado, Washington, Oregon, New Mexico, Minnesota, and Wisconsin. While the focus of most of these efforts is on primary care physicians, what they often measure matters a lot to consumers, including how well these physicians can take care of chronic conditions.”

Mechanisms that Determine Behavior of Bone Cancer Identified Researchers at the University of Minnesota College of Veterinary Medicine and the Masonic Cancer Center have found evidence that supports the theory that the behavior of bone cancer is programmed in each tumor when it forms, and that the program remains unchanged throughout the progression of the disease.

They studied both canine and human bone cancer cells, because bone cancers are similar in canines and humans, and discovered the mechanism responsible for creating the gene signature, and therefore the behavior of the tumors. “Everything we have seen to be true with dog bone cancer cells, in the lab or in experimental animals, is the same with human cells,” said Jaime Modiano, VMD, PhD, professor in the department of veterinary clinical sciences at the University of Minnesota and one of the researchers on the project. Researchers say these findings will help guide future research for osteosarcoma, the most common type of bone cancer. “Our findings give us great hope for the future that veterinarians and physicians will be able to provide a more accurate prognosis for bone cancer patients and tailor therapies to treat tumors more effectively and with less side effects,” said Modiano.

Mayo Clinic to Standardize Kidney Disease Diagnosis Researchers have put together a detailed recommendation for standardizing the diagnosis of glomerulonephritis, which describes various conditions involving inflammation of glomeruli (the filtering unit in kidneys that removes excess fluid, electrolytes, and waste from your bloodstream and passes them into your urine). “Earlier this year, we convened renal pathologists and nephrologists from around the world at Mayo Clinic to begin work on an effort that could transform the way kidney disease is diagnosed for patients everywhere,” said Sanjeev Sethi, MD, PhD, professor in the department of laboratory medicine and pathology at Mayo Clinic, who led development of the consensus paper. “It was time to move the field toward diagnosing glomerulonephritis based on the underlying cause of the disease, which leads to a more personalized diagnosis and more targeted treatment for the patient.” Currently, glomerulonephritis is typically classified by the pattern of inflammation. However, researchers say this does not relate to the underlying cause of the disease, which could help guide treatment options if taken into account.

Recommendations include making kidney biopsy reports disease and etiology-based, making it easier for physicians to interpret reports from other institutions, and providing clearer pathways for treatment. “The approach outlined in the consensus paper provides a detailed approach to diagnosing kidney disease that has many advantages for clinicians and patients,” said Fernando Fervenza, MD, PhD, professor in the department of internal medicine, division of nephrology and hypertension at Mayo Clinic, who led development of the consensus paper alongside Sethi. “In addition to being focused on the individual patient’s pathology and potential cause of disease, this approach makes the data more adaptable should new diseases be identified by future research. It aligns with database reporting, and it focuses on information that is relevant to the patient and [his or her] potential treatment option.” The paper has been endorsed by the Renal Pathology Society and published by the Journal of the American Society of Nephrology.

State Forms Group to Address Opioid Prescribing Issues The Minnesota Department of Human Services (DHS) has formed a work group to address the wide availability of prescription opioids and determine recommendations to guide the state’s response to opioid overuse and abuse. The work group has 17 members including consumers, health care professionals, mental health professionals, law enforcement, and representatives of the managed care organizations that contract to serve Minnesota Health Care Program clients. They met for the first time Nov. 23. “The consequences of the wide availability of opioids include increased addiction, prenatal exposure, overdoses, and deaths,” said Lucinda Jesson, Minnesota human services commissioner. “DHS and the Minnesota Department of Health will work together with the provider community to prevent the spread of opioid abuse in Minnesota. The work group is an important first step.”

Physician Driven. Patient Inspired.

“The time“The theytime save they me meeting save me meeting reporting requirements allows MS reporting requirements allows meatoCspend pprov me to spend more time ed more time with patients.”A C O with patients.” — Christopher Wenner, MD, Clinic Owner Integrity Health Network member, Cold Spring – Christopher Wenner, MD, Clinic Owner Integrity Health Network member, Cold Spring

Helping Independent Hospitals and Clinics compete:

Helping clinics facilities • Referral independent network of 215 primary and and specialty physicians

• Network of over 200 physicians, providers and •facilities QI/P4P Measurement development & reporting

• Competitive group purchasing contracts to control

• Q1/P4P Measurement development & reporting your costs

• •Competitive contracts to control Latest in EHRgroup & Webpurchasing Portal technology your costs • Partnering with health plans on new models of care Partnering with with select hospitals, clinics andon employers to • •Partnering health plans new models work on clinical integration and delivery of care Data Warehouse under development. Information is • •Partnering with hospitals, clinics, employers and key to competing and improving quality government entities to work on clinical integration •and Marketing, deliveryrisk management, clinic staff training • Developing strategies to leverage exciting new

• Grant-funded health information exchange (HIE) opportunities: Accountable Care Organizations, development Medical Home, Baskets of Care • Data analytics. Informationphysicians is key to competing and Our independent keep improving quality hometown healthcare where it belongs. • Marketing, risk management, clinic staff training • Developing strategies to leverage Jeff Tucker, CEO new opportunities (jtucker@ihnhealth.com) including Accountable Care Organization, medical home, episodes of care, bundled COO care, HIE and care Rachael Nyenhuis, coordination(rnyenhuis@ihnhealth.com)

Our Independent physicians keep 888.722.8802 hometown healthcare where it belongs.

JeffreyaL.network Tucker, CEO Delivering of solutions jtucker@ihnhealth.com

IntegrityHealthNetwork.com 218.722.8802.112 Melissa Larson, Vice President, Operations mlarson@ihnhealth.com 218.722.8802.115 IntegrityHealthNetwork.com Delivering a network of solutions

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HealthPartners to Broaden Delirium Prevention Program HealthPartners is expanding an initiative to help prevent delirium in older adults. The program, based on the Hospital Elder Life Program (HELP) that was developed at Yale University School of Medicine, has been in place at Park Nicollet Methodist Hospital since 2010. It was the first in Minnesota to implement a program based on the HELP program. Almost 3,000 patients received dementia prevention services at Methodist Hospital in 2014. Regions Hospital began implementing a similar program in July 2015. Other HealthPartners hospitals are working to implement the program in 2016, including Lakeview Hospital in Stillwater and Hudson Hospital & Clinic, Amery Regional Medical Center, and Westfields Hospital in Wisconsin. The program assesses any patient over the age of 70 within four hours of admission to

determine if they would benefit from preventive services. Patients have the highest risk of developing delirium within 72 hours of admission. The Confusion Assessment Method tool is part of the electronic medical record system and is repeated twice a day each day the patient stays at the hospital. If it is determined that they would benefit, patients receive visits from trained volunteers who engage them in activities to maintain mental alertness up to three times a day. In addition, nurses ensure that patients receive adequate fluids and get up to walk as often as possible, and physicians are trained to detect early warning signs and manage pain with minimal use of narcotic painkillers. Data from Methodist Hospital shows that since 2010, more than 87 percent of patients over 70 admitted to Regions Hospital do not show signs of delirium. However, 98 percent of the patients who did receive prevention services were not affected by delirium when they were discharged from the hospital. They estimate that preventing delirium reduced medical costs by $2,500 per patient.

“Delirium is very frightening for patients and families, and it is associated with serious medical complications,” said Mary Brainerd, HealthPartners president and CEO. “This analysis adds to growing evidence that it can and should be prevented.”

HCMC Expanding in Downtown Minneapolis Hennepin County Medical Center (HCMC) broke ground on construction of a new 377,000-square-foot clinic and specialty center on Nov. 12 in downtown Minneapolis. HCMC has been planning for this new building since 2013. The $220.8 million ambulatory outpatient specialty center will consolidate 40 clinics and specialty services currently spread across nine buildings within the five blocks of its downtown campus into one location with six floors and 377,000 square feet. It will house a combination of clinics and services, including 27 outpatient clinics for primary care

and specialty services, same-day surgery center, radiology services, an outpatient pharmacy, and a comprehensive cancer center. It is expected to open in 2018. “Right now our primary care and specialty care clinics downtown are spread across nine buildings that we own or lease. Bringing them together into one building will make it more convenient for our patients and more efficient for our staff,” Jon Pryor, HCMC CEO, said when the plan was announced. In addition to the groundbreaking, HCMC saw the inaugural helicopter land on its new helistop, located on the roof of the building that houses the emergency department, operating rooms, and intensive care units. The new $3.8 million helistop doubles the capacity to receive trauma patients by air and reduces transport time to the hospital, according to officials. The original helistop, located on top of a nearby parking ramp, will remain available for when multiple patients are being transported to the hospital by air.

WE ARE EXCITED TO ANNOUNCE... The integration of St. Croix Orthopaedics and Twin Cities Orthopedics!

The integration allows for us to expand the services we offer across the entire metro area and into western Wisconsin with a team of more than 100 orthopedic surgeons and 35 locations. Both St. Croix Orthopaedics and Twin Cities Orthopedics share a similar vision of providing exceptional care and outstanding service. Visit TCOmn.com or stcroixortho.com to learn more

Minnesota Physician December 2015

Medicus

Sanne Magnan, MD, PhD, president and chief executive officer of the Institute for Clinical Systems Improvement (ICSI), has announced her retirement effective Jan. 4, 2016. Magnan previously served as ICSI president and CEO in 2006 and 2007, before being appointed commissioner of health by then Gov. Tim Pawlenty. She was reappointed to the position at ICSI in Sanne Magnan, January 2011. Magnan has also served as a staff MD, PhD physician at the Tuberculosis Clinic at St. Paul– Ramsey County Department of Public Health; a clinical assistant professor of medicine at the University of Minnesota; vice president and medical director of consumer health at Blue Cross Blue Shield of Minnesota; lead physician at Lino Lakes Correctional Facility; and a staff physician at various other clinics. She has served on several boards, including MN Community Measurement. Magnan holds a medical degree and a PhD in medicinal chemistry from the University of Minnesota. Kevin Garrett, MD, vice president and executive medical director of ambulatory and community services at HealthEast, has been chosen to assume the role of senior vice president and chief medical officer after Steve Kolar, MD, retires in January. In his new role, Garrett will help oversee the health system’s newly consolidated care services. Garrett joined HealthEast Kevin Garrett, MD in 2012. Prior to that, he served as managing director and chief medical officer at Christus St. Vincent Regional Medical Center in Santa Fe, New Mexico, and as vice president for medical affairs at ThedaCare, Inc., in Appleton, Wisc. He earned his medical degree at the University of Iowa College of Medicine. Dania Ann Spies Kamp, MD, family physician at Gateway Clinic in Sturgeon Lake, has received the Degree of Fellow of the American Academy of Family Physicians for her work in the field of family medicine and within her community. Kamp specializes in maternal health including obstetrical care, child and adolescent health, preventive medicine, hospice and palliative care, and health care policy. She earned her medical degree at the University of Minnesota and completed her residency at Oregon Health Sciences University.

VÄNSKÄ CONDUCTS KULLERVO

RECORDED LIVE IN CONCERT

Feb 4–6 Osmo Vänskä, conductor The music world was rocked in 2010 when Alex Ross of The New Yorker said the Minnesota Orchestra sounded like “the greatest orchestra in the world” in a Carnegie Hall performance of Sibelius’ darkly beautiful Kullervo. CARNEGIE HALL PREVIEW

HILARY HAHN PLAYS SIBELIUS Feb 18–20

Hear our Minnesota stars in the program they’re taking to Carnegie. This all-Sibelius program features the sweeping Romanticism of the composer’s early symphonies, as well as the breathtaking virtuosity of American violinist Hilary Hahn.

THE PEKING ACROBATS* Feb 21

Come see why the Peking Acrobats have been astounding audiences since 1986 with the difficult, death-defying and downright unbelievable—from trick cycling to balancing a precarious pagoda of chairs. And it’s all accompanied by a live Chinese orchestra!

OSMO VÄNSKÄ

Dania Ann Spies Kamp, MD

HILARY HAHN

Dianne Neumark-Sztainer, PhD, MPH, RD, has been appointed as the new head of the division of epidemiology and community health at the University of Minnesota School of Public Health. She has served as the interim head of the department since December 2014. Neumark-Sztainer has been with the School of Public Health since 1995 as a researcher and professor and is the Dianne Neumarkprincipal investigator on numerous research Sztainer, PhD, studies focused on nutrition, physical activity, MPH, RD and the prevention of weight-related problems. She earned her doctorate in behavioral sciences and nutrition and her master of public health degree at Hebrew University– Hadassah, Jerusalem, Israel. She has served on the board of directors for the Academy for Eating Disorders, the Society for Adolescent Medicine, and the International Society for Behavioral Nutrition and Physical Activity.

PEKING ACROBATS

minnesotaorchestra.org 612.371.5656 / Orchestra Hall *Please note: The Minnesota Orchestra does not perform on this program.

Media Partner:

PHOTOS Vänskä: Joel Larsen; Hahn: Michael Patrick O’Leary; Acrobats: Tom Meinhold

December 2015 Minnesota Physician

Interview

The future of post-acute care P lease tell us about the work you do with Good Samaritan. I am currently the regional operations rehabilitation/skilled care consultant for the Minnesota region of the Good Samaritan Society. My role focuses on all aspects of clinical care and delivery, providing support and consultation associated with operations of our post-acute and care centers across the state of Minnesota. Additionally, I provide guidance and consultation to areas such as health information, life enrichment (activities), dining, and social services.

Renae Peterson, RN Good Samaritan Society Ms. Peterson is regional operations rehabilitation/skilled care consultant for the Minnesota Region of the Good Samaritan Society. She began her professional nursing career in 1980 and worked for 10 years in a hospital acute care setting. She has held various leadership roles in the long-term care profession over the past 25 years, including director of Nursing Services for the Good Samaritan Society–Albert Lea. Ms. Peterson has served as senior examiner for the American Health Care Association and is a committee member of the Regulatory Forum for Care Providers of Minnesota. She is also a member of the Minnesota Directors of Nursing Administration, and is a fellow of the Minnesota Area Geriatric Education Center with the University of Minnesota.

 Where do you see the future of post-acute care delivery heading? We are seeing a shift in the care and services traditionally provided in our post-acute locations from serving mainly post-surgical lower extremity patients (hips and knees) to patients coming from the hospital with serious health issues and multiple comorbidities. These types of patients require a higher level of skilled nursing care and therapies, as well as potential collaboration with a multidisciplinary approach. We are beginning to see a younger population that often does not have insurance or is not eligible for Medicare. This in turn creates a funding source challenge in being able to provide the services they require within the current reimbursement system.

The bill fully implements a new payment operating system on Jan. 1, 2016 for Minnesota care centers or post-acute locations that participate in Medicaid funding. The passing of this proposal gave $138 million in additional funding to longterm care providers in Minnesota. This bill hopes to achieve the following goals: 1) preserve access to the continuum of care, 2) invest in recruitment and retention of professional caregivers, 3) reward quality care, 4) preserve dignity and quality of life, and 5) institute a payment system that fully funds the true cost of care in a post-acute or care center setting. In addition, this reform will enable us to serve the younger population that is not Medicare eligible or lacks insurance. Because of this payment reform, we are able to increase compensation for our nurses and invest in their continued education and professional development, which allows us to retain current staff and recruit new nurses.

 What further legislative action do you feel is necessary? Payment reform is greatly appreciated, but is long overdue. We need to be able to count on the legislators to continue to invest in our elderly and those who serve them. Post-acute care is not long-term care. We must be proactive and continue to educate our legislators, and encourage them to consider modifying the regulations. This is important so we can provide a continuum of care between the hospital and post-acute settings. Too often there is T ell us about the Physician and Provider Network partnerships that you have and how a lack of care coordination without evaluating what they impact your delivery of post-acute care? the goal of the customer actually is. If more coordination of care could occur, this would potentially Several of our post-acute locations are engaged in prevent having to expend resources by duplicating bundled payment projects. These projects provide assessments and evaluations already completed by the opportunity for us to partner with the primary a hospital or clinic. care physician or physician groups, hospital system, and outpatient services in order to improve  What are the most significant changes you outcomes for those we serve. Services such as our have seen in how post-acute care services patient navigator, which assists customers for a peare delivered? riod of time during and following their acute care stay. The goal of the navigator is to educate custom- The biggest changes that I have seen are in how our staff approaches their caregiving. We use a cusers and encourage them to stay focused on their tomer-centered model, focused on the well-being of own personal well-being, and this helps to avoid the customer’s mind, body, and spirit, rather than unnecessary rehospitalizations. Many of our postthe traditional institutional model. The response acute locations are blessed to have onsite nurse from the consumer is so much better. The environpractitioners, physicians, and physician assistants ment that we are providing now promotes overall who partner with our clinicians to deliver care during their patients’ stay. I would encourage more well-being. of this partnership with physicians going forward.  Can you tell us about the employment challenges that the post-acute care industry faces?  How have legislative changes impacted funding for post-acute care? There is a shortage in professional caregivers such as nursing assistants and registered nurses in The Long-Term Care Imperative brought forward Minnesota. Providers in Minnesota are struggling a bill this year, which was passed by the 2015 to recruit and retain caregivers, forcing many of Legislature and signed by Gov. Mark Dayton. them to suspend admissions, which in turn affects

Minnesota Physician December 2015

the access to health care that many seniors need. With the recent legislative changes in Minnesota, we are hopeful that this will address the shortage of professional caregivers, and improve recruitment and retention of caregivers in long-term care. Providers must be able to give employees a livable wage in order to remain competitive. The goal is to create a viable career pathway to ensure competent, experienced caregiving for seniors.

T he demand for senior care is expanding faster than the supply. Please tell us about these issues and how we can best address them?

We need to be able to count on the legislators to continue to invest in our elderly.

ing are also gaining more momentum with adult children who are concerned about the safety of their loved ones because they do not live nearby. These options are much more economical than long-term placement in a nursing home. Most individuals today want the option to stay in their home as long as possible with some type of support.

W hat advice can you give physicians with senior patients asking questions about post-acute care?  What are the best ways to measure the quality of postPhysicians cannot be expected to acute care? know the differences between the care People are living longer, which can lead to and services provided by post-acute care As a health care provider we are consisproviders. I think it is critical for post-acute tently working to ensure the highest level of the exhaustion of personal assets. However, people still need care. There are many more providers to partner with physicians and quality care and services to those we serve affordable senior care options for customers their patients and educate and inform them daily. It is important to measure quality in to choose from than in the past. As an orga- about choosing the right provider for the post-acute care using the Minnesota Qualnization we focus on meeting the customer services they require. Shared access to clinic ity Indicators, CMS Quality Measures, and where they are at and offering services or hospital electronic medical records is Minnesota Department of Health survey outcomes. Quality and success are measured across the spectrum of care when and where one way to collectively provide a seamless they need them. Care in the home whether delivery of care to patients with all primary by analyzing rehospitalization rates, length it is post-acute following a hospitalization, caregivers having access to health informaof stay, and final outcomes for patients private duty home health, or outpatient tion to assist customers in achieving their who are able to return to the place they call therapies are becoming a major trend. Our care outcomes. home or who can receive a lower level of care. Customer engagement is also a key in- LivingWell@Home suite of home-based dicator to examine for post-acute customers. technologies that monitors personal well-be-

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December 2015 Minnesota Physician

Positive psychiatry from cover

physicians, newer and more expensive procedures and treatments, and the political focus on reducing health care costs. As a result, health care funding will shift from resource-intensive treatment of illnesses to illness prevention through improved lifestyle. The time has come to integrate positive mental health into medical practice, and to expand our care to encompass the full spectrum of psychosocial functioning. What is positive psychiatry? Positive psychiatry is the science and practice of psychiatry that seeks to understand and promote well-being through assessment and interventions aimed at enhancing behavioral and mental wellness. The main objective is greater well-being, which may be achieved through optimal increase in positive

psychological factors such as resilience and social support. Positive psychiatry, with its focus on positive behavior modification, is not restricted to mentally ill people but is an approach applicable to all of medicine.

“mind-cure,” which referred to the purported healing powers of positive emotions and beliefs. However, positive psychiatry traces its most important lineage to the positive psychology movement pioneered by Martin Seligman and colleagues in the late 1990s.

Aging of body tissues is inevitable, aging of the mind is not.

Historically, the concepts of positive psychiatry date back at least to 1906 when William James, a physician and psychologist, argued for a new approach to study and apply psychological principles underlying the success of the so-called

Positive psychological states Positive mental health outcomes include 1) well-being, which is not an absence of disease, but the presence of positive psychological states such as life-satisfaction and happiness, 2) low level of perceived stress (the degree to which an individual believes that his/her contemporary demands or challenges exceed his/her ability to cope), 3) post-traumatic growth (the opposite of post-traumatic stress disorder or PTSD), manifested by personality growth in the form of greater appreciation of life, changed priorities, greater sense of personal strength, and recognition of new possibilities for one’s life, and 4) prevention of illnesses such as post-partum psychosis, post-stroke depression, PTSD, and even dementia. Positive psychosocial characteristics Positive outcomes are at least partially mediated by positive psychological traits and environmental factors. Several such traits have a positive impact on longevity with effects rivaling or exceeding those of well-established health risk factors such as smoking, hypertension, and obesity. These traits include: Resilience (ready recovery from or positive adaptation to illness or other adversities) and optimism (a tendency to expect good outcomes) are associated with

Minnesota Physician December 2015

better physical health, cardiovascular outcomes, physiological markers (including immune function), health-related quality of life, self-care, treatment and exercise adherence, and reduced all-cause mortality. Personal mastery denotes one’s expectations of personal effectiveness in achieving desired outcomes. It promotes specific, adaptive, goal-oriented behaviors, despite ongoing stresses. Social engagement refers to how well integrated a person is into a social network, including the number and quality of close relationships, frequency of socialization, and the degree to which one finds pleasure from social integration/interactions. Quality of one’s social relationships is associated with health outcomes and greater longevity across a range of medical populations. Spirituality refers to the degree to which one’s personal beliefs, thoughts, and behaviors focus on transcendent topics such as the meaning of life and belief in a higher being. It has been found to be associated with greater well-being as well as better health outcomes. Wisdom includes pro-social behaviors (compassion, empathy, altruism), social decision-making, insight, decisiveness, acknowledgement of uncertainty, emotional regulation, tolerance of divergent value systems, openness to new experience, spirituality, and a sense of humor. Greater wisdom may be important for an older adult’s ability to survive and even thrive in spite of worsening physical health. Similarly, wisdom transmitted from older to younger generations may help to neutralize the loss of fertility in old age—the so-called Grandma hypothesis. Positive environmental factors include family support, social support (the degree to which other people are available for emotional and physical support), availability of regular medical care; opportunities for physical, cognitive, and social activities; and provision of adequate nutrition. These factors

are associated with reduced depression, anxiety, substance use disorders, hypertension, cardiovascular disease, and dementia, as well as longer survival. Finally, city planning, transportation, and community environment have also been shown to affect mental and physical health. Successful aging Traditional definitions of successful aging have emphasized the absence of physical and cognitive disabilities. Recent studies, including some we have done at UCSD’s Stein Institute for Research on Aging, suggest that for older adults, subjective quality of life is very important. There is a paradox of aging—whereas physical health declines with age, there is greater happiness, better mental health, and better management of interpersonal relationships. New learning is possible in later life, and older adults continue to exhibit new forms of adaptive capacity. That is successful aging. When I went to medical school, I was taught that most of the growth and development of the brain occurred early in life and that after 60 years of age, it was a downhill course with progressive and unavoidable shrinkage of the brain. Yet, one of the most exciting findings in neuroscience research during the past 20 years has been that of the neuroplasticity of aging—i.e., the fact that brain growth and development continue into old age. Interestingly, such a positive outcome is related, not so much to the genes we inherit from our parents, but to our own behavior, attitude, and environment. Older individuals who keep their bodies and brains active are happier and more productive than are those who do not. How can an aging brain improve its function and structure? One mechanism relates to “compensation” which involves increased recruitment and more efficient utilization of brain networks. Even more interesting, new synapses and in some areas of the brain, new neurons form in older brains

if stimulated by living in an enriched environment. Incorporating positive psychiatry in clinical practice There are several lifestyle interventions that physicians should explicitly encourage their patients to use. For example, exercise is effective for improving physical health as well as for reducing depression and enhancing cognitive functions. Meditative practices such as tai chi, yoga, qigong, and mindfulness meditation have potential benefits across a range of psychiatric and physical diseases. A healthy diet may reduce the risk of severe depression, while junk food, sugar and processed meats may increase depressive symptoms. The Mediterranean diet is associated with decreased risk of heart disease and cognitive dysfunction. Sleep is another important area of focus. Sleep hygiene can make a difference in patients’ quality of sleep and quality of life. Decreasing alcohol, nicotine, and caffeine intake, increasing physical activity, and keeping the bedroom dark and free of distractions like a cellphone, are well-documented strategies to improve sleep.

For details, please see Jeste DV and Palmer BW: “Positive Psychiatry: A Clinical Handbook,” American Psychiatric Publishing, 2015.

rotations and to reinforce them during supervision. For written treatment plans in evaluation and progress notes, trainees should be taught to include aspects of positive psychiatry,

Positive psychiatry has the potential to improve health outcomes and reduce morbidity.

Training in positive psychiatry Positive psychiatry needs to be an integral component of the didactic and clinical learning experiences of each trainee. In addition to initiatives such as new didactic courses, concerted efforts should be made to weave these principles into existing

perhaps as a separate category to be addressed. Similar considerations would also apply to the training of non-physician professionals involved in health care. Of course, there are potential social/political and ethical Positive psychiatry to page 42

In children, exercise has a positive impact on ADHD and depression and positive parenting techniques reduce oppositional behavior. An example of a positive psychiatry model of care in pediatrics is the Vermont Family-Based Approach, which strives to expand the focus of care from illness to wellness and from the individual child to the entire family environment. There is growing literature on behavioral interventions to increase a person’s resilience, change attitudes toward aging or illnesses, reduce levels of perceived stress, lower negative emotions such as anger and anxiety, and increase positive ones such as enjoyment and empathy. Some studies have documented overall health benefits of these types of interventions.

December 2015 Minnesota Physician

Improving health care delivery from cover

engagement is essential to achieving maximal levels of quality and safety. From December 2011 to December 2014, MHA participated in a Centers for Medicare and Medicaid Services (CMS) initiative called the Partnership for Patients, a national public/ private partnership to improve the quality, safety, and affordability of health care. MHA was among 26 hospital engagement networks (HENs) created to meet the bold aims of reducing readmissions by 20 percent and reducing 10 hospital acquired conditions by 40 percent. More than 3,700 hospitals participated nationally; including the 115 Minnesota hospitals in the MHA-led HEN. The results in Minnesota were impressive: a 37 percent reduction in harm across the board, and a cost savings of $93 million, from health systems working together.

CMS endorses patient and family engagement as “the right thing to do” and stresses the urgency to implement it. It is through the work of the Partnership for Patients that best practices were surveyed, analyzed, and the metrics materialized from the field of information about emerging best practices. In 2012, CMS added the PFE component to the Partnership for Patients work and identified five goals (P1–P5) for hospitals to meet (see Table 1). The addition of these core goals reflects the growing consensus that meaningful patient and family involvement on the health care team improves health care delivery. MHA has set the lofty goal of 100 percent of Minnesota hospitals identifying a dedicated person or team to patient and family engagement work (P3), and 80 percent of hospitals establishing functioning Patient and Family Advisory Committees (P4).

The journey MHA’s journey into increasing patient and family engagement began by helping hospitals meet the CMS patient and family engagement criteria, and starting the first state association Patient and Family Advisory Committee (PFAC).

provide clarity and assistance to member hospitals in meeting more of the patient and family engagement goals. Patient and family engagement concepts are not new. For more than a decade, many tools and resources have been created, and best practices identified,

Table 1. CM S Partnership for Patients’ patient and family engagement criteria P1 Prior to admission, hospital staff provides and discusses a

planning checklist that is similar to CMS’s Discharge Planning Checklist with every patient that has a scheduled admission, allowing questions or comments from the patient or family.

P2 Hospital conducts shift change huddles and does bedside

reporting with patients and family members in all feasible cases.

P3 Hospital has a dedicated person or functional area that is

proactively responsible for patient and family engagement and systematically evaluates patient and family engagement activities.

P4 Hospital has an active Patient and Family Advisory Committee (PFAC) OR at least one former patient that serves on a patient safety or quality improvement committee or team.

P5 Hospital has at least one or more patient(s) who serve on a governing or leadership board and serves as a patient representative.

Source: Centers for Medicare & Medicaid Services.

As a first step, Lisa Juliar was invited to participate because in early 2010 she was the first patient to share a story at an MHA board meeting. In 2012, she was invited to become a member of MHA’s Quality and Patient Safety Committee, and in 2013 was invited to join MHA’s Patient and Family Advisory Committee. She was then brought onboard as MHA’s patient and family engagement advisor. The partnership quickly evolved into a whole new approach to patient and family engagement.

Minnesota Physician December 2015

A first task was to verify the accuracy of hospitals’ patient and family engagement criteria scores. It was quickly apparent that there was significant variation not only in how the questions were being interpreted, but in the very definition of “patient and family engagement.” With input from Lisa and the MHA PFAC, MHA was able to

to provide safe and effective patient-centered care, yet many health systems struggle with the translation of this information into practice. MHA endeavored to become the translator of this information—not to reinvent the wheel, but to find an innovative way to expedite the use of established patient and family engagement structures. MHA, through its Patient and Family Advisory Committee, sought to inspire hospitals and health systems to recognize the value of these new partnerships with patients, create strategies to move quickly into this exciting new way of doing business within the health system, and to authentically include patients and families at every stage of the health care delivery process. The result was the patient and family engagement campaign “Include Always.” Realizing that if hospitals and health systems—from leaders

into such an intense project, to frontline staff—are going to but strong top-level leadership transform their thinking, they helped. The CEO attended an must be motivated by fresh, enevent for the potential patient ergizing, and innovative ideas. So MHA created Include Always advisors and said to them, “We think we know how to deliver not merely as an information excellent care, but we want to resource, but as a foundation know what excellent care means of awareness and eagerness to you.” This made patients feel to implement critical changes not only welcomed onto the in health care delivery. One team, but empowered them to hospital leader shared, “I feel share their perspectives and like PFE is getting back to why ideas. All 12 patients present I went into health care to begin energetically committed to bewith—the relationships with ing members of the new PFAC. those whom we are privileged Some hospitals to serve.” These included not relationships only patients, can bring a new The success but also invited kind of energy, of the pilots representation joy, and passion from their into the healthexceeded MHA’s outpatient care delivery initial vision. clinics, longsystem. term care and assisted-living The pilot partners, In January 2015, four pilot underscoring the prospect that hospitals applied a rapid timepatient and family inclusion line for implementing the could positively impact care Include Always model. Prior across the entire continuum. to implementation, each hospital completed an assessment The success of the pilots allowing MHA and the hospitals exceeded MHA’s initial vision. to identify their strengths in Each hospital created a PFAC patient inclusion, and opportuof five to 12 patients and one nities to increase that inclusion. to three staff. Newly formed The hospitals all agreed to use PFACs typically require up to a the Include Always materials, year before they are prepared to create a Patient and Family undertake meaningful projects. Advisory Committee, and hold Patient advisors must take their PFAC meetings monthly from time learning about the healthJanuary to the state-wide kickcare delivery system, sharing off in April. They also partictheir own health care stories, ipated in a site visit followed and learning about each other. by virtual learning sessions One exciting measure of success every other week. Site visits at of the pilot was that all hospieach hospital included training tals in the pilot started a new to hospital-wide staff, potenPFAC and completed a project tial advisors, board members, in the first six months. physicians, and leadership and included the patient advisor Project examples who shared her personal story In order to sustain PFE/ of adverse events. The webinars PFACs, it is essential to include included topics such as training patients in meaningful work hospital staff, creating and oper- and demonstrate to hospital ating Patient and Family Advistaff that including patients in sory Committees, and recruiting quality and safety work benand training new patient adviefits everyone. By providing sors. The webinars also allowed resources and suggestions to the hospitals to share successes the pilot hospitals on how to and challenges, giving opporquickly engage their PFACs in tunity to learn from each other effective projects, it created through the process. swift momentum and evolution. Leadership involvement is critical to success. One hospital was initially hesitant to jump

Each hospital demonstrated success with their PFACs in one of the following projects:

• A “walk-about” through the emergency department. Immediate, positive changes followed based on the PFAC’s recommendations, prompting other departments to seek their recommendations as well. Other “quick-win” projects: • A patient room closet redesign • A long-term care partner trialing new beds • A process improvement plan for patients required to be on gurneys in the waiting room • A suggestion box for projects for the PFAC to consider Each pilot has reported a great increase in interest and passion to look for ways to more fully integrate patients and their families into the health-care delivery process. These findings, along with other lessons learned, formed the basis of MHA’s Include Always educational campaign, which was unveiled at the statewide Include

Always kick-off in April 2015. The kickoff was well attended by leaders, staff, and most important, patients and family advisors from across the state. Additional educational support is provided to hospitals through bi-monthly webinars (virtual learning seminars or VLS) and networking calls. The webinars provide didactic instruction and step-by-step direction to hospitals on the PFE journey. Networking calls offer an interactive hour to support health systems in the journey to meaningfully include patients and families. The results Hospitals and health systems across Minnesota are progressing rapidly on this journey to include patients and families through PFACs. Since the inception of MHA’s patient and family inclusion work, Minnesota health systems have Improving health care delivery to page 40

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Visit us online at www.minneapolisclinic.com December 2015 Minnesota Physician

Professional Update: Neurology

ne of the most interesting and exciting areas of neurology over the past decade has been within the subfield of autoimmune neurology. Both basic science and clinical discoveries have enabled neurologists to better serve patients who present with symptoms concerning for an autoimmune process. In both pediatric and adult patients, unique clusters of symptoms have been associated with specific antibodies against moieties such as the NMDA receptor, glutamate receptor, glycine, and Ma-2. Over time, many of these clusters have been identified as particular syndromes. Importantly, there is often overlap between symptoms that in isolation may be indicative of diseases in several medical disciplines (e.g., psychiatry and neurology). The presence of this symptom overlap can lead to confusion regarding which medical system is going awry. The case illustrated here is a classic example of the difficulties inherent in encountering

Anti-NMDA receptor encephalitis A disease at the intersection of neurology and psychiatry By Ryan P. Williams, MD, EdM patients with an autoimmune neurological disease. The case Patient JJ is a 17-year-old high-functioning girl without significant past medical history who was initially brought to a community hospital emergency department (ED) following parental concerns of two days of intermittent agitation and confusion. Her parents noted that she had random episodes of crying and screaming alongside auditory hallucinations and writhing movements of her hands. Of note, the episodes

Minnesota Physician December 2015

were described as stereotyped. Following the episodes, she was slightly confused but then returned to her baseline. In the ED, a head CT was obtained which was reported as normal. Basic labs were also drawn and were normal. She was referred to a psychiatric facility for further evaluation. Following a psychiatric evaluation, she was diagnosed with stress and told to make an outpatient appointment for counseling. Her parents were unconvinced that stress was the culprit in their daughterâ&#x20AC;&#x2122;s changing behavior. As a result, she was brought to an academic medical center ED for further assessment. She was consulted on by the psychiatry service in the ED and, while they thought she was likely suffering from acute psychosis, they recommended inpatient medical admission to first rule out neurological etiologies. Following admission to the adolescent unit, she experienced a generalized convulsive seizure that was described as the turning of her head to the left followed by whole body convulsions lasting approximately 30 seconds. Following the witnessed seizure, she was placed on video EEG monitoring and a lumbar puncture was performed. The results of her lumbar puncture were as follows: In Tube 1 there was WBC 19, RBC 0; and in Tube 4 there was WBC 29, RBC 1, glucose 64, protein 19. The differential showed a lymphocytic predominance. She was subsequently placed on broad spectrum antibiotics as well as acyclovir to cover for potential herpes simplex virus (HSV) infection. The cerebrospinal fluid (CSF) culture returned negative as did the HSV PCR leading

to cessation of the antibiotics and acyclovir. A brain MRI was obtained and was normal. At the time of the clinical seizure, the neurology service was consulted and recommended sending various infectious markers as well as serum and CSF testing for antibodies to the NMDA receptor. Over the next few days, JJ developed dyskinesias of her mouth and hands and, given her prior symptoms, there was consensus among the neurologists that the diagnosis was anti-NMDA receptor encephalitis and that treatment with immunosuppression should begin. Interestingly, the day following the emergence of JJâ&#x20AC;&#x2122;s dyskinesias, her laboratory testing returned and confirmed the diagnosis. She was subsequently started on a five-day course of high-dose Solu-Medrol (1 gram daily) and intravenous immunoglobulin (IVIG) (2 g/kg divided over five days). A pelvic ultrasound was performed to look for an ovarian teratoma and was negative. Over the course of her treatment, she remained agitated and required antipsychotic medication as well as a 1:1 sitter. She also developed difficult to treat insomnia, hyperphagia, and weight gain. She continued to have clinical seizures requiring aggressive anti-seizure management until stability was achieved with topiramate. A second round of immunosuppressive therapy was given because of her continued encephalopathy. After approximately four weeks, she achieved a degree of clinical stability and was transferred to an inpatient cognitive rehabilitation facility. Unfortunately, JJâ&#x20AC;&#x2122;s degree of encephalopathy made cognitive rehabilitation difficult. As she had already been given two rounds of therapy with steroids and IVIG, it was determined that she required more aggressive medical therapy. She was then placed on a cyclical regimen of rituximab infusion therapy alongside dexamethasone. After four rounds of therapy, her encephalopathy improved dramatically and she was at approximately 90 percent of her mental status baseline. She

finished her inpatient cognitive rehabilitation and returned home. Over the next year, she continued to improve and eventually completed her high school studies and enrolled in community college. She completed a year of studies—getting straight A’s—and transferred to a four-year university. She was tapered off topiramate and continues to be seizure-free. Repeated tumor surveillance was negative.

link to a viral prodrome but this is not consistent across all patients. Besides the aforementioned symptoms, there is also a link to ovarian teratomas in woman and testicular tumors in men. In a 2013 study by University of Pennsylvania researchers, 38 percent of 577 patients with anti-NMDA receptor encephalitis were diagnosed with a tumor. Of those diagnosed with a tumor, 97 percent were women. Interestingly, it

anti-NMDA receptor antibodies. Therefore, patients who present with psychiatric symptoms in the absence of symptoms like seizure, movement disorder, or autonomic instability, are unlikely to have anti-NMDA receptor encephalitis. The diagnosis of anti-NMDA receptor encephalitis is primarily supported by clinical symptoms and the presence of antibodies in the serum and/ or CSF. Lumbar puncture is

are a part of an autoimmune disease or simply ascribed to mental illness. There have been a few studies that have attempted to define the borders on this decision. The University of Pennsylvania study, for example, revealed that only 4 percent of the 577 individuals studied displayed two or fewer symptoms within the first month of diagnosis versus 87 percent showing four or more symptoms. Additionally, a 2012 study of patients with new-onset schizophrenia did not reveal

Anti-NMDA receptor encephalitis to page 38

Nearly all patients experience more than two symptoms within the first month of diagnosis.

Discussion The story of anti-NMDA receptor encephalitis began in 2005 following the discovery by Josep Dalmau and colleagues at the University of Pennsylvania of a clinical syndrome involving the tetrad of encephalitis, psychiatric symptoms, hypoventilation, and an ovarian teratoma. By studying the CSF and serum of women with the syndrome, they discovered that each patient had developed extracellular neuronal antibodies. Subsequently, in 2007, Dalmau, David Lynch, and colleagues identified the target of these antibodies as the NMDA receptor. The NMDA receptor is a post-synaptic cell surface receptor that is involved in the regulation of excitatory glutamate neurotransmission. The antibodies bind to the receptor, leading to their endocytosis and subsequently decreasing electrical activity. The emergence of the neurologic and psychiatric symptoms is hypothesized to occur as an effect of the decreased electrical activity of these neurons. Symptoms The symptoms of anti- NMDA receptor encephalitis include agitation, impaired concentration and memory, hallucinations, seizures, dyskinesias and other movement disorders, and autonomic instability. There has been an occasional

appears that there is a higher likelihood of tumor in black and Asian individuals than in white or Hispanic individuals. Who does it affect? This disease encompasses all age groups, from childhood through late adulthood. The median age of onset in the aforementioned University of Pennsylvania study was 21, with a range from eight months to 85 years. There is a female predisposition (81 percent versus 19 percent). Notably, while the disease is present in all age groups, the initial manifestations differ between younger children and adolescents and adults. A majority of children younger than 12 (50 percent) were brought to medical attention secondary to seizures or movement disorders whereas a majority of people age 12 or older presented with behavioral changes. Most of the children are noted to have cognitive or behavioral changes as the disease progresses and it remains a possibility that subtle behavioral changes were missed earlier simply because of age. Diagnosis Given the association of both neurological and psychiatric symptoms in anti-NMDA receptor encephalitis, it can be difficult for medical professionals to decide when seeing a patient with psychiatric symptoms whether those symptoms

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December 2015 Minnesota Physician

Special Focus: Senior and Long-Term Care

ong-term care is an eventuality for many Minnesotans. According to the Minnesota Department of Human Services, the number of people living in nursing homes in Minnesota, not including those in a transitional care unit, is approximately 29,000. The number in long-term care settings other than nursing homes, such as assisted living, is significantly higher. Rough estimates are that well over 100,000 individuals reside in an assisted living, group home, or other long-term care setting in Minnesota. Given the vulnerability and volume of residents, staff alone cannot meet all of the social, physical, spiritual, and psychological needs. The support of family members is key to the resident’s overall quality of life. Family involvement Involved family members are a good thing for residents and providers, and should be seen

Family advocates in long-term care Understanding their role By Suzanne M. Scheller, JD as such. For instance, family members generally allow for a substitute decision maker when health care decisions need to be made for a client with diminished capacity. Involved family members may be able to transport their loved one to the doctor, provide input on their care given their extensive knowledge of the resident, and communicate messages back and forth. Family members provide social interaction and facilitate outings that promote overall quality of life and minimize depression, which often accompanies longterm care. In addition, most family members ensure that bills to the provider get paid.

However, providers at times do not embrace the family’s role and if a family member’s voice gets too loud, he or she is labeled as a “detriment” to care; as “interfering” with care; or as a trouble-maker. While there are always outliers who require provider intervention, the vast majority of family members support and speak up appropriately when necessary. As a representative of many vulnerable adults and their families, I label these mainstream family members as “advocates,” and unfortunately providers may bristle at advocates. Advocates need to continue to speak up and providers need to continue to listen, for the good of the elder. Effective family advocacy

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Minnesota Physician December 2015

A family member can effectively advocate for their loved one and work with the provider to ensure quality care. In general, there are a few important themes for family advocates to keep in mind: visit the resident; take the time to read documents prior to signing them, even if the facility says that they must be signed right away; document any concerns; and periodically review medical records to ensure that concerns are incorporated and that the records are accurate and complete. • All providers must make the admission agreements available to the resident or family member for review (see Minn. Stat. §144.6501). Family members are advised to read admission agreements and resist the urge to simply sign under pressure. Family can ask for one or two days to review the language before signing. No signature is actually required for admission.

• Many admission agreements now contain separately signed arbitration agreements. I generally recommend that the family/resident not sign any arbitration agreements since the family does not know what dispute may arise when admitting a loved one. By not signing, the family is not precluding arbitration in the future, if both parties agree. • The resident will be asked to sign one admission agreement for both housing and care when entering a nursing home. However, in a non-nursing home setting the resident will likely be asked to sign two agreements, one as a lease under landlord-tenant law for the physical space and the other for home care services. Family members should read the agreement for home care services carefully (see Minn Stat. §144A.4791, subd. 3) to understand items such as: Valid reasons for discharge; Whether the facility accepts Medical Assistance payments (i.e., Elderly Waiver); Whether the resident is allowed to bring in their own home care services and remain a resident of the facility. • Family advocates can be present during the resident’s initial assessment, which generally happens within 14 days of admission. This allows the advocate to understand the resident’s condition when evaluated by a trained professional. (See Minn. Stat. §144A.4791, subd. 8 regulating home care assessment and 42 CFR §483.20(b)(2) regulating nursing home assessment.) • Family advocates can participate in care conferences to hear what is being said about their loved one’s progress and/or condition.

the facility’s recommended doctor (“house doctor”) may be necessary due to the convenience of the physician coming to the facility for periodic check-ups and regular communication with the facility. (See Minn. Stat. §144.651, the Minnesota Health Care Bill of Rights, and 42 CFR §483.10(d) for the proposition of the right to choose providers.)

• At the care conference, if the facility asks that each participant sign off on attendance, take the time to read over the notes to ensure accuracy and completeness of the information. Advocates should make sure that any concerns they raised are documented. • If a family advocate is unable to attend a care conference on a given date or time, they can ask to reschedule and/or participate via phone if necessary.

The support of family members is key to the resident’s overall quality of life.

• Remember that the resident may choose their own physician, but the family should weigh the factors since using

• K now the Care Plan or Service Agreement under which the facility is providing care. This document dictates what staff will be doing when caring for a resident. If a particular concern isn’t addressed on the care plan, no matter how often the family member tells staff about the concern, the structure to meet the concern is not in place. • Find out the chain of command within the facility to report concerns effectively. Reminding a nursing assistant or perhaps even an LPN that the care plan is

not being followed is not the same as notifying the facility. • Family advocates can request medical records, and should do so periodically for accuracy, completeness, and to determine any information not previously shared with the family. If the records are in error, advocates should ask for an amendment to the record, which is allowed under HIPAA laws and regulations. • When a family member’s concerns are not addressed, there are several options that may be appropriate for them to pursue: • Get a second opinion from another physician related to concerns of diagnosis or condition.

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• In drastic situations of suspected maltreatment by staff and/or patterns of detrimental care, the family can consider finding a different facility. This is considered a last resort option and must be weighed against the detrimental effects of moving the resident.

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December 2015 Minnesota Physician

Special Focus: Senior and Long-Term Care

hen a patient is admitted to a nursing facility for any reason, it’s a time of transition for both the patient and his or her family. Health care professionals are there to provide care, support, and guidance, but there are other services available to patients and their families to help with the transition. One such service that must be completed before the patient goes to a nursing home is pre-admission screening (PAS). Federal and state laws require that patients entering certain types of nursing homes receive a PAS, regardless of anticipated length of stay, who is paying, or the patient’s age (see the sidebar on PAS supports). Unless an admission meets an exemption or exception, the screening must be completed prior to admission. In Minnesota, a screening request is submitted online at https:// mnhelpreferral.revation. com, overseen by the Minnesota Board on Aging with

The pre-admission screening process What physicians need to know By Stephanie Minor, MPP the process completed by the Board’s Senior LinkAge Line. The physician who determined the need for nursing home admission and wrote the admission orders must request the screening. However, physicians must be limited to those practicing in hospitals, clinics, and hospice programs because they best understand the patient’s needs and abilities, since they completed the evaluation for nursing home placement. However, staff working directly with the physician, such as nurses, case aides, and administrative support staff within the hospital or clinic, as well as nursing facility staff, may also complete

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Minnesota Physician December 2015

the online referral for a PAS, using information provided by the physician. If the physician requesting the screening does not have enough information to complete the PAS referral online, he or she, or their designated staff, can complete the online form to the best of his or her ability. Staff at the Senior LinkAge Line will then determine whether a face-to-face assessment with the county, tribe, or managed care plan is needed. Ensuring a successful referral The Senior LinkAge Line strives to complete all PAS referrals within one business day. To assist with this effort it is important that the PAS contains as much information as possible. Some tips for ensuring timely processing include: • Complete all of the required fields using the information available, or you will not be able to submit the form. These required fields are necessary to process the screening and if they are not filled out, it will result in a call to the hospital or clinic worker that submitted the form;

• Be sure that you have selected the Finish button and you will see a confirmation number and the current date. If this step is missed, the referral will not transmit to the Senior LinkAge Line; • Securely save or print a copy of the completed PAS, as it contains an initial nursing facility level of care and screening results that can be shared with the admitting nursing facility. This is your proof of completion, which can help your patient and the nursing home avoid delays. • If the reviewer who receives the screening cannot determine the results, a faceto-face assessment will be completed by the county or managed care plan. This assessment uses MnCHOICES (formerly Long Term Care Consultation). The faceto-face assessment must be completed within 20 calendar days of the initial request for screening, and prior to admission. Please note: Step-by-step instructions are available on the referral site. Click the question mark next to the form submission option on the start page to access this information. The importance of assessments Rose was considering a permanent move to a nursing home because she was worried that her family thought she was a burden. Rose’s doctor had discussions with both Rose and her family about this move.

PAS supports care transitions PAS is required for nursing homes, certified boarding care facilities, or hospital swing beds that are Medical Assistance- certified. PAS is important to seniors and their caregivers because it helps people: • Avoid unnecessary admissions to nursing homes for those whose needs might be better met in the community; • Connect to community-based services; • Who have mental illness or developmental disabilities by making sure that they are evaluated for specialized mental health or developmental disability services (required under federal law); • Determine and document the need for a nursing home for purposes of Medical Assistance payment for these services; • Provide assistance after the person is admitted to get them back to their community or home.

The doctor’s office submitted a PAS in preparation for the time when Rose was ready to move. Because the information on the screening did not provide enough information to determine if Rose met the level of care required, a referral was made to Rose’s county. A trained county staff person met with Rose and discussed housing options to help her make an informed decision. In addition, the county was able to connect the patient back to the Senior LinkAge Line for additional assistance. Please note that if a patient is being admitted to a nursing facility outside of Minnesota, a PAS must be completed for the state where the nursing facility is located. For example, if a patient is at a Minnesota hospital, clinic, or nursing facility, but will be admitted to a nursing facility in Wisconsin, a screening must be completed using that state’s process, which may be different than Minnesota’s. Similarly, if a patient is in a

North Dakota hospital, clinic, or nursing facility, but will be admitted to a Minnesota nursing facility, the PAS process for Minnesota must be followed using the online referral site.

swing bed, or certified boarding care facility in Minnesota to another. • A nursing facility to acute hospital to nursing facility transfer: When a person transfers from a Medical Assistance-certified nursing or boarding care facility in Minnesota to an acute (non-psychiatric) hospital and then back to the same or another MA-certified facility.

presented to the patient, his or her family and/or legal representative. However, if a nursing facility admission cannot be prevented, the admission must be approved by the Department

There may be times when a physician determines that a nursing home admission must occur immediately. It is important to note that for all individuals aged 20 or younger, a face-to-face assessment is required before admission, regardless of projected length of stay, admission source, or result of the screening. The physician or their staff should still complete the online referral to facilitate the scheduling of this assessment. The Senior LinkAge Line will contact the appropriate lead agency for the next steps. During this assessment all community alternatives must be explored and

of Human Services by calling (651) 431-4300 or toll-free at 1-866-267-7655. An “inter-facility transfer” is exempt from screening. This is when the patient moves from one nursing home to another, involving only Minnesota facilities, and the consumer cannot return to the community/home. There are two types: • A nursing facility to nursing facility transfer: When a patient transfers from one Medical Assistance-certified nursing facility, hospital

Transferring to another state If the transfers occur to a nursing facility in another state, a new PAS must be submitted. There may be times when a physician determines that a nursing home admission must occur immediately, resulting in an emergency admission. A screening must still be submitted, however it can be done the next working day. For purposes of PAS, an emergency admission is permitted when all of the following criteria are met: The pre-admission screening process to page 35

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Special Focus: Senior and Long-Term Care

innesota’s health care providers are in the midst of changing how they collect and share data between themselves and with beneficiaries. They are changing from paper-based systems to electronic health records (EHRs) for reasons that include improved care coordination and care transitions, as well as better data sharing and analytics. Incentives

The Centers for Medicare & Medicaid Services (CMS) provides incentives for clinical providers to achieve electronic exchange of health data by offering Medicare and Medicaid EHR incentive program payments, referred to as “meaningful use” incentives. There are now three stages of these incentives that must be met by clinical providers who wish to receive maximum reimbursement for serving people on public programs. Stage 1 focuses on capturing and sharing data,

Personal health records Improving care coordination By Tom Gossett, MM, PMP, and Rolf Hage Stage 2 on advancing clinical processes, and Stage 3 on improving outcomes (additional information about meaningful use can be found online at www.healthit.gov/providersprofessionals/meaningful-usedefinition-objectives). In Minnesota, the legislature has given the Minnesota Department of Health’s (MDH’s) Office of Health Information Technology the responsibility for overseeing the health information exchange (HIE). According to data compiled by that office, meaningful use incentives have contributed greatly to the adoption of EHR technology in clinical settings. As of 2014, 100 percent of Minnesota hospitals and 93 percent of clinics have adopted EHR technology.

While hospitals and clinics have progressed in adopting EHR systems, achieving interoperability between clinical systems remains challenging. Adopting EHR technology has been slower in parts of the health care system where meaningful use incentives are not available. Based on its most recent data, the Office of Health Information Technology reports that in 2011, 69 percent of Minnesota nursing homes had adopted EHRs. Reliable data on adoption rates of EHRs in the home and community-based service (HCBS) provider community are not available but, given the limited size and resources of these organizations, it is logical to assume they lag behind nursing homes. Long-term services

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Minnesota Physician December 2015

To expand the health information exchange beyond the clinical community to HCBS providers, CMS issued Testing Experience and Functional Tools (TEFT) grants to nine states, including Minnesota, in 2014. Grantees were challenged to demonstrate the use of a personal health record (PHR) system with beneficiaries of community-based long-term services and supports (LTSS). Medical Assistance waiver programs pay for long-term services and supports in community settings to help eligible seniors and people with disabilities avoid more expensive institutional forms of care. Community-based services include home health care, homemaker and chore services, home delivered meals, transportation, respite care, case management, and mental health services. Medical Assistance also pays for long-term care in nursing homes and assisted living facilities. Personal health records An ideal PHR is defined by CMS as providing “a complete and accurate summary of the health

and medical history of an individual by gathering data from many sources and making this information accessible online to anyone who has the necessary electronic credentials to view the information.” PHRs typically present information from primary and acute care EHRs as well as user-entered data. They do not typically include information from clinics and systems using other EHRs or from post-acute care providers or HCBS. DHS intends to test the concept of a PHR that includes data provided by the user as well as data from primary and acute care EHRs and data about long-term services and supports from DHS systems. While PHRs appear to be a good idea, they have not been enthusiastically adopted by most users. According to an article in Health Affairs (Volume 28, Number 2) by Kahn, Aulakh, and Bosworth titled What it Takes: Characteristics of the Ideal Personal Health Record, “because health information such as financial or clinical data does not flow freely among multiple organizations, PHRs do not automatically receive data. This means that the data must often be entered manually by consumers—a time-consuming and error-prone process. For most consumers, this lack of safe and reliable automation makes it problematic to maintain a PHR, and a PHR that is not up to date is not useful and thus will not be used.” Populating data DHS plans to work with a PHR Community Collaborative to demonstrate how a PHR that is prepopulated with data from clinical and state systems could be made available to Medical Assistance waiver beneficiaries. Populating the PHR with data from state systems will require efforts by DHS IT and program staff to identify data about beneficiaries, their care plans and the services they receive, aggregate that data, and securely transmit it to an outside system. The PHR Community Collaborative— made up of one or more counties, LTSS providers, and one or more technology vendors—will securely store and display the information from DHS in a

beneficiary’s PHR. It will also display data from clinical providers that serve the beneficiary. The county and LTSS providers will help identify beneficiaries who will test the PHR for accessibility and usability during the demonstration period. DHS has identified the requirements for a system that will make DHS data available to beneficiaries through a secure PHR. This includes determining what data about beneficiaries DHS currently collects and where that information is stored within DHS systems. It also includes deciding what parts of that data would be of interest to beneficiaries or their legal representatives. DHS has learned from stakeholders that: • It would be helpful to include the name and contact information for the waiver case manager in the PHR. Waiver recipients may not know they have a case manager or, if they do, how to contact them. • In many cases, hospital long-term services and supports intake workers have to make numerous phone calls to find out who a waiver recipient’s case manager is. If that information is included in the PHR, the beneficiary or legal representative will be able to more readily contact their case manager when they need to, and will be able to easily share the name and phone number of their case manager with others who need to know, including clinical providers. Passing information to beneficiaries Historically, DHS information about beneficiaries stays within DHS systems. Legitimate concerns about data security (including compliance with HIPAA and the Minnesota Data Practices Act) and the limitations inherent in older DHS technology have made passing information to beneficiaries electronically a challenge. This project will provide DHS with an opportunity to test the concept of securely transmitting data out of its systems to beneficiaries.

Currently, beneficiaries receive copies of service agreements, explanations of benefits, and eligibility reminders from DHS through the mail. The sheer volume of letters and the inherent complexity of the information communicated can lead to confusion. Letters are often misplaced, discarded, or ignored by beneficiaries. An electronic repository of this information would make it easier for beneficiaries to track, review, and share this information with others within their circle of care.

to earlier points out that mobile phone use is higher than Internet access in underserved communities, especially among Hispanic youth. As devices become more sophisticated and application developers design mobile-ready solutions, the mobile phone may also serve as an important entry point for consumers to access their PHRs. The mobile phone also introduces an important opportunity to support consumers in a behavior change through direct and customized text reminders.

Data must often be entered manually by consumers—a time-consuming and error-prone process.

limited area in Minnesota by Sept. 30, 2016. Minnesota’s TEFT Grant lasts through the end of March 2018. The PHR demonstration will compile lessons learned about how LTSS beneficiaries might use a PHR, and what value they would find from better understanding the services they receive from DHS. Time will tell whether the demonstration will expand to other counties or even statewide in the future. Ultimately, the demonstration is another effort on the part of DHS to provide and enhance person-centered supports to beneficiaries. To learn more about the PHR for LTSS Demo, visit the DHS Web site at: www.dhs.state.mn.us/ main/dhs16_184574. Tom Gossett, MM, PMP, is the TEFT

CMS requires that providers use a person-centered planning process with beneficiaries, which “addresses health and long-term services and support needs in a manner that reflects individual preferences and goals.” DHS believes that an important aspect of person-centered planning is ensuring that people have easy electronic access to their service agreements, which will be demonstrated through the MN TEFT project. A person-centered approach requires that the PHR be easy to access and use. DHS is committed to ensuring that the PHR is: • Simple: Information about long-term services and supports can be complex and confusing. DHS will work to ensure that the information included in the PHR is as simple as possible, so users can understand and act upon the information they receive. • Accessible: Web accessibility refers to ensuring that people with disabilities (such as blind or low vision users) can make optimal use of a website. The PHR will be compliant with standards for accessibility published by the World Wide Web Consortium (W3C). • Available: DHS will ensure that the PHR can be used easily on mobile devices. The Health Affairs article referred

Conclusion The PHR for long-term services and supports community collaborative is projected to launch in one geographically

Grant project manager for the Minnesota Department of Human Services. Rolf Hage is the manager of the Resource Development Team at the Minnesota Department of Human Services.

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Orthopedic Surgery

o set the scene, a 13-yearold male patient visits your clinic with six weeks of increasing knee pain. He is an otherwise healthy teen who participates in basketball yearround. A physical exam shows significant effusion and tenderness to palpation along the medial joint line. Plain radiographs show lucency along the medial femoral condyle. An MRI finds a large piece of bone and cartilage displaced from its native location along the weight-bearing aspect of the medial knee. The diagnosis becomes clear: osteochondritis dissecans (OCD). The family is anxious about what the future may hold and the young athlete is concerned about his upcoming season. Though it’s rare, impacting less than 1 percent of the population, the condition is becoming increasingly common. Fortunately, there are key symptoms and technologies to help diagnose the condition, as well as numerous treatment options.

Osteochondritis dissecans Increasingly common in adolescent athletes By Jeffrey Macalena, MD, and Bradley Nelson, MD

Symptoms Osteochondritis dissecans of the knee is a disease of both the subchondral bone as well as the overlying articular cartilage. The affected bone is sequestered from the surrounding subchondral bone. This sequestered fragment, as well as its overlying cartilage, is termed the progeny fragment. With time, instability of the progeny fragment from the surrounding bone will develop and the overlying cartilage will become soft and fissured as its underlying support is

Psychiatric Care evolved.

the lesion often becomes unstable and fragments. Juvenile OCD is frequently diagnosed in the early adolescent athlete. The age of presentation seems to have become younger in recent years (which is particularly true in girls). Researchers attribute this early onset to an increase in competitive sports, single sport specialization, and loss of free play.

Minnesota Physician December 2015

weakened. In advanced stages of OCD, the progeny fragment can become completely displaced from its native location leaving a cavitary defect within the weight-bearing zone. The cause While the exact etiology is unknown, OCD is thought to arise from the interplay of genetic predisposition and repetitive micro trauma, which leads to an insult in the small vessels that service the bone and cartilage. Multidisciplinary researchers at the University of Minnesota Veterinary School, Center for Magnetic Resonance Research (CMRR), and the Department of Orthopaedic Surgery have furthered this research though their work with advanced imaging of young patients with symptomatic OCD lesions and histological samples in an animal model.

Patients with OCD frequently present with complaints of activity-related knee pain. The knee pain is often diffuse and nonspecific and frequently attributed to “growing pains.” Locking, or catching are important clinical complaints and may portend instability of the progeny fragment or even displacement. Swelling is an important physical exam finding and should be diligently evaluated. Persistent swelling in a young athlete should be evaluated by physical exam and radiography to confirm that an OCD lesion is not present.

Plain radiography is the initial diagnostic test.

Who OCD affects

Diagnosis

The overall incidence of OCD is thought to be approximately 20 in 100,000 individuals with a male predominance of 5:3. It is present bilaterally in approximately 25 percent of patients. OCD can be classified as adult or juvenile depending on the status of the distal femoral physis. The juvenile form, characterized by an open distal femoral physis and a cartilage surface that is frequently intact, has a higher potential to heal with a course of rest and activity modification. Adult OCD, which is thought to be an unresolved juvenile lesion, will not heal spontaneously. Its course is frequently progressive and

Plain radiography is the initial diagnostic test. A knee series—AP, lateral, and sunrise views are frequently obtained; however, consideration to obtaining a flexed notch view in place of or in addition to the AP view may allow improved visualization of posterior-based lesions. Lucency along the weight-bearing surface is how early lesions present; whereas, later lesions will often present with a rim of sclerotic bone and a well-circumscribed progeny fragment. While reviewing the plain radiographs, it is also important to note the status of the patient’s distal femoral physis as patients with open

growth plates can frequently be treated initially with nonsurgical management. MRI is the standard for advanced imaging of OCD lesions in both juvenile and adult varieties. We can utilize proton density and fluid sensitive sequences to evaluate the overlying cartilage and predict stability of the progeny fragment to the underlying bone. Interposition of high signal behind the progeny fragment suggests instability. Treatment The treatment of OCD lesions depends on whether the patient is an adult or juvenile. The juvenile variety of OCD (those with open distal femoral physes) can frequently be treated with a period of rest and activity modification. Use of the mantra, “If it’s not hurting it’s healing,” can be a useful guide for patients and their families. Crutches as well as an unloader brace (to decrease forces across the affected compartment) can also be considered. Experts recommend three months of rest and avoidance of running or pounding sports. At this time, radiographs are frequently repeated and re-initiation of sports in a gradual manner is started. If pain, swelling, or other symptoms return, then surgical intervention should be considered. Providers should be careful to avoid the rest-improvement-pain-rest-improvement-pain cycle because it can be hard to tell if the patient is making progress. For this reason, experts recommend one period of definitive rest and if this fails, providers should explore surgical intervention. The surgical management of juvenile OCD depends upon the stability of the bone fragment as determined by arthroscopy. Stable progeny fragments can be treated with drilling as a way to increase local blood flow, release marrow elements, and initiate healing. Progeny OCD fragments that are unstable at the time of arthroscopy require fixation. This can be completed utilizing an open or arthroscopic approach and is

frequently combined with drilling or bone grafting as a way to improve the biologic healing of the fragment. An adult OCD lesion may be treated by fixation and bone grafting of the progeny fragment, but these lesions are often unrepairable. In this situation, excision of the progeny fragment and debridement of the unstable flaps of cartilage is

(chondrocytes) are grown in a laboratory. After there are enough cartilage cells, they are re-implanted where they continue to grow and mature. Osteochondral allograft transplantation is a procedure where a piece of bone and cartilage is transplanted from a cadaver donor to the recipient, reconstructing the cartilage defect in the process.

OCD is thought to arise from the interplay of genetic predisposition and repetitive micro trauma.

usually performed. If symptoms persist, providers should consider cartilage reconstruction. The results The clinical outcomes of juvenile patients treated with surgery are good overall with a healing rate of greater than 80 percent. No consensus has yet been reached on the specific techniques of marrow stimulation, the need for bone grafting, or the specific type of implant. The University of Minnesota is part of a multicenter study group called Research in Osteochondritis of the Knee (ROCK), whose members are looking to answer these questions with prospective studies and creation of an OCD registry. Cartilage reconstructive surgery for the treatment of adult OCD lesions is also filled with promise and innovation. Conventional techniques like microfracture and debridement have shown improvement in patients’ symptoms in the short term; however, outcomes scores seem to deteriorate with time, which suggests that scar cartilage is not as durable as desired. This finding has led experts to use other techniques such as autologous chondrocyte implantation (ACI) or osteochondral allograft transplantation. ACI is a technique where a patient’s cartilage is harvested. Then, cartilage cells

The medical field has made great improvements in the treatment of OCD. Future studies will focus on early detection with MRI specific sequences to better predict healing potential in early OCD lesions as well as controlled studies to determine

the ideal treatment of both juvenile and adult patients. These future breakthroughs make this an exciting time in the treatment of osteochondritis dissecans of the knee.

Jeffrey Macalena, MD, is an orthopedic surgeon specializing in sports medicine at the University of Minnesota. His clinical interests include ligament and cartilage reconstruction in the knee, patellofemoral disorders in both children as well as adults. He is the team physician for the University of Minnesota baseball and softball teams. Bradley Nelson, MD, is an orthopedic surgeon specializing in sports medicine and sees patients at the University of Minnesota and TRIA Orthopaedic Center. His clinical interests include ligament and cartilage reconstructions in children and adults as well as shoulder instability. As medical director for the University of Minnesota Department of Athletics, he is responsible for the care of Gopher athletes and is a team physician for the Minnesota Wild.

Read us online Wherever you are!

www.mppub.com December 2015 Minnesota Physician

Behavioral Health

ften, in health care, patient spirituality is considered a taboo topic. Understandably, health care providers often do not feel comfortable addressing the topic, or they may feel it borders on being unethical. However, a 2010 article in Professional Psychology: Research and Practice by Saunders, Miller, and Bright, describes the levels at which spirituality might be considered in mental health care. • Spiritually avoidant care involves a provider who deliberately avoids any discussion of the patient’s spirituality; this approach fails to adhere to ethical requirements to provide culturally consistent care if the patient’s spirituality is relevant to treatment. • Spiritually conscious care includes awareness of and openness to the patient’s spirituality as it is relevant to treatment, without active effort to use spiritual resources in treatment.

Building spiritual strength New treatments for PTSD and moral injury By Cory D. Voecks, MA; Lucas P. Hansen; and J. Irene Harris, PhD, LP

• Spiritually integrated care uses the patient’s spirituality as a resource to facilitate treatment. • Spiritually directive care involves teaching spiritual principles in the context of care, and in most settings, would constitute the same ethical failure to respect the patient’s culture that we see in spiritually avoidant care. Ethical concerns In his book, “Spiritually Integrated Psychotherapy,” Kenneth Pargament, PhD, states that spiritually integrated care

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Minnesota Physician December 2015

consists of both spiritual and psychological aspects. Although this may seem obvious, it is important to clarify the differences. First, it is considered spiritual because the therapist has an awareness of complex matters ranging from undisputed truths, to personal beliefs. Part of this therapy seeks to show respect and reverence for the patient who is sharing a unique aspect of their identity, thus shedding light on the patient’s morals, values, and culture. Second, this is a psychological approach, in that spiritually integrated care is not rooted in religious authority. Therapists do not operate like clergy; they make no assumptions of religious truths, or deliver any type of religious rituals. They operate using their professional code of ethics, requiring respect for the client’s religious beliefs. In this same vein, research is a guiding principle of this approach, as it would be with any approach to psychotherapy. Constant observation and measurement of clinical outcomes are fundamental in the evolution of spiritually integrated care. Pargament goes on to state that spiritually integrated care is not a competitor but a supplement to traditional psychotherapy. Most important, spiritually integrated psychotherapy is a means to understand and engage a patient in a more complete way. Pargament’s text cites research supporting spiritually integrated care in many different populations and for many presenting concerns, including depression, anger, illness or disability, sexual abuse, etc. There are ethical concerns to address when providing

spiritually integrated care. In every case, it is vital that the patient provide informed consent to the type of care with which they feel most comfortable; spiritually integrated care should not be forced on clients who are not interested in this approach. Furthermore, it is essential that therapists respect the patient’s religious identification throughout the therapeutic process. Practitioner competence is also important. Most often, this type of therapy is provided by a mental health practitioner who has a history of specialized experience, training, or research in spiritual aspects of mental health. Another approach is to use providers who are clergy with a history of specialized experience or training in mental health. In many VA settings, this type of care is provided by a team of co-therapists, one mental health provider and one chaplain. Adherence to the disciplinary scope of practice is an important ethical concern in spiritually integrated care as well. Because mental health providers are not trained in theology, it is imperative that they do not teach theology in therapy. To further define this, a mental health provider should not interpret the nature of a patient’s Higher Power, nor should they interpret scripture in any form. The therapist should address psychopathology as it

There is no focus on any specific theological doctrine.

affects relationships, and this includes relationships with a Higher Power or community of faith. For example, a client who belongs to a faith that teaches about a loving and forgiving Higher Power, but believes that they are unforgivable or unacceptable to their Higher Power, can benefit from education about the ways that symptoms

of depression and anxiety can distort perceptions of relationships, including relationships with a Higher Power. Spiritually integrated therapy then includes education on the role symptoms play in relationships with a Higher Power or community of faith (i.e., using guilt as a coping strategy, trying to avoid feeling angry with God, inappropriate guilt due to depression), not education about theology. Spiritually-integrated care in the VA Like all hospitals, VA medical centers are required by the Joint Commission to provide spiritually-sensitive care. Two common spiritually involved mental health concerns within VA are post-traumatic stress disorder (PTSD) and the somewhat newer concept of moral injury. A growing number of studies are documenting relationships between spiritual distress and clinical outcomes in PTSD and moral injury. Studies of moral injury, led primarily by Brett Litz, PhD, at Boston’s National Center for PTSD, define moral injury as challenges to deeply held moral or spiritual beliefs. According to Litz and colleagues, symptoms of moral injury may include guilt, shame, anger, emotional distress, and poor self-care. Moral injury research has almost exclusively focused on soldiers’ experiences and actions during times of war. Often, soldiers are put in morally and ethically ambiguous situations where it is necessary to make quick decisions in order to survive or maintain the integrity of their unit and fellow soldiers. There are many examples of morally injurious events from each war era where, for example, a soldier may have to use lethal force to eliminate a perceived threat only to find out later that there was no threat at all. Although the moral conflicts that service members face may seem obvious, morally injurious events are not exclusive to the military. Moral injury may be present wherever a person witnessed, engaged in, or observed an action that

participants. This is exciting a waiting list for such a group. is in contradiction with their because in many studies of A larger randomized clinical deeply held moral beliefs or psychotherapy we see limited trial of the intervention, includvalues. For instance, there was effectiveness with minority poping an active control group, is a young woman in New York ulations. Finally, while research underway at the Minneapolis who was driving, when a child in the field of moral injury is VA Health Care System, inentered the street. Although just starting, BSS is one of the cluding many of the system’s she swerved, her vehicle hit a first interventions available that Community Based Outpatient guardrail and bounced back has been designed to address Centers. hitting and killing the child. An that concern. Research in this There are a number of poevent such as this can precipifield is still comparatively new, tential advantages of using BSS tate many of the symptoms of and further studies will be necand similar therapies. Many moral injury similar to those essary to determine the reliabilveterans avoid mental health reported by combat veterans. ity of the findings from initial treatment due Within the studies, but based on current to stigma; Minneapolis research, further exploration because BSS VA Health of spiritually integrated care is interventions Care System, Research in warranted. are provided a team of the field of by specially psychologists, trained chapchaplains, and moral injury Cory D. Voecks, MA, is a research aslains in commental health sessor at the Minneapolis VA Health is just starting. munity (not technicians Care System. Lucas P. Hansen, is a mental health) collaborate research coordinator at the Minneapsettings, the in research olis VA Health Care System. J. Irene intervention on spirituHarris, PhD, LP, is a psychologist and provides a more socially acally integrated approaches to clinician-investigator at the Minnepost-traumatic stress and moral ceptable and accessible route to apolis VA Health Care System. Her care. Furthermore, data trends injury relevant to veteran trauresearch focuses on spirituality, PTSD, in the pilot study suggested that ma survivors. This research is and psychosocial rehabilitation. this approach may be especially funded largely by grants from effective for ethnic minority private sources, such as the John Templeton Foundation and the Bristol-Myers Squibb Foundation. The team has developed a spiritually integrated group therapy protocol called “Building Spiritual Strength” We are specialists in Apple devices (including iPads (BSS), designed as an inteand iPhones) and software. We also support Windows grative treatment option for and Windows to Apple integration. We are certified veterans managing post-trauthrough the Apple Consultants Network serving individmatic stress and moral injury. uals and businesses inquiring about moving to Apple, BSS is designed to help particior how to improve existing systems. pants make the best use of their pre-existing faith resources to Services include: manage stressful life events and • On-site training – in your make meaning of traumatic or clinic, hospital or at home morally injurious events. People from any religious or spiritual • Group Workshops tradition can participate in • Expedited Computer BSS as there is no focus on any Repairs specific theological doctrine or religious scripture. The ther• Data Recovery apy uses a person’s concept of • System upgrades a Higher Power, which can be • Network connectivity issues broadly defined based on each individual’s beliefs ranging Rapid service and reasonable rates from G-d to the Universe. A pilot study of this intervention Providing service throughout the metro area and demonstrated that veterans who remote service connection throughout Minnesota participated in an eight-session Building Spiritual Strength 612-643-0643 Group had significant reducwww.perfecteden.com tions in symptoms of PTSD and depression, and improvements in effectiveness of religious coping, as compared to veterans on

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December 2015 Minnesota Physician

Practice Management

e know that when left to traditional processes, the rate of identifying and treating common mental health and substance abuse disorders in a primary care clinic setting is abysmally low. There are many individuals who are in need of treatment for mental health and substance abuse disorders who will never be identified in primary care, and even if they are identified, will then rely on referrals to outside agencies, which are followed-through on less than 50 percent of the time. Collaboration between psychiatric and primary care providers is difficult, but can be transformative by integrating the care models. Based upon epidemiological data, approximately 17 percent of the population has both a comorbid mental and medical condition. This complication leads to higher risk factors, decreased quality of overall care, and increased cost of care. There are also striking

Transforming care Integrating behavioral health and wellness into primary care By L. Read Sulik, MD, and Todd Archbold, LSW, MBA

correlations between mental and medical conditions that may trigger onset or exacerbate one another. Integrated care PrairieCare is developing a strategic initiative to combine collaborative care with integrated care to build a comprehensive behavioral health solution for primary care clinics. This is a tremendous opportunity to transform pediatric and adult behavioral health care. Partnering behavioral health care with pediatric, family medicine, internal medicine, and OB/ GYN primary care clinics will

belong HERE.

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Minnesota Physician December 2015

inevitably lead to significant innovation in primary health care delivery that will better serve the broad population of children, adults, and families. PrairieCare has established formal relationships with South Lake Pediatrics and Wayzata Children’s Clinic and will be launching integrated services by the end of the year. These integrated behavioral health care services will create “clinics within clinics” that will provide an array of behavioral health services, health coaching, care coordination, care management, professional consultation, education, and training. These clinics will offer behavioral health screening, behavioral health diagnostic and needs assessments, and triage to local or remote access psychiatry and psychotherapy appointments via telehealth video suites. Transforming behavioral health care delivery by integrating a community-wide team-based model of care will improve access to care, quality standards, clinical outcomes, efficiency of resources, and patient and provider satisfaction. Untreated mental health issues Many studies over the past 25 years have found a correlation between physical and behavioral health-related problems. Individuals with serious physical health problems often have comorbid behavioral health problems. Nearly half of those with a behavioral health disorder meet the criteria for having two or more medical disorders, with severity strongly linked to comorbidity. While patients typically present to a primary care provider with a physical health complaint, data suggest that there are often underlying

and unrecognized broader behavioral health needs that often trigger these visits. It is estimated that between 50 to 70 percent of primary care visits involve a behavioral health need that may or may not be known to the patient or provider. Studies have also shown that the cost of treating chronic medical conditions can nearly double if an untreated mental health disorder is present. South Lake Pediatrics has been on the cutting edge by employing care coordinators to assist with mental health assessments, referrals, and timely connections to mental health providers. Integrated behavioral health care services will complement and enhance those roles by also offering brief therapeutic intervention and comprehensive evaluation, enabling assessments and connections to be individualized and targeted. The focus of this integration is to empower healing collaboratively in a safe and familiar environment. The clinical and financial effectiveness of integrating behavioral health and primary care is being demonstrated more and more. A recent worldwide review by the Cochrane Collaboration of 79 randomized controlled trials, including 24,308 patients of all ages, found that collaborative care for the treatment of depression and/or anxiety, when compared to routine care, is more effective. This leads to improved patient engagement and treatment adherence, which increases patient satisfaction and quality of life (Archer et al., 2012). Integrated behavioral health care does not merely involve placing mental health professionals into physical health clinics. It involves expanding the primary care team beyond the physician, advanced practice provider, and clinic nurse to include care managers, triage social workers, therapists, psychologists, and psychiatrists. These collaborative care teams treat and manage chronic conditions and promote wellness, by promoting new relationships and broadening current mental health relationships.

Targeting chronic illness A collaboratively integrated care model with an emphasis on wellness can provide the support and structure for change benefiting any patient, regardless of their health condition. The term “wellness,” refers to how we can change the way we support and lead

ownership over lifestyle decisions such as food choices, exercise, habits, and attitude. Leveraging technology with telehealth A key to efficiently integrating behavioral health services into primary care is to improve the quality and access of resources.

Between 50 to 70 percent of primary care visits involve a behavioral health need.

patients through the changes they need to make in order to achieve optimal health. Managing wellness includes awareness and focus on one’s physical and mental fitness, which includes: sleep, nutrition, exercise, spirituality, socialization, education, stress, and more. Traditionally, health care has not effectively prepared patients for the changes they need to make regarding their wellness, nor has it provided the appropriate structure and support for patients to achieve the change. Regardless of the chronic condition, an individual must undergo a process of change. How we support and lead that individual through his or her change process matters. When thinking about leveraging adaptive changes to problems, we realize that when it comes to health care we traditionally and repeatedly apply “quick fixes” to our patients’ problems that don’t promote awareness or empower wellness. For example, we view many medicines as a treatment to help manage symptoms while we focus more deeply on recovery, wellness, or lifestyle change. Most medicines are not fixes. A Lakota Medicine Man once said that to really know the difference between “treatment” and “healing,” we need to understand that “treatment is what you do to us, but healing is the work we each need to do.” Understanding this can help care systems and ultimately individuals learn to improve their health by taking

We promote evidenced-based practices throughout our continuum-of-care and work hard to make them accessible. For a service to be accessible, it needs to both be publicly known and have capacity. Awareness of behavioral health services is low among the general population, as many only become aware when they are in need.

Most health care consumers generally know their options for primary care, same-day surgery, orthopedics, dermatology, and more. Even if they are not aware, they can quickly find referrals from friends and on the Internet. This is not generally true of behavioral health care, which can be unchartered territory for many with uncommon terms and acronyms that make identifying the correct service more difficult. Integrating these services into primary care help build common awareness among providers and patients alike. Once awareness is enhanced, the use of technology and telehealth can help make them accessible to more individuals through scaling. A full-time psychiatrist may be able to help the needs of thousands of patients within a single primary care system spread among different locations. Telehealth would allow this psychiatrist to see patients at any setting within the specified Transforming care to page 34

Telephone Equipment Distribution (TED) Program

A clinic within a clinic An integrated behavioral health team is embedded into a primary care clinic or specialty clinic and establishing a “clinic within a clinic” that provides behavioral health screening, wellness coaching and mental health treatment. In this model, behavioral health can be a separate business entity, bringing operational, clinical, and financial solutions at no financial cost to the primary care clinic, regardless of whether the clinic is independently owned or owned by a health system. An integrated behavioral health team can be an effective “bridge” that enhances the relationship that the primary care clinic and health care providers have with internal and community behavioral health providers through increased communication and a shared care model. We see these relationships and referrals for ongoing treatment not only continuing, but becoming enhanced with improved communication and flow between services. The psychotherapy services that we envision will be brief or time-limited interventions that would otherwise not be provided or accessed. If longer psychotherapeutic services are needed, coordination to established mental health relationships will complement any mental health care that is needed. Clinic readiness and system readiness does matter though. There is a process of change required in order to move into broader integrated and teambased care. While integrative care may sound philosophically fundamental (“caring for the whole person”) preparing a care setting for this is a massive transformation and shift in traditional care delivery models. Partnerships are forged between administrators, clinicians, and vendors alike, all with a shared vision. A clear and common vision among all parties is critical to align expectations for both those working in the care settings as well as the patients.

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

1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services December 2015 Minnesota Physician

Transforming care from page 33

system without the patient or psychiatrist having to travel. Technology can be used to great advantage in rural settings to facilitate access, communication, and collaboration of care. The use of telehealth can eliminate the need for patients or clinicians to travel to other locations and allow staff to quickly access a myriad of specialists within the network. While the shortage of psychiatrists in Minnesota remains an issue, telehealth does not add capacity, it can, however, allow for more equally distributed accessibility. There are a lot of nuances to setting up an effective telehealth suite so that the video monitor is an extension of the room and truly creating a virtual presence. This means testing equipment and software, and assuring quality Internet connections. Having a technically savvy team that is comfortable using various devices is critical to telehealth being successful.

Educating patients and physicians The PrairieCare Institute in Minneapolis is set up to promote innovation in care delivery and education. From this training center, we can broadcast educational videos to train both patients and physicians in our remote access clinics and partner with primary care clinics across the state. This will expand the number of patients

(tablet, kiosk, or online via a patient portal link), can improve the ability to identify individuals struggling with common mental health conditions and who need further assessment and assistance. In addition, access to an electronic form of screening allows providers to monitor ongoing change in symptoms and level of functioning once treatment has been provided.

Behavioral health can be a separate business entity.

and families who have access to different topics on health and wellness. It also offers professional CME and CEU training through telehealth outreach to an entire staff within a primary care clinic. Implementing screening tools in an electronic form

Conclusion PrairieCare will be launching several integrative behavioral health and wellness clinics into existing primary care systems throughout 2015 and 2016. This transformational model is perfectly aligned with the triple aim, which will increase the

Notable Encounter: Berg’s Chamber Concerto Ordway Concert Hall, Saint Paul Friday, January 15, 10:30am Friday, January 15, 8:00pm Frequent SPCO guest conductor Scott Yoo has a gift for captivating classical music audiences with his insightful commentary and his ability to explain advanced aspects of musical style and structure through clear musical examples. He brings all of his talents to bear for this deep dive into Berg’s 20th century masterpiece. The first half of the concert will feature commentary and musical examples from the Chamber Concerto, often in subtle arrangements by Yoo himself, followed by a complete performance of the Berg, with SPCO Concertmaster Steven Copes as violin soloist.

Tickets: $12-$50 34

Minnesota Physician December 2015

overall patient experience, lower the total costs of care, and increase the quality of health care delivered in our communities. While the infrastructure is easily replicable throughout settings, the true value lies in the intangible qualities of the care delivery model and is embedded in the individual’s providers who are adapting to the growing needs of the population and are ready to deliver care in a truly integrative way. A combination of promoting more integrative health care practices and focusing more on health wellness will help drastically improve long-term population health outcomes. L. Read Sulik, MD, is board-certified in child, adolescent, and adult psychiatry as well as pediatrics. He is the chief integration officer at PrairieCare and executive director of the PrairieCare Institute. Todd Archbold, LSW, MBA, is a licensed social worker, the chief development officer at PrairieCare, and the practice manager of PrairieCare Medical Group.

The pre-admission screening process from page 25

• A physician has determined that delaying admission until the screening is completed would adversely affect the person’s health and safety. • There is a recent event and the patient is not able to live safely in the community, e.g., injury, sudden onset of acute illness, or when a caregiver is unable to continue to provide care. • The attending physician must authorize the emergency placement and document the reason. • It is outside business hours (Monday through Friday 8:00 a.m.–4:30 p.m.). The Senior LinkAge Line must be contacted on the first working day following the emergency admission. However, screening referrals can be made online 24 hours a day, including holidays. • A person has had a hospital admission for observation (e.g., stabilization of

and professionals serving older adults. It is the federally designated State Health Insurance Assistance Programs (SHIPs) Returning home for Medicare-related questions or concerns, Senior Medicare Physicians, nursing facilities, Patrol (SMP) to provide inforand hospital staff often have mation and limited ability assistance to conduct longwith health term follow-up care fraud and All community after a patient abuse, as well returns home. alternatives must as providing The Senior be explored and assistance LinkAge Line to help older follows-up with presented to the adults age well patients who patient. and live well return to their in the comhome within 30 munity setting days of admitof their choice. This includes tance to a nursing facility. Folhelping individuals underlow-up may be in the form of a stand housing options, finding letter or phone call, depending services in their community, or upon the patient’s situation. By support during a move. (See the submitting a PAS or contacting sidebar on linking up with an the Senior LinkAge Line, folexpert.) low-up is offered to the patient to ensure they have the necessary supports in place. Stephanie Minor, MPP, is the care The Senior LinkAge Line transitions policy lead at the Minnealso provides many services to sota Board on Aging. older adults, their caregivers, medications), or for care in an emergency room without hospital admission.

Three patients. Who is at risk for diabetes?

Link to an expert General referrals for older adults and their caregivers who need general supports like Medicare counseling, or help finding services brought into the home, can be made by any health care staff online at https:// mnhelpreferral.revation. com. Patients and their caregivers can call the Senior LinkAge Line for assistance at 1-8 00-333-2433 or chat live with a specialist at minnesotahelp.info Monday through Friday, 8:00 a.m.–4:30 p.m. Booklets are available for patients that can be used by hospital staff to discuss the referral or raise awareness about Senior LinkAge Line services.

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

1 in 3 adults are at risk!

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

Minnesota Department of Health DIABETES PROGRAM

December 2015 Minnesota Physician

Family advocates in long-term care from page 23

for the provider to partner with the family advocate and better understand their concerns. • Take the family member’s concern seriously and avoid being condescending, even if “justified.” Many times clients express being treated as if they don’t know what they are talking about and that the provider knows best. • Acknowledge harm or gaps in services, which are bound to occur in the long-term care environment, instead of pretending they never happened and thereby sending a negative message to the resident and family. Most all of the clients that make their way to me to bring a civil claim have some story of their concerns not being acknowledged, receiving no apology for harm, and/ or no explanation of what happened.

• Often, family concerns are escalated because of the delivery method or bedside manner of the provider. Being short or rude, even if warranted, is not going to improve the relationship.

often do not match that of the care environment for staff. Try to bridge the gap in understanding. • See the resident as the consumer and not the burden.

Family members are advised to read admission agreements and resist the urge to simply sign under pressure. • If the family’s concerns seem to keep cycling back, ensure that the family is sharing the concern in an avenue where it can be addressed and not simply making verbal statements to each aide that walks in the room. • Remember that the longterm care facility is the resident’s home, not just their outpatient clinic. Expectations of the home environment for residents

• Remember that the time for determining, to the best of the provider’s ability, whether the provider can meet the resident’s needs with the current staffing, is before admission. A provider must not admit someone outside of their scope of practice (see Minn. Stat. §144A.4791, subd. 4). In extreme situations, prevention of family involvement is warranted for the safety of the resident, but

such a measure is not to be used as a sword but rather a shield. Even if dysfunctional, the family member may be all that the resident has by means of outside support. Effective advocate/provider relationships stem from mutual respect, knowledge, and understanding of the respective roles of each. With the number of residents in long-term care rising, families and providers must continue to partner in order to maintain the highest possible quality of life for the elder. Suzanne M. Scheller, JD, practices

elder law and advocacy at Scheller Legal Solutions LLC, with a focus on nursing home litigation, financial exploitation, and public policy. She is also a founding board member of the Minnesota Elder Justice Center, former chair of the Elder Law Section of the Minnesota State Bar Association, and an adjunct faculty member at Hamline University School of Law and William Mitchell College of Law.

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Sioux Falls VA Health Care System

MAYO CLINIC HEALTH SYSTEM is a family of clinics, MAYO CLINIC HEALTH SYSTEM is a family of clinics, hospitals, and other healthSYSTEM care facilities serving more than 60 MAYO CLINIC HEALTH is a family of clinics, hospitals, and other health care facilities serving more than 60 Minnesota, Iowa,facilities and Wisconsin. Mayothan Clinic communities hospitals, andinother health care serving more 60 communities in Minnesota, Iowa, and Wisconsin. Mayo Clinic Health System the expertise of Mayo Clinic in practice, communities in links Minnesota, Iowa, and Wisconsin. Mayo Clinic Health System links the expertise of Mayo Clinic in practice, education and research with the health-delivery systems of our Health System links the expertise of Mayo Clinicsystems in practice, education and research with the health-delivery of our local communities. education and research with the health-delivery systems of our local communities. local communities. The Northwest Wisconsin Region opportunities include: The Northwest Wisconsin Region opportunities include: The Northwest Region opportunities include: Dermatology Wisconsin OB/GYN Dermatology OB/GYN Emergency Medicine OB/GYN Occupational Medicine Dermatology Emergency Medicine Occupational Medicine Family Medicine Ophthalmology (General & Glaucoma) Emergency Medicine Occupational Medicine Family Medicine Ophthalmology (General & Glaucoma) GeneralMedicine Surgery Orthopedics Family Ophthalmology (General & Glaucoma) General Surgery Orthopedics Hospitalist Psychiatry (Adult & Child) General Surgery Orthopedics Hospitalist Psychiatry (Adult & Child) Infectious Disease Pulmonary/Critical Hospitalist Psychiatry (Adult &Care Child) Infectious Disease Pulmonary/Critical Care Internal Medicine Urgent Care Infectious Disease Pulmonary/Critical Care Internal Medicine Urgent Care Neurology Urology Internal Medicine Urgent Neurology UrologyCare Neurology Urology action and equal opportunity Mayo Foundation is an affirmative Mayo Foundation is an affirmative action and equal opportunity employer and educator. Mayo Foundation is an affirmative action and equal opportunity employer and educator. employer and educator. If you wish to learn more or to express interest in these positions, If you wish to learn more or to express interest in these positions, please 800-573-2580; If you wish to learncontact more orus toat express interest inemail these positions, please contact us at 800-573-2580; email euphysicianrecruitment@mayo.edu; oremail apply at please contact us at 800-573-2580; euphysicianrecruitment@mayo.edu; or apply at http://www.mayoclinic.org/jobs/physicians-scientists euphysicianrecruitment@mayo.edu; or apply at http://www.mayoclinic.org/jobs/physicians-scientists http://www.mayoclinic.org/jobs/physicians-scientists

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

Sioux Falls VA HCS, SD Cardiologist

Orthopedic Surgeon

Endocrinologist

Primary Care (Family Practice or Internal Medicine)

ENT (part-time) Emergency Medicine Gastroenterologist Hospitalist

Psychiatrist Pulmonologist Urologist (part-time)

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

Anti-NMDA receptor encephalitis from page 21

abnormal in approximately 80 percent of individuals, showing a lymphocytic pleocytosis, and was seen to have a 74 percent sensitivity and 96 percent specificity in a 2013 study. Antibodies are found in nearly 100 percent of CSF samples and approximately 85 percent of serum samples. Brain MRI findings, however, are two times more likely to be normal than abnormal. In cases of abnormal MRIs, the abnormality is usually either T2 hyperintensities or cerebral edema. Interictal EEG can reveal a pattern called “delta brush” but can also be normal or simply reveal general encephalopathy. Treatment Treatment often involves a multi-disciplinary team of neurologists, psychiatrists, intensivists and, occasionally, surgeons and oncologists. Firstline treatment involves the use

of IV steroids and IVIG and, if there is an associated tumor, surgical resection. Approximately 50 percent of individuals will respond to first-line therapy. It does appear that there is a slightly higher response to firstline therapy among individuals with a tumor. If a patient does not improve following first-line therapy, second-line treatment with anti-cancer medications such as rituximab or cyclophosphamide should be implemented. The 2013 Uni-

whether long-term immunosuppression with steroid-sparing agents is necessary. Recovery Recovery times can vary tremendously with some patients experiencing disease remission within a few months and some requiring years or, sadly, dying secondary to disease complications. Nearly all patients do require some degree of structured rehabilitation, with cognitive rehabilitation being particularly important.

Isolated psychiatric symptoms are rare. versity of Pennsylvania study showed that, among patients who did not respond to first-line therapy, those who underwent second-line therapy had a better clinical response (nearly 70 percent versus 50 percent) as measured by modified-Rankin scores. It remains controversial

Conclusion Anti-NMDA receptor encephalitis is a rare autoimmune disease with neurological, psychiatric, and oncological manifestations. Nearly all patients experience more than two symptoms within the first month of diagnosis and

isolated psychiatric manifestations are exceedingly rare. Important diagnostic studies include lumbar puncture, neuroimaging, and EEG. As the pathophysiology of this disease involves autoimmune antibodies, treatment centers on immunosuppression. Screening for tumors is essential as treatment response is slightly higher in patients with a tumor than without one. In the event of non-response to first-line immunotherapy with steroids and IVIG, it is essential to aggressively progress to stronger immunosuppression in the form of agents like rituximab and cyclophosphamide. Cognitive rehabilitation is an important part of the recovery process. Ryan P. Williams, MD, EdM, is a general pediatric neurologist with the Minneapolis Clinic of Neurology. He enjoys all realms of neurology, but particularly enjoys working with infants and children with epilepsy.

Physician Opportunities

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tion collabora ical/dental fits of med DDS

, E. Gulon By John al isning medic ts any concer ct their patien encounter Denta l dentists instru sues our ues at Park physicians. y colleag patients to visit their dozens of Joseph F. and I see focus is dentists, a While our One of our ly shared every day. onally enDDS, recent an ocs, we occasi that Rinaldi III, just such led to me about on their mouthhealth-related issues with schedu story was i ian. counter other Dr. Rinald of a physic Prior to the currence. attention routinely t’s molar. require the e a patien pressure hygienists perand remov blood ts re, t’s patien Our dentis blood pressu look surger y, the patient’s ings, and 16 take each s to page cancer screen that might be new alliance form oral symptoms If we Forging for any other larger health issue. of a indicative

Leveraging

At Essentia Health, we believe in collaborative care that values the perspective of patients and their families. Backed by the resources of a large, integrated health system, our physicians provide quality care across the large and small communities we serve. A physician-led organization, we offer access to research initiatives, clinical device and medication trials, NIH studies, and independent research.

Open positions include: • • • • • • •

Cardiology Dermatology Endocrinology Family Medicine Geriatrics General Surgery Neurology

• Outpatient Internal Medicine • OB/GYN • Rheumatology • Pediatric Specialties • Urgent Care

800-882-7310

ProviderRecruitment@EssentiaHealth.org www.essentiahealth.org

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 • Dermatology

•• Hospitalist Hospitalist

•• Pain Medicine Pediatrics

• Emergency • Emergency

•• Hospice Hospice

•• Psychiatry Psychiatry

Medicine Medicine

• Endocrinology • Family Medicine • Family Medicine • General Surgery • General Surgery

• Geriatric

• Medicine Geriatric

Medicine

•• Internal Medicine Internal Medicine •• Rheumatology Rheumatology •• Med/Peds Med/Peds

•• Urgent Care Sports Medicine

•• Ob/Gyn Ob/Gyn

• Urgent Care

•• Orthopedic Orthopedic

• Vascular Surgery

Surgery

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

Sorry, no J1 opportunities.

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: • Dermatology • ENT • Family Medicine • Gastroenterology • General Surgery • Geriatrician • Outpatient Internal Medicine

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

• Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Sleep Medicine • Urgent Care

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

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

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

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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:

POSITIONS AVAILABLE: INTERNAL MEDICINE– No call EMERGENCY MEDICINE FAMILY MEDICINE – Full-scope practice avail. (ER, OB, C-Section, Hospitalist, Clinic)

Erik Dovre, OB/GYN

Lakewood Health System is seeking to expand the care team for its progressive and patient-focused clinics and hospital. Located in Staples, Minnesota, Lakewood is an independent, growing healthcare system with ﬁve primary care clinics, a critical access hospital and senior living facilities. Practice consists of 14 family medicine physicians and 10 advanced practice clinicians, as well as a variety of on-staff specialists. Competitive salary and beneﬁts. Relocation and sign-on bonus available.

Visit www.lakewoodhealthsystem.com, or contact Brad Anderson at 218-894-8587 or bradanderson@lakewoodhealthsystem.com.

www.lakewoodhealthsystem.com

Join the top ranked clinic in the Twin Cities

• 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.

Please contact or fax CV to:

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

763-504-6600 Fax 763-504-6622

www.NWFPC.com December 2015 Minnesota Physician

Improving health care delivery from page 19

seen improvement in all five of the CMS criteria. The greatest improvement is in P3 (percent of Minnesota hospitals with a person or team dedicated to PFE); where the percentage of hospitals meeting the criteria has increased from 2 to 51 percent. The number of hospitals with an active PFAC or a patient on a committee (P4) has gone from 30 to 41 percent. MHA is also analyzing data to see if there is any correlation between the PFE criteria and other outcome measures; preliminary review indicates that hospitals meeting at least four of the CMS patient/family engagement criteria had fewer readmissions than hospitals meeting fewer than four criteria. The partnership between MHA and a patient and family engagement advisor has proven to be a critical component of this program’s success.

Including a patient in this work from the beginning has provided an opportunity to truly understand how things appear from a patient’s perspective, and has reinforced the importance of going beyond the “business as usual” approach

What physicians can do Physicians are critical members of multi-disciplinary care teams and can lead by example. They can engage patients and families, not just at each encounter but also broadly via bodies such as PFACs. Physicians can

“Alone we can do so little, together we can do so much.” Helen Keller

expert in his or her care, and proactive work is necessary to help patients understand the differences between what you know and what they know. When patients choose other options, providers should not abandon them, but instead should demonstrate support, even in disagreement. As Helen Keller said, “Alone we can do so little, together we can do so much.”

Lisa Juliar currently partners with

of focusing on the provider’s perspective in addressing health-care delivery issues. The potential for positive change in health care quality and safety is unlimited if every health system, hospital, clinic, and LTC facility in Minnesota embraces and embeds the principles of authentic patient and family engagement by including the patient and family ... always.

promote patient/family involvement in various ways, such as inviting a patient to share her story, good or bad, at a department meeting to remind physicians and staff why they joined this industry in the first place. Inviting a patient to serve on one of the committees can also be effective. Through this journey, it is important to assume that each patient is an

the Minnesota Hospital Association (MHA) as a patient and family engagement consultant, and is cochair of the MHA Patient and Family Advisory Committee (PFAC). After experiencing an adverse event, Lisa became passionate about sharing her story for positive results. Nora Vernon, MS, RN, is a quality and patient safety clinical specialist at MHA and is the staff lead for PFE. Rahul Koranne, MD, is the chief medical officer of MHA.

Olmsted Medical Center, a 220-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: Anesthesiologist Hospital

ENT

Rochester Southeast Clinic

Family Medicine Rochester Clinics

Pain Medicine

Rochester Northwest Clinic

Plastic Surgery

OMC Hospital – Women’s Health Pavilion

Psychiatrist

Rochester Southeast Clinic

Psychiatrist– Child & Adolescence

Rochester Southeast Clinic

Sleep Medicine

Rochester Northwest Clinic

Send CV to: Olmsted Medical Center Human Resources/Clinician Recruitment 210 Ninth Street SE, Rochester, MN 55904

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

www.olmstedmedicalcenter.org 40

Minnesota Physician December 2015

Urology Hospital

Join a primary care team where you can grow in your profession and partner with those who share your passion. We’re looking for physicians to join our rural care teams. Whether you value small community charm, top-notch school systems or easy access to urban amenities, you’ll find a practice and community that is right for you.

Make a difference. Join our award-winning team. Explore our current openings on physicianjobs.allinahealth.org or contact: 1-800-248-4921 (toll-free) Katie.Schrum@allina.com

physicianjobs.allinahealth.org

Join our team

St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria

Opportunities for full-time and part-time staff are available in the following positions: • Associate Chief of Staff, Primary Care • Dermatologist • Internal Medicine/ Family Practice

• Physician (Compensation & Pension) • Physician (Pain Clinic)/Outpatient Primary Care

• Occupational Health/ • Psychiatrist Compensation & Pension Physician • Radiologist • Physiatrist

• Urgent Care Applicants must be BE/BC.

Family Medicine & Emergency Medicine Physicians

Great Opportunities

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

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information: Visit www.USAJobs.gov or contact Nola Mattson, STC.HR@VA.GOV

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

Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301 December 2015 Minnesota Physician

Positive psychiatry from page 17

professional life—i.e., they do not retire from their work. Aaron Beck, MD, (1921-) is emeritus professor of psychiatry at the University of Pennsylvania. This “Father of Cognitive Behavior Therapy” continues to write and conduct research. Some physicians continue their clinical work. Michael DeBakey, MD, (1909-2008), a pioneering heart surgeon, didn’t put down his scalpel until his 80s. Some physicians turn to community service. Shigeaki Hinohara, MD, (1911-), chairs the board of trustees of an international hospital and a nursing school in Tokyo. He has published several books since his 75th birthday, including “Living Long, Living Good” that has sold over a million copies. Finally, there are inspiring examples of physicians who fought physical and mental illnesses and remained creative in their later life. William Carlos Williams, MD, (1883-1963), a pediatrician from New Jersey, loved to write poetry. He suffered from

implications of unbridled promotion of positive psychological traits. For example, excessive optimism in adolescents may result in feelings of omnipotence, leading to damaging and even fatal consequences.

Positive psychiatry for physicians themselves How do the principles of positive psychiatry apply to physicians’ lives? Physicians obviously constitute a unique group of individuals—highly educated, self-disciplined in most ways, and well respected by society. At the same time, ours is a constantly demanding profession with a very low margin for error. Accordingly, we need to personalize our own strategies for successful aging. There is no one size that fits all. There are a variety of role models of successfully aging in physicians. Some physicians continue to do what they have done during most of their

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While aging of body tissues is inevitable, aging of the mind is not. A positive attitude, a rational mix of optimism and realism, resilience, engagement in stimulating physical and cognitive activities, and having a good time with friends and family—that is the prescription for successful aging. Summary Positive psychiatry is of relevance to non-psychiatrist physicians too. It has three main components: 1) positive mental health outcomes such as well-being; 2) positive psychosocial characteristics such as resilience, optimism, social engagement, spirituality, and

wisdom as well as environmental determinants of overall health; and 3) positive psychiatry interventions for changing behaviors and attitudes in a positive manner. Through well-designed and implemented preventive strategies, positive psychiatry has the potential to improve health outcomes and reduce morbidity as well as mortality in the population at large. Clearly, more work is needed to make positive psychiatry a norm in practice, but it is time to start that process.

Dilip V. Jeste, MD, is the senior associate dean for Healthy Aging and Senior Care, the Estelle and Edgar Levi Chair in Aging, the Distinguished Professor of Psychiatry and Neurosciences, and director of the Sam and Rose Stein Institute for Research on Aging at the University of California, San Diego. He is board-certified in general psychiatry and geriatric psychiatry. He is a past president of the American Psychiatric Association, and is a member of the Institute of Medicine.

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Minnesota Physician December 2015

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rehabilitate a body, we start T owith the mind and soul. If you or someone you know needs rehabilitation after an accident, surgery, illness or stroke, we have a simple premise for you to consider: To recover physically, you need support mentally and emotionally. How positive and how determined someone is can make all the difference. We believe the most effective therapy treats your body, mind and soul. Thatâ&#x20AC;&#x2122;s our approach. Post-acute rehabilitation services from the Good Samaritan Society are offered at multiple inpatient and outpatient locations throughout Minnesota and the Minneapolis/St. Paul area.

To make a referral or for more information, call us at (888) GSS-CARE or visit www.good-sam.com/minnesota.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. ÂŠ 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G1553

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