MN Physician Nov 2015 by Minnesota Physician Publishing

Vo l u m e x X I X , N o . 8 N o v e m b e r 2 015

The Interstate Medical Licensure Compact Expediting multiple licenses By Jon Thomas, MD, MBA

f I asked you to describe government, I doubt the first word that would come to mind would be “innovative.” Yet the Interstate Medical Licensure Compact is an innovation of state governments and their medical boards. Every practicing physician in the U.S. has gone through the process of acquiring a medical license. The process varies from state to state and it can take months for a single license to be approved. I have been asked on many occasions why all the states can’t agree on a single licensing process that is acceptable to all states and territories. Others have asked why the federal government doesn’t intervene and provide a single national medical license that is good in all of the states and territories. These are all good questions! And the Interstate Medical Licensure Compact may provide the answer.

Rural health care A look at the challenges By Sen. Al Franken

ural communities in Minnesota and across the country face unique challenges when it comes to ensuring access to quality health care. As the co-chair of the Senate’s bipartisan Rural Health Caucus, addressing those challenges has been a top priority for me. Late last year, I convened a group of rural health experts at the University of Minnesota to kick off a “Rural Health Tour” of our state. Since then, we have led nearly 30 meetings with

providers, patients, and local officials in dozens of communities across Minnesota. We talked with almost 300 key health care stakeholders and community leaders who helped us identify the most pressing issues facing our rural health care systems. In each of those meetings, we asked people to explain their biggest challenges in delivering care, the actions they’re taking to address those challenges, and potential opportunities for Rural health care to page 16

The history of licensure The quest for licensure nirvana began over 100 years ago. In the early 20th century, prior to the standardization of medical school education, the American Confederation of Reciprocating Examining and Licensing Boards, as the name implies, advocated for reciprocity of licensure between states. At that time, there were no The Interstate Medical Licensure Compact to page 18

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

An approach to consider for type 2 diabetes therapy starts here

Trulicityâ&#x201E;˘ 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 mellitus. 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.Â 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, and see Brief Summary of Prescribing Information on following pages. Please see Instructions for Use included with the pen. November 2015 Minnesota Physician

Trulicity offers proven glycemic control* and once-weekly dosing in 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.1-5

Trulicity may be a good option to be used along with diet and exercise for adult patients with type 2 diabetes who need more control than one or more oral medications alone are providing.1 Recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg.

To learn more about Trulicity and the savings card for patients, talk to your Lilly sales professional or visit www.trulicity.com. 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 mellitus. 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 • Trulicity

is contraindicated in patients with a personal or family history of medullary thyroid carcinoma or in patients with Multiple Endocrine Neoplasia syndrome type 2, and in patients with a prior serious hypersensitivity reaction to dulaglutide or to any of the product components.

• Cases

of medullary thyroid carcinoma (MTC) in patients treated with liraglutide, another 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.

• 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 sulfonylurea or insulin to reduce the risk of hypoglycemia.

Minnesota Physician November 2015

Once-weekly Trulicity 1.5 mg demonstrated comparable A1C reduction* to once-daily Victoza® 1.8 mg at 26 weeks2 A1C reduction from baseline to week 262 8.2 8.0

LS mean A1C (%) ± SE

7.8 7.6

Victoza® (1.8 mg) (n=300; Baseline A1C: 8.1%) Injections: ~182

Consistent with product labeling, patients randomized to Victoza started at 0.6 mg/day in week 1, then were up-titrated to 1.2 mg/day in week 2 and to 1.8 mg/day in week 3.

Trulicity™ (1.5 mg) (n=299; Baseline A1C: 8.1%) Injections: ~26

Trulicity recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg.

7.4 7.2

6.8

†American Diabetes Association recommended target goal. Treatment should be individualized.7

85% fewer injections6

†

7.0

Most common side effects were gastrointestinal (GI). They were nausea, diarrhea, vomiting, and dyspepsia.

Victoza® is a registered trademark of Novo Nordisk A/S.

-1.36 -1.42

6.6 6.4

Week 0

Week 8

Week 12

Week 26

Once-weekly Trulicity delivered results* in clinical trials A1Creduction reduction from baseline A1C from baseline Add-on to metformin (26 weeks) Compared to Victoza®2

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

0.0

Add-on to metformin (52 weeks) Compared to Januvia®1,8,9

Add-on to metformin and Actos® (26 weeks) Compared to Byetta®1,10

Add-on to metformin and Amaryl® (52 weeks) Compared to Lantus®1,4,11,12

-0.2 -0.4

-0.39

-0.6

-0.46

-0.63 -0.76

-0.8

-0.87

-1.0 -1.2

-0.99

-1.10

-1.4

-1.30

-1.36 -1.42

-1.6

-1.08 -1.51

-1.8 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%)

™

Data represent least-squares mean ± standard error.

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

•

26-week, randomized, open-label comparator phase 3 study of adult patients with type 2 diabetes treated with metformin ≥1500 mg/day

•

104-week, randomized, placebo-controlled, double-blind phase 3 study of adult patients with type 2 diabetes treated with metformin ≥1500 mg/day

•

Primary objective was to demonstrate noninferiority of Trulicity 1.5 mg vs Victoza 1.8 mg on A1C change from baseline at 26 weeks (-1.42% vs -1.36%, respectively; difference of -0.06%; 95% CI [-0.19, 0.07]; 2-sided alpha level of 0.05 for noninferiority margin 0.4%; mixed model repeated measures analysis)

•

Primary objective was to demonstrate noninferiority of Trulicity 1.5 mg vs Januvia on A1C change from baseline at 52 weeks (-1.1% vs -0.4%, respectively; difference of -0.7%; 95% CI [-0.9, -0.5]; multiplicityadjusted 1-sided alpha level of 0.025 for noninferiority with 0.25% margin; analysis of covariance using last observation carried forward [LOCF]); primary objective met

•

Primary objective of noninferiority for A1C reduction was met; secondary endpoint of superiority was not met

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

•

52-week, randomized, placebo-controlled phase 3 study (open-label assignment to Byetta or blinded assignment to Trulicity or placebo) of adult patients with type 2 diabetes treated with maximally tolerated metformin (≥1500 mg/day) and Actos (up to 45 mg/day)

•

78-week, randomized, open-label comparator phase 3 study (double-blind with respect to Trulicity dose assignment) of adult patients with type 2 diabetes treated with maximally tolerated metformin (≥1500 mg/day) and Amaryl (≥4 mg/day)

•

Primary objective was to demonstrate superiority of Trulicity 1.5 mg vs placebo on change in A1C from baseline at 26 weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; 95% CI [-1.2, -0.9]; multiplicityadjusted 1-sided alpha level of 0.025; analysis of covariance using LOCF); primary objective met

•

Lantus titration was based on self-measured fasting plasma glucose utilizing 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. November 2015 Minnesota Physician

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

DG97710

07/2015 PRINTED IN USA

Minnesota Physician November 2015

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 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. 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. 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. 3. 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. 4. 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. 5. 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. 6. Data on file, Lilly USA, LLC. TRU20140919B. 7. American Diabetes Association. Standards of medical care in diabetes—2015. Diabetes Care. 2015;38(suppl 1):S1-S93. 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.

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

Trulicity DG HCP BS 20APR2015 Brief Summary 7 x 9.75

DG HCP BS 20APR2015

PRINTER VERSION 1 OF 2 November 2015 Minnesota Physician

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 Minnesota Physician November 2015

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)

DG HCP BS 20APR2015

PRINTER VERSION 2 OF 2

November 2015 • Volume XXIX, No. 8

Features Rural health care A look at the challenges

By Sen. Al Franken

The Interstate Medical Licensure Compact Expediting multiple licenses By Jon Thomas, MD, MBA

CAPSULES

10 Pain Medicine

MEDICUS

INTERVIEW

DEPARTMENTS

One size does not fit all

The importance of a pain management plan By David Schultz, MD

e-health

Utilizing the electronic health record By Deanna Teoh, MD; Shalini Kulasingam, PhD; and Genevieve Melton-Meaux, MD, PhD

David C. Herman, MD Essentia Health

Managed Care Practice Management

Integration role reversal By Margaret Lloyd, MD; Dave Cook, MSW, LICSW; and Sean Rice, MBA

Integrating care and coverage By Michael Van Scoy, MD, and Russel Kuzel, MD, MMM

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

Professional Update: Cardiology Adult congenital heart disease By Cindy M. Martin, MD

• •Competitive contracts to control Latest in EHRgroup & Webpurchasing Portal technology your costs • Partnering with health plans on new models of care

Special Focus: Rural Health

Partnering with with select hospitals, clinics andon employers to • •Partnering health plans new models work on clinical integration and delivery of care

Rapid recovery in total 22 joint replacement By Erik P. Severson, MD, and Adam R. English, MSN, NP-C

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

The Live Well at Home 26 Coalition By Kayla Kildahl

24 The Northern Health Alliance Project By David D. Luehr, MD; Bruce Penner, RN; and Jeffrey L. Tucker

• 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)

www.mppub.com

Publisher Mike Starnes | mstarnes@mppub.com Editor Lisa McGowan | lmcgowan@mppub.com Associate Editor Richard Ericson | rericson@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.

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

888.722.8802 November 2015 Minnesota Physician

Capsules

Guidelines Published on Sharing DNA Information with Relatives A group of researchers has published the first set of consensus guidelines for how researchers should share genomic research results with relatives of those who may share a genetic risk. “These recommendations will have an impact on future human subject protection policies when genetic research is performed,” said Gloria Petersen, PhD, of Mayo Clinic and co-author of the guidelines alongside Susan Wolf, JD, of the University of Minnesota and Barbara Koenig, PhD, of the University of California, San Francisco. The study, funded with a fiveyear, $2.5 million grant from the National Cancer Institute and the National Human Genome Research Institute in 2011, analyzed the legal and ethical issues of providing genetic research results from tissue donated to research bio banks to relatives of the donor. Researchers consulted

with experts in medical genetics and genomics, genetic counseling, genomic research, biobanks and repositories, human research protection, and law. The researchers then developed recommendations offering direction on sharing information before and after the death of an individual research participant. The authors say that until now, researchers have had no guidance on how to balance individual privacy against family members’ need to know crucial information about their potential health conditions. “What makes these issues so challenging is current bioethics, law, and research rules focus on protecting individuals, but genetics is about families,” said Wolf. The authors recommend that researchers should anticipate requests from relatives for results and seek participants’ preferences about sharing results and who should act as their representative after their death, and strive to protect the choices of research participants regarding what information is shared. They also recommend that relatives, rather than researchers, should

Minnesota Physician NOVEMBER 2015

be the ones to raise the question of sharing individual results. The authors note that in unusual cases where sharing is likely to avert imminent harm, researchers may be ethically justified in reaching out to the participant’s relatives to offer genomic information.

State Receives Behavioral Health Planning Grant The Minnesota Department of Human Services has received a $982,000 federal planning grant to support community-based treatment for mental and substance use disorders in an effort to improve behavioral health care. This is the first phase of a two-phase process that supports planning for certified community behavioral health clinics, including soliciting input from stakeholders, establishing prospective payment systems for demonstration reimbursable services, and preparing an application to participate in the demonstration program.

The planning phase will end in October 2016, at which point grantees will have the opportunity to apply to participate in the two-year demonstration program that will begin January 2017. These grants are part of a comprehensive effort to integrate behavioral health homes with physical health care. “We see this program as a game changer in our efforts to improve care quality, and access to services,” said Kana Enomoto, acting administrator at the Substance Abuse and Mental Health Services Administration (SAMHSA). “Today’s awards will assist states in working closely with community clinics to bring together essential behavioral health services, integrate primary care services, and improve quality and data reporting systems.” In total, $22.9 million in grants were awarded to 24 states to certify community behavioral health clinics through the SAMHSA, in conjunction with CMS and the Assistant Secretary of Planning and Evaluation.

Accountable Care Organizations on the Rise in Minnesota The Minnesota Department of Health (MDH) recently conducted a survey of more than 70 of the state’s largest health care providers and health plans and found that half of hospitals, clinics, and physicians are part of an Accountable Care Organization (ACO). The analysis shows that about 40 percent of the commercially insured population is receiving care from a provider affiliated with an ACO. It is the first analysis of its kind in Minnesota. MDH studied the capabilities that organizations need for success with an ACO model, including population health management, disease management, patient engagement, clinical decision support, performance management, and utilization management. It found that ACOs in Minnesota have achieved expertise in less than one third of the areas needed for optimal implementation of the care delivery model. “When you look at Minnesota’s providers, they’re moving in the right direction, but there’s a lot more that we need to do to make progress on improving health through ACOs,” said Ed Ehlinger, MD, Minnesota commissioner of health. “Through our State Innovation Model work, we are giving providers and communities the tools to work with a broad range of partners to promote health with a more coordinated approach.” Results from the analysis also indicated fee-for-service payment is still most common in Minnesota and only a small portion of revenue is associated with ACO arrangement. Of the survey respondents, two-thirds indicated that 10 percent or less of their organization’s revenue was at risk and a quarter expect to see that number rise to 30 percent by 2020. “As our state moves toward paying for better health care outcomes, as opposed to the volume of procedures, this report establishes a baseline for measuring much-needed progress,” said Lucinda Jesson, human services commissioner. “But health care experts alone cannot accomplish this transformation. To be successful, patients and community-based providers will play a critical role.”

Recommendations from the MDH report include increasing education on population health management, increasing access to data to manage patients’ health, supporting partnerships with nonclinical providers, and investing in technology and core infrastructure.

New Medical Center in Olivia Offers Increased Access to Care Renville County Hospitals and Clinics opened its new medical center on Oct. 28 after a year of construction. The $25 million, 65,000square-foot facility is located along U.S. Highway 212 on the eastern edge of Olivia. It features 16 private patient rooms, two obstetric suites, 18 exam rooms, two surgical suites, and a helipad that can transport trauma patients to the Twin Cities within half an hour. Officials say the medical center will serve the 15,000 or so residents in Renville County. The new medical center offers residents access to care they previously had to travel long distances for, including kidney dialysis, chemotherapy, bone density scanning, and MRI. “It’s really a game changer, we’re renovating our old building into a dialysis center which is a service we didn’t have in this community,” said Nathan Blad, CEO of Renville County Hospitals and Clinics. Patients will also have increased access to mental health services at the medical center. Renville County Hospitals and Clinics was able to finance the project with the help of a donation campaign and local partnerships, as well as grants for new equipment.

First Minnesota Hospital Receives Specialized Chest Pain Accreditation North Memorial Medical Center is the first hospital in Minnesota to receive full Chest Pain Center with Primary PCI Accreditation from the Society of Cardiovascular Patient Care (SCPC) through August 2018. SCPC is an international nonprofit that focuses on transforming cardiovascular care. Capsules to page 12

Restoring function to patients with chronic neck and back pain. 5 Convenient Twin Cities Locations Edina 952-908-2700 Chanhassen 952-908-2730 Burnsville 952-908-2710 Coon Rapids 952-908-2580 Maplewood 952-908-2727

• 98% patient satisfaction • 71% of patients rate their headache reduction between 50-100%

• 65% of patients rate their use of medications decreased 50-100%

• 101% increase in Lumbar Extension ROM & strength

• 145% increase in Cervical Rotation

PDR is a member of FPA, the AIM network and a HealthPartners designated MSC.

ROM & strength

Specialists in Nonsurgical Treatment of Neck and Back Pain www.PDRclinics.com November 2015 Minnesota Physician

Capsules from page 11

The hospital’s achievement means it demonstrated expertise in integrating the emergency department with local emergency medical systems; assessing, diagnosing, and treating patients quickly; and treating patients at low risk for acute coronary syndrome who have no assignable cause for their symptoms. The hospital was also recognized for supporting community outreach programs to educate the public to seek medical care if they show symptoms of a possible heart attack.

New Model for Determining Breast Cancer Recurrence Risk Could Save Time and Money There may be a new way to determine the recurrence rate, and subsequent treatment, of women with invasive lobular carcinoma

(ILC) breast cancer, according to a new study from Allina Health’s Virginia Piper Cancer Institute. More than 180,000 women in the U.S. are diagnosed with invasive breast cancer each year, and about 10 percent of those have invasive lobular carcinoma. Many of these patients undergo the Oncotype DX test, a breast cancer assay that measures gene expression in tumor tissue to determine recurrence risk and the benefit of chemotherapy. The test costs about $4,000 and is performed in Redwood, Calif. Researchers conducted this study to determine if there are certain features of invasive lobular carcinoma that correctly predict low Oncotype DX recurrence scores. If so, women with this distinct subtype of breast cancer may not need to undergo the expensive, time-consuming test. “This model, if validated, may be useful in changing local practice patterns of ordering Oncotype DX testing for many ILC cases with low-risk features. This would enable earlier and more cost effective treatment

decision making for patients with this breast cancer subtype,” said Michaela Tsai, MD, oncologist at Minnesota Oncology and breast cancer researcher at Virginia Piper Cancer Institute at Abbott Northwestern. Researchers reviewed 158 cases of patients with invasive lobular carcinoma breast cancer that were diagnosed at the Allina Health Laboratory from the past eight years and underwent the Oncotype DX test. Along with Allina Health pathologists, they defined a model that included characteristics of tumors that most accurately predicted the recurrence risk determined by the Oncotype DX test and found that in a subset of cases, the predictions were very accurate. “Less is known about the optimal management of this less common subtype of breast cancer,” said Tsai. “It has been lumped together with ductal cancer and treated the same way. Our study helps prove that not all breast cancers are the same. This subtype requires a unique treatment approach.”

FirstLight Adds Urgency Services in Pine City FirstLight Health System’s Pine City clinic now has urgency services available to patients whose conditions are not life threatening but require prompt attention. However, people who need emergency services will still have to get care at another location. “It’s immediate needs—it’s not trauma services,” said Randy Ulseth, CEO of FirstLight Health Systems. “We don’t have ambulances running out of there, and we don’t have any running into here. If we have a need…we’ll call the local ambulance and have the patient taken to the appropriate location.” Plans to add urgency services at the clinic have been in place since the clinic was built in 2011. “What it means for FirstLight is that we are finally meeting the challenge of providing health care in Pine City,” said Ulseth. “We hope that eventually emergency services will be able to be provided here.

You’ll love what you hear!

DID YOU KNOW? X 21% of diabetics have hearing loss – compared to 9% of non-diabetics X Hearing loss is tied to three-fold higher incidence of injury-causing falls, as well as more frequent and longer hospitalizations X Untreated hearing loss can affect cognitive brain function – and is associated with the early onset of dementia

After discovering I needed hearing aids, I wanted the best-trained, most competent and experienced audiologist I could find. I also wanted the widest selection of quality products and finest follow-up services. After information-seeking visits with several recommended audiologists, Dr. Paula Schwartz easily rose to the top of my list. Paula and her excellent group of audiologists, all with doctorates, have given me outstanding care over the past eight years.

Refer Your Patients to Audiologists that You can Trust! 6444 Xerxes Ave South Edina, MN 55423 (952) 831-4222

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www.audiologyconcepts.com 12

Minnesota Physician November 2015

Medicus Ruth Martinez, MA, executive director of the Minnesota Board of Medical Practice, and Jon Thomas, MD, MBA, otolaryngologist and chief operating officer of Ear, Nose, and Throat SpecialtyCare of Minnesota, have been appointed by Gov. Mark Dayton to the Interstate Medical Licensure Compact Commission to expedite Ruth Martinez, MA the process of licensing physicians to practice medicine in multiple states. The commission consists of two voting representatives appointed by each of the 11 states that have enacted the legislation. They held their first meeting on Oct. 27 in Chicago to discuss management and administration of the compact. According to the Federation of State Medical Boards, which created the compact, the commission’s role in the licensure process will be to “provide oversight and administration of the Compact, create and enforce rules governing the processes outlined in the Compact, and Jon Thomas, MD, MBA promote interstate cooperation.” Jamie Lohr, MD, associate professor of pediatrics in the division of pediatric cardiology at the University of Minnesota and medical director of Fairview Ridges Specialty Clinic for Children, has been named chair of the American Heart Association, Midwest Affiliate Research Committee. Lohr has served on the committee since 2013 and will now serve as Jamie Lohr, MD chair for a two-year term, in which she will oversee the allocation of funds to research projects aimed at preventing and treating heart disease and stroke. Lohr earned her medical degree at the University of California School of Medicine in San Diego, completed her residency in pediatrics and a research fellowship in physiology and pediatric cardiology at Oregon Health Sciences University in Portland, and completed a fellowship in pediatric cardiology at the University of Minnesota. Ronald Holmgren, MD, president and CEO of Affiliated Community Medical Centers (ACMC) and physician at its Willmar clinic, has received the 2015 ACMC Physician Excellence Award. Holmgren earned his medical degree from the University of Minnesota, completed his internship in family practice at St. Paul Ramsey Hospital, and completed his residency in family Ronald Holmgren, practice at North Memorial Hospital. Holmgren MD has been a part of the ACMC leadership team for most of his time with the organization, serving on the board of directors for many years, as medical director, and now as president and CEO since 2000. He is also the president of Affiliated Community Health Foundation. Holmgren plans to step down from his role as president and CEO when he retires at the end of 2015.

7 PSALMS with the debut of The Radio Choir from American Public Media Sat Jan 23 8pm JASON HARMS

A TRIBUTE TO BENNY GOODMAN The Julian Bliss Septet Sat Jan 30 8pm

THE JULIAN BLISS SEPTET

FLY ME TO THE MOON An Afternoon of Big Band Love Songs Sun Feb 14 2pm CHARLES LAZARUS

minnesotaorchestra.org 612.371.5656 / Orchestra Hall PHOTOS Harms: Marty McAlpine; Lazarus: Joel Larsen;

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November 2015 Minnesota Physician

Interview

One size does not fit all

David C. Herman, MD Essentia Health Dr. Herman is CEO for Essentia Health, headquartered in Duluth. He oversees 69 clinics, 16 hospitals, and nearly 14,000 employees who care for patients in Minnesota, Wisconsin, North Dakota, and Idaho. He is board-certified in ophthalmology and received his medical degree from Mayo Medical School in Rochester, Minn., and completed his residency in ophthalmology at Mayo School of Graduate Medical Education. He was a senior staff fellow in ocular immunology and uveitis at the National Eye Institute. Dr. Herman has been very active in professional societies serving as a member of the Minnesota Board of Medical Practice, and on the board of trustees of the Minnesota Medical Association and the Institute for Clinical Systems Improvement. He currently serves on the board of trustees of Ronald McDonald House Charities, The College of St. Scholastica; the Minnesota Hospital Association; and on the board of directors of the American Board of Ophthalmology.

■■ What can you tell us about Essentia Health? This January, I joined Essentia Health, an integrated health system headquartered in Duluth, Minn. As an International Falls native, I was excited about the opportunity to serve the region I consider “home.” Yet our footprint goes far beyond northeastern Minnesota. We care for patients in Minnesota, Wisconsin, North Dakota, and Idaho. We began fully integrating operations in the summer of 2010, bringing together the resources of our member organizations—SMDC Health System, Innovis Health, Brainerd Lakes Health, and the Essentia Institute of Rural Health.

■■ What are some of the challenges facing health care today? Scientific developments have driven health care for the last 60 years. Yet during that same time, health care has gone from 3 percent of the U.S. gross domestic product to almost 18 percent. So economics play more of a role in the decisions we make every day and, more importantly, in the decisions our patients make every day.

When it comes to long-term goals, we strive to be the patients’ choice for care and our employees’ choice for work. Access, experience, and outcomes drive our patients’ choices, and they tell us they want and need high-quality, compassionate, and affordable care. Our employees must find dignity, joy, and meaning in their work along with a sense of pride in the organization. We have great people, from top to bottom, at Essentia, and I am confident we can do the work needed to accomplish this.

This new venture will allow us to try some things and determine what works within the community to affect the health of the population outside of our clinics and hospitals. We are also investigating some opportunities for intergenerational activities that support health. We want to pair up youth and the elderly so they can learn from and inspire each other for better health, well-being, and a better future.

The money we spend on health care in the U.S. can’t be spent on anything else, so as stewards for those health care dollars we need to make sure we’re spending that money effectively. We truly have an opportunity to work and partner with Our organization combines the strengths and people to keep them healthy, because we know talents of 13,900 employees. As a practicing ophit’s much more expensive and detrimental to their thalmologist, I count myself among the nearly quality of life to step in only 1,800 physicians and adafter they become ill. These vanced practitioners here are great opportunities to at Essentia. Together, we all Finding innovative ways not just work at the far end strive to provide high-quality to work closely with our of that value stream when care while making patients patients are sick, but to feel known and understood. patients and communities work at the beginning when We are guided by the is very important to me. patients are healthy. values of quality, hospitality, We recently announced respect, justice, stewardship, a unique collaboration with and teamwork. Our orgaUCare to create a new Medicare Advantage Plan— nization delivers on our promise to be “Here with it’s one way we are working to combine greater afyou” in 16 hospitals, 69 clinics, seven long-term care facilities, two assisted living facilities, four in- fordability with personalized care models designed dependent living facilities, five ambulance services, to keep patients healthier. and one research institute. ■■ Tell us about the work that you do to facilitate patient and community partnerships. ■■ As CEO, what are your short- and long-term goals for the organization? Finding innovative ways to work closely with our patients and communities is very important to Growing pains are not uncommon for organizations that have grown as quickly as Essentia Health me. For example, we just announced an exciting partnership with the city of Hermantown, Minn., to has. As a system, we have worked well together build the Essentia Health Regional Wellness Center. to develop common operational processes. DevelThe partnership will help us provide the facilities, oping a common culture is a more difficult and methods, and educational offerings to have a postime-consuming task. In the short term, we need itive impact at the community level outside of the to better define and implement a common culture based upon our core values. We have 14,000 people formal health care environment. who come to work each day to provide great care It’s estimated that 10 percent of a community’s for patients, families, and communities. Sharing a overall health is attributable to the health care sercommon culture will help us work better together vices in that community. In contrast, 70 percent of to serve our mission to make a healthy difference in a community’s well-being is influenced by residents’ people’s lives. behaviors and other social determinants of health.

Minnesota Physician November 2015

■■ How are you using telehealth? How do you see it developing in the future? We are actively using telehealth in more than 25 specialties at 29 sites, from behavioral health to emergency services. Our care footprint is more than 67,000 square miles, an area larger than the state of Florida, and very rural. We were recently awarded a grant to expand access to these valuable services in Minnesota, Wisconsin, and North Dakota. The funds will add an additional 21 rural clinics and two hospital/clinic sites to our telehealth network, benefiting more than 300,000 people in our rural service area. This grant, which matches Essentia’s contribution to the program dollar-for-dollar, will allow us to purchase state-of-the-art videoconferencing carts, cameras, stethoscopes, and ear scopes used for telehealth visits. ■■ Talk about your experiences in building a strong accountable care organization. We were an early adopter of the ACO methods, and one of the first six organizations in the country to be accredited as an Accountable Care Organization. We participate in the Medicare Shared Saving Program and

Medicaid’s program in Minnesota, called Integrated Health Partnerships. With more than 140,000 patients in ACO programs, we have built a durable care infrastructure that supports accountable care across Essentia. We have had some great success, yet there is always more to learn. We are setting higher expectations for ourselves to move more quickly to deliver on accountable care goals, which are well reflected in the Triple Aim. We are not waiting for market changes to push us—we are moving forward now. ■■ What are some of the unique challenges that Essentia Health faces delivering health care in a rural environment? Although Minnesota is a healthy state, we face greater challenges in the northern, rural part of the state. Our levels of cancer, obesity, smoking, and poverty are far above the state average. We are working with our communities to mitigate the adverse social determinants of health, as well as designing our care to be effective in the populations we serve. A “one size fits all” strategy does not work across such a large and demographically diverse system such as Essentia, yet the principles are the same, as illustrated by the Triple Aim.

■■ How do the faith-based origins of Essentia Health affect the day-to-day operation of the organization? Our faith-based origins are embodied in our primary values, which guide all of us each day. The rich heritage provided by people of faith who worked tirelessly and against long odds to provide health care to our region is an inspiration to all of us, regardless of our religious backgrounds. This year marks the 100th anniversary of the founding of the Duluth Clinic, a secular organization that worked closely with the Benedictine Sisters of St. Scholastica Monastery to provide great health care. We are fortunate to be the stewards of such an enduring legacy. ■■ Your predecessor, Peter Person, rode a Harley to relax. What do you do to unwind? I learned at a young age that a motorcycle and I are not a good mix! I am a pilot, and very much enjoy the outdoors. Cycling, fishing, hunting, and shooting sporting clays are activities that I make time to enjoy. We have a lake home in northern Minnesota that is our focus for time with family and friends. Each night I make time for leisure reading. It helps me wind down and broadens my perspectives from the challenges at work.

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November 2015 Minnesota Physician

Rural health care from cover

public policy solutions. While no single community had all the answers, I saw firsthand that leaders from all across the state are taking innovative steps to make health care more efficient and more affordable for all Minnesotans, regardless of where they live. Difficulty accessing needed care and services At the most basic level, rural residents have a difficult time accessing preventive services, affordable housing, healthy foods, and environments that promote physical activity. On top of that, options for mental health, primary care, long-term care, dental, obstetrics, and other specialty services are limited. This forces patients to travel long distances or experience long waits to receive the care they need. Many forgo those

services entirely, because rural Minnesotans have fewer public transportation options than their urban counterparts. In addition, rural providers

Rural residents have a difficult time accessing preventive services.

who try to implement modern delivery services—like telemedicine—often encounter challenges because of limited access to high-speed Internet. That’s one of the reasons I’ve been fighting so hard to expand broadband throughout our rural communities. We also have to realize that our rural populations are aging and growing more diverse. For those facing barriers related to language, culture, insurance

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coverage, and income inequality, navigating health systems is often difficult and can lead to confusion and poor health outcomes.

Minnesota Physician November 2015

Despite all these challenges, our communities and providers are doing a lot of great things to bring rural residents the care they need. For instance, New Ulm Medical Center has established partnerships to bring social workers into local emergency departments, and has also created a program with Oak Hills Living Center to bring in teams of health professionals to visit with long-term care patients. In Brainerd, a program called Crow Wing Energized has put the focus on preventive care by creating community groups that focus on healthy choices, mental fitness, workplace wellness, and community connections. And then in Fergus Falls, PioneerCare is using MedSmart devices that help elder adults better manage their chronic conditions and medications. These are just a few examples of what our providers and communities are doing to knock down the barriers that rural Minnesotans face when trying to access quality health care services. Critical workforce shortages Rural providers have trouble recruiting and retaining a skilled workforce—especially for mental health services, long-term care, dental care, and primary care. This growing problem was a recurring theme at nearly every single roundtable my office held. The Minnesota Medical Association, Minnesota Hospital Association, and Minnesota Department of Health all forecast a statewide shortage of both primary and specialty care physicians in the

coming years, ranging from 800 to several thousand fewer doctors than needed. We’re also not recruiting enough rural nursing assistants, social workers, health data analysts, dentists, and registered nurses. Much of the current rural health care workforce is either aging out or leaving for higher-paying jobs in other fields or larger markets. Rural health systems must compete for a limited number of available workers, and tight budgets cause some rural health employers to be less competitive. Fixing this crisis won’t be easy. A number of roundtables brought up the idea of promoting “homegrown care” by getting kids interested in health care careers at an earlier age. And expanding loan forgiveness programs to encourage health professionals to serve in rural communities is an existing approach that many suggested expanding. While the challenges facing rural Minnesota are shared nationwide, our state appears to be ahead of the curve in addressing many of them. In Perham, for example, Perham Health brings together high school, college, and medical students into health care settings and allows them to participate in basic levels of care. Our colleges are rising to the challenge as well. The University of Minnesota Medical School in Duluth has put a focus on educating rural family physicians and increasing the number of Native American physicians. And the Minnesota State Colleges & Universities network has been forming public/private partnerships to address nursing shortages in rural long-term care facilities. Fragile funding sources Health systems in our rural communities rely heavily on government funding and public and private grants to deliver care. But these funding streams aren’t always enough. Many providers told me that unstable funding has put their facilities

under considerable financial pressure. In response, they’ve been forced to eliminate or scale back important specialty care services. And because providers in rural communities rely on reimbursements for smaller patient populations, they have fewer resources to make quality improvements or invest in new technologies and infrastructure. At many of the roundtables, I heard about frustrations with the current fee-for-service payment system, and was urged to look into sustainable payment reforms that properly compensate facilities for investing in preventive care strategies. Our providers want to deliver health care, not sick care, to their patients. The ever-changing mix of public, private, and grant funding that rural health systems lean on makes it difficult to sustain health services, and almost impossible to plan for the future. But I’m proud that Minnesota communities and providers are coming up with

innovative ideas to improve care while lowering costs. To take one example, Southern Prairie Community Care in Marshall is bringing together clinics, hospitals, public health and mental health centers, and local agencies to improve the health of the community and keep costs down. This model of care, known as an Accountable Care Organization (ACO), is being put in place in several communities around Minnesota. Health care rules and regulations Minnesota’s rural providers sometimes encounter rules and regulations that, while well-intentioned, can create administrative hurdles, strain financial resources, and complicate health care delivery. With the shift in our health care system toward quality, affordability, and patient-centered care, many providers feel that well-intended policies don’t meet the realities of their rural communities. Take telemedicine, for example. Because of

the long distances that patients have to travel, telemedicine is especially important to delivering care in rural areas. But our policies don’t always take into account the circumstances and struggles rural providers face in expanding telehealth technology. I also heard that many providers just don’t have the administrative staff to handle what they called burdensome and duplicative reporting requirements. Some providers in Minnesota have already taken innovative steps to deal with these hurdles. In the White Earth Nation, the tribal government developed a patient database to streamline information and break down silos across community-based providers. This type of approach not only decreases redundant administrative work and services, but it improves the long-term outcomes for children, families, and entire communities. Where we go from here Minnesota is—and always has

been—a leader in health care. And that includes our rural health care systems. There’s much to be proud of in rural Minnesota, and during my tour of the state I saw great dedication and innovation. Communities are working incredibly hard to improve outcomes and solve some of our biggest health care obstacles. But challenges remain, and working to address them will continue to be an important part of my job as senator. As we take up further reforms to our health care system in Washington, D.C., a top priority for me will be ensuring that rural residents in Minnesota and across the country have access to the health care services they need. Sen. Al Franken (D-Minnesota) was elected to the U.S. Senate in 2008, and re-elected in 2014. He sits on the Health, Education, Labor, and Pensions (HELP) Committee; the Judiciary Committee; the Energy and Natural Resources Committee; and the Committee on Indian Affairs.

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November 2015 Minnesota Physician

The Interstate Medical Licensure Compact from cover

clearly recognized national standards for education, training, assessment, licensure, and practice. It was, to borrow an oft-quoted phrase, the Wild Wild West of medical practice and regulation. There was a great deal of variation in what was considered the practice of medicine and the skills of those practitioners. Constitutionally, states are responsible for protecting the health, safety, and welfare of their citizens. To protect their citizens, states created and empowered medical boards through the Medical Practice Act to issue licenses only to those who met the standard for the state. A state medical board scrutinized and assessed an applicantâ&#x20AC;&#x2122;s worthiness to be granted a license to practice in the state. This often included an oral exam before the state medical board. Because of the variation in standards, reciprocity was impossible. Most, if

practice in many states, obtaining and maintaining multiple licenses often requires dedicated personnel whose responsibility it is to oversee the process. Currently, 16 percent of physiObtaining a medical license cians are licensed in two states We have made and 6 percent much progress of physicians over the last 100 are licensed in Nothing mandates years in stanthree or more. that a physician dardization of As we are on medical educathe cusp of a use the Interstate tion, assessment, technological Medical Licensure and practice. Yet revolution in there has been Compact. health care, little change in we anticipate the process of that more getting a license. For over 90 physicians will want and need percent of physicians, this is a multiple licenses to practice in minor inconvenience that ocmany jurisdictions and these curs at the beginning of a long percentages will likely increase. career, spanning decades. HowIn response to this, a small ever for physicians who pracbut growing contingent in the tice in multiple states or who business community feels that desire to expand their practices, the federal government should this can be a logistical nightissue a national license. Their mare. For example, if you are a reason is simple: it would mean teleradiologist, locum tenems one license and one regulatory physician, or an organization authority for their employees. employing physicians who State governments, however, have constitutional authority to protect their citizens and believe that the only effective way to carry out this duty is through the retention of a statebased licensure system. It is in this milieu that the idea of an Interstate Medical Licensure Compact was developed. not all, states felt their process was the best and were unwilling to cede the authority to license physicians to the processes of another state.

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Minnesota Physician November 2015

What compacts do A compact is a constitutionally recognized agreement between states that solves a national problem, while obviating the need for federal intervention. State participation is voluntary. A state joins the compact by enacting legislation through each participating state legislature and having it signed into law by the governor. (Likewise, a state can leave the compact in the same way it joined, through legislative action). Because a compact acts as a contractual agreement between states, each state can sign on to the same agreement and any changes to the agreement have to be unanimously agreed on by all of the participating states. Nothing obligates a state to sign on to a compact other than the potential benefit from the compact.

States have used this mechanism to solve issues of mutual interest since the founding of the country. There are many compacts that control water rights between states. The Drivers License Compact allows a licensed driver in one state to cross state lines without having to obtain a license in the states of travel. Similarly, the Nursing Compact allows nurses to practice in compact states with one nursing license. The benefit of using a compact is that the participating states can craft the terms to address the unique problems related to the underlying issues. Expediting licensure The Interstate Medical Licensure Compact offers physicians a way to obtain an expedited medical license that would improve license portability and increase patient access to care. It is an alternative to the current system of licensure. Nothing mandates that a physician use the Interstate Medical Licensure Compact process. It is simply an option much like obtaining a TSA-expedited airport screening where a passenger can pay a fee and go through a one-time evaluation process. In similar fashion for the Interstate Medical Licensure Compact the physician would have to meet certain requirements (see the sidebar). Once vetted, the physician would be able to get a license in all other participating compact states within a very short time, probably on the order of days to weeks. The Interstate Medical Licensure Compact only addresses an administrative function, expediting a license. It is silent on all other issues. It does not supersede the Medical Practice Acts of any state or territory. The physician would still be required to comply with the the laws and CME requirements of that state. In addition, state medical boards would still carry out their normal functions. Challenges Now that you have heard the pitch and the promise, are you wondering when you can you get your 50 licenses? The Interstate Medical Licensure

Compact requires the participation of seven states for the Compact to become effective. Minnesota was one of the initial seven states to sign on. Now that the compact has been established, participating states will meet and form the Compact Commission, which will administer the compact. Each participating state will elect two commissioners from its medical board. The first official meeting of the commission will take place in late October 2015. That is when the hard work starts of actually making the Compact a real entity. It is hoped that the Interstate Medical Licensure Compact will begin processing licenses in January 2017. As with all good things there are those who see darker forces at work. There have been concerns expressed by a variety of groups opposed to the Compact. One of the concerns is that the Compact Commission will change requirements in the laws of the participating

state’s practice act to require maintenance of certification. This is simply not true. As stated earlier the Interstate Medical Licensure Compact only addresses expediting a license. The Compact is written in such a way that makes it impossible

state-based licensure is antiquated and there needs to be one national license with national standards. This criticism ignores the Constitutional basis for states to protect their citizens. This becomes a question of state’s rights.

There was a great deal of variation in what was considered the practice of medicine. for it to override any state’s medical practice act outside of the process of expediting a license. In addition, any potential change to the compact language requires unanimous agreement among the participating states. Another criticism is that the Compact is really a way to get to national licensure. Again, this is simply not true. The point of a Compact is to solve national problems without federal intervention. Many in industry opine that nothing will change because the system of

Threshold requirements for multistate licensure application through the Interstate Medical Licensure Compact

Another is the criticism, even from some state medical boards, that the Compact Commission will supersede the authority of the state medical boards. Again the Compact Commission will perform an administrative function and act as a clearinghouse for information shared among the participating states. It will have nothing to do or say with adjudication of complaints. Since January 2015, 19 states have introduced the legislation and, as of this writing, there

are 11 states that enacted the legislation. It has also been endorsed by nearly 30 state medical boards. This may be too slow for critics of state-based licensure. However in speaking with organizations with large numbers of physicians in multiple states, this is seen as very promising, welcome, and innovative legislation. As with all government innovations there will always be those who see nefarious activity. Nonetheless, this is one of the few government initiatives that has the potential to truly ease the burden of a slow and cumbersome licensure process. The best part is that it is a choice. Jon Thomas, MD, MBA, is a member and past chair of the board of directors of the Federation of State Medical Boards and member and past president of the Minnesota Board of Medical Practice.

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1. Is a graduate of a medical school accredited by the Liaison Committee on Medical Education, the Commission on Osteopathic College Accreditation, or a medical school listed in the International Medical Education Directory or its equivalent; 2. Passed each component of the United States Medical Licensing Examination (USMLE) or the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) within three attempts, or any of its predecessor examinations accepted by a state medical board as an equivalent examination for licensure purposes; 3. Successfully completed graduate medical education approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association; 4. Holds specialty certification or a time-unlimited specialty certificate recognized by the American Board of Medical Specialties or the American Osteopathic Association’s Bureau of Osteopathic Specialists; 5. Possesses a full and unrestricted license to engage in the practice of medicine issued by a member board;

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6. Has never been convicted, received adjudication, deferred adjudication, community supervision, or deferred disposition for any offense by a court of appropriate jurisdiction; 7. Has never held a license authorizing the practice of medicine subjected to discipline by a licensing agency in any state, federal, or foreign jurisdiction, excluding any action related to non-payment of fees related to a license; 8. Has never had a controlled substance license or permit suspended or revoked by a state or the United States Drug Enforcement Administration; and 9. Is not under active investigation by a licensing agency or law enforcement authority in any state, federal, or foreign jurisdiction.

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November 2015 Minnesota Physician

Practice Management

Integration role reversal

Telephone Equipment Distribution (TED) Program

The organization already he integration of provided a wide range of primary care and behavioral health-based behavioral health services, including: services is an important • Psychiatry strategy to improving Adding primary care to a mental health center • Psychotherapy health outcomes for paBy Margaret Lloyd, MD; Dave Cook, MSW, LICSW; and Sean Rice, MBA • Detox and chemical tients diagnosed with a health counseling mental illness. Integrated • Residential treatment health care delivery has The basis for integration from a comorbid condition and crisis services repeatedly been demonstrated efforts faced significant barriers to to improve care and reduce • Community support programs obtaining effective treatment. A In early 2011, a multidiscicosts by ensuring that people such as case management plinary workgroup conducted variety of social determinants, with chronic conditions have and adult rehabilitation intensive data mining of the cultural factors, and practice timely access to both primary mental health services issues contributed to this dilem- electronic medical record and care and behavioral health ser• Homeless outreach and determined that three out of ma, including patient trust isvices, with close coordination housing sues with unfamiliar clinicians, four Zumbro Valley Health between clinicians. Offering • Employment programs Center psychiatric patients misunderstandings due to culprimary care within a commuidentified were diagnosed with tural/language limitations, and • Mobile crisis services nity mental health setting is a serious medical condition. a lack of interaction between Pharmacy and dental particularly important because This included cardiovascular behavioral health and mediservices were incorporated to this patient population has disease, diabetes, hypertension, cal providers. As the region’s the care continuum in 2011 suffered for years with comproobesity, pulmonary disease, primary behavioral health and 2012, respectively. Based mised access to primary care asthma as well as less serious services provider for these popupon these internal findings and other medical services. The chronic conditions. The majorulations, Zumbro Valley Health as well as a thorough review of tragic end result is that patients ity of patients reported that Center routinely works with existing research of integrated diagnosed with a mental illness they had not visited a health individuals requiring several care models, the addition of die, on average, 25 years earlier care provider within the past services—one in three patients primary care services was the than the general population. utilize multiple programs—who six to 12 months despite their next logical step in the organiFor years, people in southmedical condition, and many frequently miss appointments zation’s effort to improve health east Minnesota from under- or indicated they regularly utidue to these barriers. outcomes for the under- and unserved populations suffering lized local emergency rooms unserved populations. for their care. The reluctance of these patients to follow through A broad-based approach on medical care was a major Key organizations joined Zumcontributor to the 189 ambubro Valley in a pre-planning lance visits to our center that committee in mid-2011 to year. These findings mirrored explore the benefits of integratthe results of a comprehensive ing primary care, behavioral patient survey that showed 82 health, and care coordination Do you have patients with trouble using percent of patients considered services to enhance care for their telephone due to hearing loss, speech the center their primary health individuals requiring specialor physical disability? care provider despite medical ized assistance. Representaservices not being offered. tives from Mayo Clinic, OlmIf so…the TED Program Due to these findings, our sted Medical Center, Olmsted provides assistive telephone board of directors and leaderCounty, and Zumbro Valley equipment at NO COST ship team began to research the Health Center worked together to those who qualify. requirements for transforming to assess the feasibility of an the organization from a traintegrated care model at a ditional community mental Please contact us, community level. The commithealth center to a provider of tee quickly determined that or have your patients integrated health care services a need existed, especially for call directly, for more for the more than 4,000 patients those individuals with public information. served annually (see Figure 1). insurance who were less likely to successfully Figure 1. The evolution of integrated care utilize primary 1-800-657-3663 within Zumbro Valley Health Center care services. www.tedprogram.org The committee 2013 then expanded 2012 to include other Duluth • Mankato • Metro 2011 community and Moorhead • St. Cloud state partners— Primary care 2011 Olmsted County clinic added The Telephone Equipment Distribution Program is funded through the Addition of dental services Public Health, 2008 Department of Commerce Telecommunications Access Minnesota (TAM) Minnesota Addition of pharmacy and administered by the Minnesota Department of Human Services Department of Addition of electronic medical records Human Services, Integrated dual disorder treatment training

Minnesota Physician November 2015

United Way, Minnesota Department of Health, Rochester Area Foundation—to develop a framework incorporating integrated behavioral health and medical services, identify funding options, and create connections with Mayo Clinic and Olmsted Medical Center to refer patients for specialty care. Recognizing that current reimbursement levels would not financially support the development/implementation of an integrated care approach for treating under-served populations with comorbid conditions, the state legislature provided funding in mid-2013 to pilot an integrated care model over a two-year period at Zumbro Valley Health Center to provide treatment to its Medical Assistance population. An integrated model of care Although the region includes several mental health and medical providers, some of whom offer both of these types of services, no entity offers the full continuum of integrated behavioral-social-medical services currently provided by Zumbro Valley Health Center for the Medicaid/Medicare and uninsured populations. The focus of this model of care is to identify and integrate primary care services to current and prospective patients diagnosed with a comorbid condition who meet low- to moderate-income guidelines and either do not have a local primary care provider or do not see that provider on a consistent basis. (General underserved populations include individuals who are Medicaid- and Medicare-eligible, below state/federal poverty thresholds, and/or are eligible for public assistance. This number includes significant percentages of homeless and minority populations as well. Altogether, these populations form 88 percent of Zumbro Valley Health Center’s current patient base.) Our model of care integrates primary care, mental and chemical health, dental, and pharmacy services with housing, employment, and other community support programs into a comprehensive treatment plan that addresses and

coordinates all aspects of their care. Central to this model is care coordination services with the primary care clinic registered nurse managing clinical services across conditions, services, and settings. This care coordinator integrates behavioral/medical services for clinic patients by monitoring and coordinating their ongoing health care needs, collaborating with community providers to ensure patient needs are being met, and integrating patient health care into a coherent treatment plan. Key benefits of this approach include:

Outcomes Since implementing its integrated care model in late 2013, a core focus for Zumbro Valley Health Center has been to align goals and objectives with Minnesota’s Triple Aim. Our staff is currently working with the Minnesota Department of Human Services and Wilder Research to conduct an outcome evaluation, which will be completed in October 2016, for the organization’s integrated behavioral/medical services. The organization also tracks key measures such as emergency room usage (decreased

Patients diagnosed with a mental illness die … 25 years earlier than the general population.

• Providing a community destination and central point of contact to meet the needs of patients with comorbid conditions. • Offering quick, convenient access to a comprehensive assessment of people’s behavioral and medical issues. • Creating one point of contact for patients, family members, and health care providers alike. • Streamlining referrals to specialty care—medical and psychiatric—for more complex services beyond primary care. The development of an integrated care plan is especially important for those underserved individuals in our region who interface with many aspects of private sector health care delivery, as well as public sector behavioral health care, human services, and housing. This integrated care model enables them to have timely access to a full continuum of high-quality, effective mental health, medical, and addiction recovery services that are appropriate to the acuity of their symptoms and flexible enough to meet their needs, without having to go to extraordinary means or, more commonly, go without.

by 54 percent) and ambulance transport (reduced by 80 percent). Key measures are

based on the survey responses of the first 20 primary care clinic patients from their first appointment to their last appointment. A case study Numbers alone cannot tell the whole story regarding the impact of this integrated care model. For instance, EH is a 33-year-old female who presented to the primary care clinic not having accessed primary care services in nearly 10 years. Zumbro Valley Health Center Psychiatry and Psychotherapy has treated her depression, mood disorder, and alcohol dependence. In the past year, EH has been in the emergency room twice, with one of those visits transported by ambulance. During her wellness exam, she expressed concerns about acne and tobacco abuse that were addressed. In addition, a large skin mole on her upper back/shoulder area was noted by the primary care Integration role reversal to page 42

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cushwakenm.com November 2015 Minnesota Physician

Special Focus: Rural Health

otal knee and total hip replacement surgery is projected to increase drastically by 2030. The Journal of Bone and Joint Surgery of America predicts a 174 percent increase in the need for total hip replacement and a 673 percent increase in total knee replacement. Additionally, the need for previous total joint replacements to require a revision is projected to increase by 601 percent (knees) and 137 percent for hips. To complicate things, over half of patients receiving total joints are under the age of 65, and still an active part of the workforce. These patients only have so much time in sick leave before they are required to be back working. In order to meet the demand of patients requiring total joint replacement, hospitals must adjust their current protocols in order to get these patients out of the hospital faster, and back to work earlier.

Rapid recovery in total joint replacement Innovation from the heartland By Erik P. Severson, MD, and Adam R. English, MSN, NP-C Development of the Rapid Recovery Protocol In 2013, I (Dr. Severson) wanted to change the way joint replacement was being done at the Minnesota Center for Orthopaedics (MCO), located on the campuses of Cuyuna Regional Medical Center in Crosby, MN, and Riverwood HealthCare Center in Aitkin, MN. These two hospitals are located approximately two hours north of the Twin Cities in rural Minnesota. These two critical-access hospitals are limited

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to having only 25 inpatients in a 24-hour period. If the hospital is full, then any patients requiring an inpatient-stay must be diverted away to other facilities in the area. In order to keep up with the growing demand of joint replacement, the process had to change. On top of this, the overall total joint replacement industry was changing. Newer medications were being developed that could provide better pain management, while allowing the patient to ambulate shortly after surgery. Additionally, larger orthopaedic groups across the country were beginning to develop protocols aimed at decreasing the length of stay for patients. In order to stay ahead of the curve and provide excellent patient outcomes closer to home, the new Rapid Recovery Protocol was developed. Before rapid recovery Before the development of the new Rapid Recovery Protocol, patients were all given general anesthesia along with a psoas nerve block for postoperative pain. Physical therapy was initiated on postoperative day two. With this protocol, patients stayed in the hospital between three to five days before discharging to either a skilled nursing facility or home. This protocol did not have any interventions aimed at preventing complications (nausea, blood loss, pain) from occurring. Instead of scheduled interventions, nurses were often at a disadvantage and forced to treat pain or nausea after it had already occurred. For example, instead of keeping the pain at

a manageable level with scheduled medications, the patient would have breakthrough pain that then required large amounts of narcotic pain medication to manage. When using large amounts of narcotics to treat pain, the side effects of these medications (nausea, constipation, dizziness) often present themselves. This can lead to delays in physical therapy, and in effect, cause a longer than necessary hospital stay. The protocol The Rapid Recovery Protocol consists of interventions aimed at decreasing pain, nausea, and blood loss, while focusing on early ambulation. For pain, multimodal analgesia is given before, during, and after surgery. Before surgery (unless contraindicated), the patient receives Oxycontin, Lyrica, and aspirin in the preoperative area. These medications, aimed at decreasing pain, are at their peak effectiveness when the patient is in surgery. During surgery, the patient is given IV acetaminophen and IV Toradol. Additionally, the joint is injected with liposomal bupivacaine that focuses on pain relief in the joint and can last up to three days.

Early ambulation is essential to the success of the patient’s outcomes.

Nausea prevention begins with patient screening before surgery. If the patient is at high risk of developing postoperative nausea, a scopolamine patch might be placed behind the ear as a preventive measure. This intervention has decreased the number of patients who have nausea after surgery and, as a result, has decreased the amount of time they spend in the recovery room. For blood loss, tranexamic acid is used (unless contraindicated). This medication

Table 1. Patient characteristics Patient Characteristics

Gender (% Male-Female)

Pre-Rapid Recovery

50.0–50.0

Mean Age (Years)

Post-Rapid Recovery

54.0–46.0

p value

0.693

69.24

67.14

0.247

Mean ASA

2.56

2.5

0.552

Mean BMI

35.75

34.57

0.421

Source (for the table and figures): Minnesota Center for Orthopaedics

is given before the incision is made and then once again at closure of the wound. This has led to a significant decrease in the number of blood transfusions required in the postoperative period. Blood transfusions are not only expensive, but they also add at least one day to the hospital stay. Early ambulation is essential to the success of the patient’s outcomes. Physical therapy will have the patient up and walking the day of surgery and begin teaching the exercises the patient will need to be successful. Early mobility and ambulation also leads to fewer complications in terms of postoperative pneumonia, blood clots, and infection.

The outcomes Outcomes from the Minnesota Center for Orthopaedics were published at both the American Association of Hip and Knee Surgeons (AAHKS) and the American Academy of Orthopaedic Surgeons (AAOS) annual meetings in 2014. In both studies, the last 100 patients using the standard protocol were compared to the first 100 patients using the new, Rapid Recovery Protocol. Comparisons were made on pain level, narcotic consumption, length of stay, need for skilled nursing facilities, and readmissions. One fellowship-trained surgeon performed all of the operations using a posterior approach (hips) and a medial

parapatellar approach (knees) for all patients. No patients were excluded from the studies. Table 1 shows no difference in patient characteristics between the two groups measured. Total hip replacement In total hip replacement, patients in the rapid recovery dataset had a mean discharge day of 1.5 versus 2.75 days in the standard protocol dataset (see Figure 1). These patients often would discharge directly to their home instead of going to a skilled nursing facility for further strengthening or rehabilitation. Figure 2 shows the decrease in the percentage of patients requiring a skilled nursing facility stay with the new protocol. Patients also demonstrated less pain on postoperative day 1 with the Rapid Recovery Protocol that focuses on scheduled, non-narcotic pain medication, aimed at preventing pain

Figure 1. Hospital stay (hips) 3.0 3.0 2.5 2.5

2.75

2.0 2.0

■B efore Rapid Recovery ■A fter Rapid Recovery

1.5 1.5

1.5

1.0 1.0 0.5 0.5 0.0 0.0

Length of hospital stay (days) (p<0.0001)

Figure 2. Skilled nursing facility stays (SNF) (hips) 35 30

34%

■B efore Rapid Recovery ■A fter Rapid Recovery

20 15 10 5

SNF stay required (%)

Figure 3. Postoperative day 1 pain scores (hips) 5 4 3

4.1

■B efore Rapid Recovery ■A fter Rapid Recovery

2.8

1 0

Rapid recovery in total joint replacement to page 40

Postop day 1 pain (out of 10)(p= 0.002)

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717 Delaware St. SE Suite 508 Minneapolis, MN 55414 • Phone: 612.624.8776 • www.calsprogram.org November 2015 Minnesota Physician

Special Focus: Rural Health

ccountability for patient health outcomes and the costs related to those outcomes has become a foundational element in health care over the past several years. Integrity Health Network (IHN) has been deeply involved with quality improvement, Minnesota’s health care home initiative, total cost of care agreements, and the formation of an accountable care organization (ACO) in 2014. In addition, IHN partnered with the Arrowhead Health Alliance, a joint powers board consisting of five northeast Minnesota counties, to form the Northern Health Alliance Project. The Alliance will engage community resources beyond traditional health care to improve health outcomes. It is an accountable community for health (ACH), which is an integrated network of providers and community organizations that work to improve the health of northeastern Minnesota. This ACH has also approached local community hospitals and

The Northern Health Alliance Project Managing patient populations in Greater Minnesota By David D. Luehr, MD; Bruce Penner, RN; and Jeffrey L. Tucker

other potential partners to become part of the project. Social determinants As the surge in health care reform has moved forward, one of the issues that has come to the forefront is the fact that social determinants are the foundation of good health. Yet, on many fronts the task of improving population health is perceived to be solely the responsibility of medical providers. On its website, (www. health.state.mn.us/divs/che/ creatinghealthequity.html)

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Minnesota Physician November 2015

the Minnesota Department of Health (MDH) says that clinical care has only a 10 percent influence on health. They further state that, “Creating health equity requires a comprehensive solution…,” and they cite various social determinants such as housing, education, transportation, and even the criminal justice system, as areas that need attention. IHN recognized this as well, and with a long-standing relationship with various public and government organizations decided to form the alliance. How the alliance works In considering how to approach the concerns that need to be addressed, the ACH has developed an overall strategy that will utilize six key components. 1. A health information exchange (HIE) will allow all participants to share electronic health information on a real-time basis. Communication is key to the success of any collaborative effort. Currently, multiple agencies and programs operate in parallel with each other but share little information about clients and patients. This leads to inefficiencies, inadequately addressed concerns, and duplicated activities and efforts. Shared information leads to less overlap of services and better coordination of care and services across the care continuum. 2. An enhanced care coordination system that focuses on the patient’s needs. Information is one thing, but acting on it is another. Coordinating care with good information is very important. The current state of affairs does include some care coordination

at various levels, but again there is little, if any collaboration or communication between agencies or entities performing this function. Optimal coordination of care may mean having a coordinator that keeps everything organized: a coordinator of the care coordination process. That person could also streamline existing care coordination around a common data set that allows each entity to focus on what they should be doing and when they should interact with others. This reduces duplication and improves efficiency. 3. Tracking and analyzing financial and quality-related information, is necessary to improve quality and reduce the overall cost of care. Accountability implies transparency and transparency should lead to improvement. With mutual accountability comes the issue of measuring the right things from the correct sources. It also helps to understand what improvement actually looks like. Some of the questions this component needs to address are: When looking at cost, does an increase in one area result in a decrease in another? Are we striking a balance between reducing cost without sacrificing quality? Should there be more justified expenses in certain areas because of the improved quality of care, service, or outcomes?

Communication is key to the success of any collaborative effort. 4. Include public service information and services provided by county partners. According to MDH, 40 percent of the determinants of health are social or economic. Many of these are part of the scope of services provided by human services and public health departments countywide. These services can have an incredible impact on the health of the people who receive them. Under the current paradigm, much of this activity is conducted separately from other services or care delivery

providers, largely because information is not shared. It is possible that within some communities or counties there may be a lack of communication between the agencies that are working with any given client. Again the value of shared health and social information, especially through a health information exchange, is reinforced. And for the health care provider, with so much resting on these determinants of health, understanding the circumstances and issues that may be weighing on their patients is of great benefit. Good care is about the whole person and their individual and family circumstances. It’s not just about a medical condition and a brief encounter in a doctor’s office. Interestingly, the importance and strategic role of county law enforcement has come up in many discussions. Both medical and mental health issues are either a component or a driver in many situations where law enforcement is involved. Beyond that, once they are in the legal system, people still need medical and mental health services. Bringing law enforcement into the picture is important in that they are often a touch-point for individuals and families who are in critical need of better attention to the social determinants of health. 5. The creation of a new local organization, known as a Coordinated Health Services Organization, (CHSO) will achieve seamless coordination of a patient’s medical services and social services. At first glance this seems to be just another layer added to an already complex system that doesn’t function well to begin with. But in reality, this is a key component to the success of the accountable community model we are working on. The role of the CHSO is to make sure that all involved entities are connected and have access to the information they need so they can function. In essence, it allows those involved in the accountable community to do what they do best. Rather than burden providers with the task of collecting and analyzing data, the CHSO collects,

organizes, analyzes, and reports pertinent data back to the service and care providers and facilitates improvement across the community. This promotes efficiency and improves quality.

as we review all sources of revenue, expenses, and how we can ensure fairness when dividing up the “pie” in our quest to provide better, more coordinated care for our patients.

Social determinants are the foundation of good health. 6. Shared savings arrangements with participating providers. Health care providers have been working with shared savings in one form or another for many years. As the concept has matured it has moved from the days of managed care and capitation to the ACO contracts and total cost-of-care contracts now common. An important component in this trend is the addition of quality improvement measurement and reporting to help assure that savings are not generated by reducing care but by providing the appropriate level of care in an efficient manner. Our journey forward Our accountability model includes discussions with all involved agencies, providers, and community hospitals reducing costs and sharing the savings. These discussions have been interesting and they have been generally well received. On one hand it is a difficult topic because it implies smaller budgets and plunging boldly into areas that have largely been organizational silos and perhaps even fiefdoms. We openly acknowledge upfront that we want to turn the health care system on its head and redesign it—from finances, to patient flow, to coordination of services. On the other hand, when these changes improve efficiency they should also produce savings, which validates budgets by demonstrating the quality being paid for. Regardless of the concerns, improving quality and reducing costs are here to stay and sharing in the savings is one way to support the process. We have even proposed the discussion of global budgets and true transparency

The journey has been interesting and has by no means reached an end point. Integrity Health Foundation received a grant from a major payer to explore the development of the ACH model. To advance this idea, we joined forces with various partners, including the Arrowhead Health Alliance, and embarked on a robust, five-county road tour to engage medical and community stakeholders. We have received unanimous support! Additional payer funding was allocated to IHN and we were able to further develop this initiative in 2015.

IHN is also involved in an ACO, which provides us with good insights. We are actively engaged in a Minnesota State Improvement Model (SIM) grant to develop and implement an HIE, as well as collaborating with mental health providers and county services to support integration of behavioral health into primary care medical clinics. The underlying theme to all of these initiatives—the ACO, HIE, and ACH—is the importance of collaborating to effectively manage patient populations. We foster both new and longstanding relationships by reaching out in new and innovative ways. We hope to expand these projects and develop HIE and ACH initiatives in other communities where IHN clinics serve. David D. Luehr, MD, is medical

director of primary care at Integrity Health Network. Bruce Penner, RN, is director of quality at Integrity Health Network. Jeffrey L. Tucker is president and CEO of Integrity Health Network.

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Special Focus: Rural Health

he Rural Stearns Live Well at Home Coalition is a joint venture between health care entities and community-based programs that provides older adults and their caregivers in rural Stearns County with the opportunity to overcome barriers that prevent people from living independently at home. Assumption Community–Rural Stearns Faith in Action, Catholic Charities, and the Paynesville R.O.S.E Center came together to discuss the challenges of serving older adults in our rural region. Through discussion, we realized that these community-based programs all faced the same struggles and goals. We were all trying to target the same population with our services, but were not reaching those who would benefit most. As individual organizations we wanted to be everything to everyone, but our programs could not provide the holistic approach toward care necessary to keep seniors in their homes. It was decided

The Live Well at Home Coalition A community-based approach to senior care By Kayla Kildahl that we needed to invite our health care partners into the discussion, and with the assistance of the Central Minnesota Council on Aging, both CentraCare Health–Paynesville and the Belgrade Nursing Home joined our group. These new partners shared their struggle to ensure a smooth care transition of patients back into the community, and the confusion of understanding the role each community-based program played in service delivery. We decided to create a coalition to address the challenges that we were all facing, such as improving care transitions from the health care facility to home and

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helping older adults return to and live safely in their homes. We strengthened the continuum of care available to discharged patients returning home after their hospital stay at CentraCare Health–Paynesville or nursing home care at Belgrade Nursing Home. The collaborative designed a program that is customizable, emphasizes person-centered goals, holistically addresses the needs of older adults, and provides health care entities with a one-call solution to the Coalition to ensure effective care transitions. The Coalition includes CentraCare Health–Paynesville, the Belgrade Nursing Home, and five community-based program partners, Assumption Community Services–Rural Stearns Faith in Action; R.O.S.E (Reaching out to Seniors Effectively) Center in Paynesville; Catholic Charities of the Diocese of St. Cloud; Lake Region Home Health; and the Central Minnesota Council on Aging (CMCOA). The work begins Each Coalition partner brings different supportive elements to the efforts to help older adults live well at home and avoid preventable health care readmissions. Supporting independent living The R.O.S.E. Center opened its doors in 2000 with the help of a DHS grant from the state of Minnesota. They offer a Living at Home/Block Nurse Program for seniors, which is a community-based network of volunteers and professionals that provides services to Paynesville area adults so they can continue to live independently. Over the past 15 years, over 380 volunteers donating 111,000 hours of their time have helped more than 1,000 unduplicated seniors and disabled people continue to

live independently. Some of the services offered include: transportation, help with household chores, friendly visiting, support groups, a phone buddy system, and respite care. The Living at Home/Block Nurse Program uses the Live Well at Home Rapid Screen, a tool to help identify individuals at risk for long-term care placement and assess if any additional support is needed. The overstretched R.O.S.E. Center staff has been unable to devote the time needed to help those with high screening scores develop a plan that includes follow-up visits. The Coalition’s support planner fills this need. “The Coalition has been the answer to our problem,” said Inez Jones, program director of the R.O.S.E. Center. “When someone scores high on the Live Well at Home Rapid Screen, we offer them the opportunity to work with the support planner. The Coalition’s service has truly been a gift to our program.”

Over 380 volunteers ... have helped more than 1,000. Eating well The Catholic Charities of the Diocese of St. Cloud Senior Dining Program serves meals to seniors in nine Central Minnesota counties. Catholic Charities offers the Eat Well Get Well program to Coalition members, which provides 10 complimentary home delivered meals to seniors who have been discharged from hospitals and are at high risk for readmission. The deliveries include a combination of hot and frozen meals that provide one-third of the required daily calories, vitamins, and minerals. Meal delivery serves as a post discharge safety check as well. The Eat Well Get Well program focuses on improving health outcomes and reducing hospital readmissions, which in turn helps lower health care costs. After completing the program, the Coalition support planner maintains contact with those

who received meals in order to assess their progress and see if traditional home delivered meals or congregate senior dining is needed. Catholic Charities also offers evidence-based health workshops for seniors on well-being, fall prevention, and managing chronic illness. Nursing care Lake Region Home Health offers quality home nursing care so individuals can remain independent. Through the Coalition, two in-home nursing assessments are provided free of charge to program participants. The staff at Lake Region Home Health meets with the patient, and then collaborates with the Coalition and other members of their health care team to develop a care plan based on that patient’s needs. Areas of focus include home safety, generalized health assessment, medication management, health education, and the need for ongoing services. Additional services include skilled nursing, physical therapy, occupational therapy, speech therapy, home health aides, adult companionship, help with housework, independent living skills, and respite. Roxie Knisley, director of nursing for Lake Region Home Health says, “With the support of the Coalition, members are more receptive to home care and our services. Clients find that having the support of home care services makes staying at home safer.” Sustaining services Assumption Services–Rural Stearns Faith in Action (RSFIA) is a nonprofit organization that collaborates with congregations, social service agencies, and community organizations to help the elderly remain in their homes and communities. RSFIA is part of an effort throughout Stearns County to help our elderly neighbors with disabilities, and those facing difficult life situations. They provide friendly home visits, minor home repairs/modifications, housekeeping chores, transportation, shopping, running errands, respite care for caregivers, and caregiver support through one-on-one consultation.

Figure 1. Rural Stearns Live Well at Home Coalition discharge flow chart CentraCare Health Paynesville: Complete the Live Well at Home Rapid Screen upon admission. All Moderate to High risk individuals are referred to the Support Planner. Belgrade Nursing Home: Work directly with the Support Planner in discharge planning; Support Planner will complete all screenings including the Live Well at Home Rapid Screen.

The Support Planner will continue to meet with each individual enrolled on a quarterly basis until the individual graduates the program or declines services. Readmission rates will be complied on a quarterly basis as well as a Participant Satisfaction Survey to measure how well individuals feel they are doing living at home, how confident they are in their ability to remain living at home, and how satisfied they are with the services they are receiving.

Returning to the community after discharge The Coalition has developed two successful support planning models: 1) a basic referral model, and 2) a discharge referral model; both include needs assessment and person-centered planning to overcome identified barriers. The basic referral model involves only community-based referrals, through the R.O.S.E. Center, for example, for support planning services. The discharge referral model involves referrals received from the Coalition’s health care partners: the Belgrade Nursing Home and CentraCare Health– Paynesville. The Belgrade Nursing Home automatically refers discharging residents directly to the Coalition’s support planner. Screenings are completed to identify barriers that prevent a successful return to the community. CentraCare Health– Paynesville conducts the Live Well at Home Rapid Screen upon admission to the hospital and if a screening indicates a high risk for readmission or long-term care placement, that patient is referred to the support planner. Individuals who are referred through either health care entity are eligible to receive 10 free meals through

The Support Planner will then meet with the individual prior to discharge to complete: • I ntroduction to The Rural Stearns Live Well at Home Coalition • Program registration, intake, and baseline assessments • Offer support planning services • O ffer Eat Well Get Well (10 free home-delivered meals) • Offer skilled nursing (two free in-home assessments)

One month & quarterly in-home follow up The Support Planner will meet with the individuals for a one month in-home follow up and then quarterly thereafter. • Live Well at Home Rapid Screen •S urvey Questions & Safety Assessment • Medication Management • Nutrition Assessments • Continued & Additional Services • Health Promotion Workshops

the Eat Well Get Well program and two free in-home nursing visits through Lake Region Home Health Care. The support

Three to seven day in-home follow up The Support Planner will complete an in-home assess ment within three to seven days following discharge: • Live Well at Home Rapid Screen • Survey Questions • Benefits Screening • Safety Assessments • Medication Assessments • Nutritional Assessments • Continued Services • Enroll in additional services • Referrals as needed

planner meets with patients prior to discharge so they The Live Well at Home Coalition to page 41

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Professional Update: Cardiology

ongenital heart disease (CHD) is the leading cause of infant mortality and is the most common birth defect with an estimated prevalence of 10 in 1,000 live births. The true incidence of CHD however is not completely known as CHD is not necessarily apparent at birth with over one-quarter of CHD diagnoses made after infancy. Since the first intracardiac operations in the early 1950s, the survival of children born with CHD has continually increased with almost 90 percent now living into adulthood. The past two decades have seen a remarkable increase in the survival of patients with severe CHD where the median age of death has dramatically increased from two years prior to 1995 and now approaches 25 years of age. Due to this increased survival, the estimated more than one million U.S. adults with CHD now outnumber children with such a malformation almost two to one. This change in

Adult congenital heart disease Unique care concerns By Cindy M. Martin, MD demographics now necessitates that CHD no longer be considered primarily a pediatric specialty. Adults with CHD are also living longer, however many congenital heart defects are not curable and these adults with CHD will require lifelong specialized care. This need for advanced care is further highlighted in the rapidly growing population of more complex CHD (single ventricle, conotruncal defects, and AV canal defects). Unfortunately, even in the current era, the mean age of death of individuals with CHD remains greatly reduced, with recent statistics revealing median age at death being 57.

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Complications Improvements in survival, however, can no longer be the sole focus. There is also an obligation to help the CHD patient live the most fulfilled life possible. Several conditions contribute to the morbidity, in addition to the mortality, of the adult CHD population. With appropriate monitoring and early intervention, the impact of these can be mitigated. Enhanced awareness of complications is essential to not only increase life expectancy but to also maximize the quality of life for adults with CHD. Arrhythmias Arrhythmias are the most common long-term complication with a lifetime risk of more than 50 percent in patients with complex CHD and the leading diagnosis of hospital admissions. All forms of both tachyarrhythmia and bradyarrhythmia may be encountered. Mechanisms for arrhythmia in the CHD patient include scarring from previous surgeries, the consequences of long-term hemodynamic abnormalities as well as direct effects of congenital malformations such as the presence of accessory pathways. Patients with CHD lesions associated with increased risk for significant electrophysiological abnormalities, such as transposition of the great arteries, tetralogy of Fallot, or single ventricle anatomy should be monitored routinely for arrhythmias and associated symptoms. Heart failure Heart failure (HF) is a common and difficult complication of CHD and is the leading cause of death in adults with CHD. Myocardial dysfunction in CHD can be the end-result of multiple insults such as abnormal pressure or volume loading, ventricular hypertrophy,

myocardial ischemia, or even effects of prior cardiopulmonary bypass or ventriculotomy from surgical procedures. These hemodynamic and structural derangements may lead to both systolic and/or diastolic impairment and the resultant heart failure is associated with significant morbidity. The number of CHD hospitalizations for heart failure has more than doubled from 1998 to 2005, with rates close to three times that of population norms. The data is lacking to guide both diagnosis and treatment of HF in the patient with CHD and extrapolation from exisiting conventional HF data and guidelines may not apply well to CHD lesions. Once present, for many CHD patients cardiac failure becomes progressively resistant to medical management. Studies suggest that as many as 10 to 20 children currently being cared for with CHD may eventually need heart transplantation. These issues emphasize the need for close monitoring and aggressive heart failure risk factor (arrhythmias, valvular dysfunction, HTN, CAD, etc.) modification as prevention or at least the delay of heart failure is even more important in the CHD population. Pulmonary hypertension Pulmonary arterial hypertension is another complication of CHD and is prevalent in 4 to 10 percent of adults with CHD. This can also impair exercise tolerance and lead to heart failure. Eisenmenger syndrome, the most advanced form of pulmonary arterial hypertension coupled with congenital heart disease, is associated with a 10to 12-fold increase in mortality. Ongoing screening for the development or worsening of pulmonary hypertension in patients with residual significant cardiac shunts or those who had corrective surgery later in life is recommended. It has also been identified that manifestations of congenital heart disease extend beyond the cardiovascular system. Alterations in noncardiac organ systems (lung, kidney, liver, neurologic/ psychiatric development, and peripheral vasculature) can

also progress during adult life further contributing to the complexity of ongoing care. The challenge of pregnancy Contracepetion and pregnancy requires special attention in the adult CHD population especially given the increasing number of women with CHD who are in their childbearing years. Several factors such as the presence of arrythmias, residual cardiac shunts, or systemic and/or pulmonary hypertension can directly affect the choice of contraception as it is often necessary to avoid estrogen-containing forms of birth control in these cases. A recent analysis of a large nationally representative hospital discharge database in the United States demonstrated that annual deliveries for women with CHD increased 34.9 percent from 1998 to 2007 compared with an increase of 21.3 percent in the general population. To reduce both maternal and fetal risk and to optimize pregnancy and peripartum care, preconception counseling is essential for patients with CHD. Although many women with CHD can tolerate pregnancy well, women with CHD are eight times more likely to experience cardiovascular complications during pregnancy and have a six times higher risk of dying than women without CHD. The risk of pregnancy-related complications is doubled further in women with complex congenital heart disease compared to those with simple heart defects. Heart failure and arrhythmias are the most common maternal complications, whereas frequent neonatal adverse outcomes include small for gestational age birth weight, respiratory distress, and intraventricular cerebral hemorrhage. Managing these complex patients through pregnancy safely can be extremely challenging and requires a multidisciplinary approach. Patients with CHD, both female and male, have an increased risk of CHD in their children. The risk varies widely from 3 to 8 percent when there is no family history of CHD to 50 percent in autosomal

dominant conditions such as Marfan syndrome. Genetic counseling should be offered to all patients with CHD and fetal cardiac echocardiography may be recommended in pregnancies where either the mother or father has CHD.

than a decade. Ongoing public and health care education and awareness is needed to help close these gaps. Conclusion Adult congenital heart disease is one of the most rapidly grow-

Patients with CHD, both female and male, have an increased risk of CHD in their children.

Care guidelines To help guide the care of adults with congenital heart disease, the American Heart Association/American College of Cardiology (AHA/ACC) published Guidelines for the Management of Adults with Congenital Heart Disease in 2008 and earlier this year the AHA released a scientific statement manuscript specifically focused on the management of CHD in patients over 40 years of age. In addition to reviewing care recommendations, both documents highlight conditions that can be successfully managed by primary care physicians and/or a general cardiologist and those that require the involvement of specialized adult congenital heart disease physicians. Current management guidelines suggest that approximately half of the adult population with congenital heart disease would benefit from care optimization by the involvement of adult congenital heart centers. Despite continuing efforts, it is estimated that only half of adults with CHD receive any cardiovascular care and very few are cared for by an adult congenital specialist. This lack of ongoing care was further highlighted by the HEART-ACHD study published in the Journal of the American College of Cardiology, which surveyed patients on initial presentation to an adult congenital heart disease clinic. The survey found that almost half of congenital heart disease patients suffer significant gaps in their care (more than three years) and almost 10 percent were lost to follow-up for more

ing sectors of cardiology today. Due to advancements in palliative and corrective surgical procedures as well as improved perioperative management, this previously predominant pediatric population is now transforming into an adult patient population, which is precipitously increasing, not only in size but also in complexity. This adult population presents health care providers

with unique issues and clinical problems, frequently developing complications including arrhythmias, heart failure, pulmonary hypertension, as well as manifestation of extra-cardiac disease sequelae. Further challenges arise with the management of pregnancy and the maintenance of appropriate ongoing care and follow-up. An increasing body of evidence suggests that outcomes can be improved by collaboration and, when appropriate, referral to specialized centers with multidisciplinary teams dedicated to adult congenital heart disease.

Cindy M. Martin, MD, is boardcertified in cardiology and advanced heart failure and transplant and is an associate professor of medicine at the University of Minnesota. She is also co-director of the Adult Congenital and Cardiovascular Center and section head of the Advanced Heart Failure, Transplantation and Mechanical Support program.

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November 2015 Minnesota Physician

Pain Medicine

reating patients with chronic pain is often complicated and labor intensive. Managing chronic pain with long-term opioids is a controversial practice as the U.S. is experiencing an epidemic of opioid-induced morbidity and mortality. According to recent Centers for Disease Control and Prevention (CDC) data, the overdose death rate from prescription opioids more than tripled from 1990 to 2013 and opioid overdose is now the leading cause of injury death in the U.S. Doctors who prescribe longterm opioids to treat chronic pain are increasingly being held liable for patient overdoses, patient traffic accidents, and drug-related patient injuries. As a physician prescribing opioids, you could be sued for causing addiction, wrongful death, and patient injury; you could be investigated by the medical board and lose your medical license; you could even be prosecuted for murder. Reimbursement for managing opioids is low and does not adequately compensate

The importance of a pain management plan A guide for primary care physicians By David Schultz, MD the physician for the time, effort, and liability risks involved. Why prescribe opioids? Why should any sane primary care physician manage opioids in chronic pain patients? The following reasons come to mind: • As physicians, we want to help our patients. • Uncontrolled pain can have harmful physical effects such as elevated blood pressure and elevation of stress hormone levels. • Chronic pain can imprison the patient in a sedentary lifestyle and lead to suicide from chronic anxiety and depression. Opioids allow some patients to get out of bed and lead a more normal life.

• Opioids, even at high dose, do not harm the body’s organs, unlike NSAIDS and acetaminophen, which, according to the American Journal of Gastroenterology, cause thousands of American deaths each year from bleeding or liver damage respectively. • Some chronic pain patients achieve excellent pain relief, better physical functioning, and life-changing improvement with minimal side effects on long-term opioids and never become addicted. • Opioids have been the standard of care for pain management for over 100 years.

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If you weigh the pros and cons and make an informed decision to manage your chronic pain patients, with or without opioids, a pain management plan will help to keep your patients safe and you out of trouble. The importance of a plan A pain management plan is important in part because it lends structure and thoughtful logic to the management of a complex, controversial, and high-risk disease state. According to the Institute of Medicine, 100 million Americans suffer from chronic pain and one quarter of them have pain that is severe enough to reduce their quality of life. Recent NIH data suggests that 9.4 million Americans take opioids for long-term pain management and approximately 2.1 million may be considered addicted. There is little scientific evidence to prove that opioids are effective after six months of continuous use. In 2014, the American Academy of Neurology concluded that the risks of long-term opioid

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Minnesota Physician November 2015

treatment for headaches and chronic low back pain likely outweigh the benefits. In 2015, an NIH Panel on Opioids concluded, “There is insufficient evidence for every clinical decision that a provider needs to make regarding use of opioids for chronic pain.” Nonetheless, most experienced physicians agree that a substantial number of chronic pain patients benefit from long-term opioids and use them responsibly. A comprehensive pain management plan will facilitate safe opioid prescribing, help legitimate patients achieve pain relief, and reduce abuse and diversion of prescription opioids. The plan should consider the following. 1. I dentify and document the pain diagnosis you are treating. Chronic radiculopathy, complex regional pain syndrome, failed back surgery syndrome, and rheumatoid arthritis are well-defined pain diagnoses that have been historically treated with opioids. Fibromyalgia and chronic headache

are more ephemeral diagnoses for which opioid management would be more controversial. 2. Determine the relative abuse and diversion risk for each patient. It is possible to assess pre-treatment addiction risk by using screening questionnaires such as OTORI, ORT, SOAPP-R, and DIRE while screening questionnaires such as PMQ, COMM, and PDRQ may iden-

3. I dentify specific, achievable patient goals for chronic pain therapy before beginning opioids. For example: • The patient will go shopping for groceries without assistance once per week. • The patient will attend their child’s school functions twice per week. • The patient will stay out of bed for at least 14 hours per day.

A comprehensive pain management plan will facilitate safe opioid prescribing. tify abuse once treatment has started. According to a 2013 VA study by Zedler et. al., the 14-item OTORI screening questionnaire may be the best tool to predict opioid overdose prior to starting treatment. The most important medical history items associated with opioid abuse include personal or family history of addiction and comorbid psychiatric conditions.

4. D efine your opioid philosophy and rules for opioid prescribing in writing. For example: • Chronic opioids will be provided to you at the lowest possible dose that relieves pain and improves function in conjunction with multidisciplinary physical and psychological therapies and referral for interventional procedure as appropriate.

• You agree to obtain opioids only from this medical practice. If you obtain controlled substances from any other source, you must inform us immediately. • Lost and/or early prescriptions will not be refilled. • R andom urine drug screens will be performed. • We will involve family members in the evaluation and treatment process whenever possible. • Functional improvement is as important as pain relief and we will regularly measure physical function. Your patient should sign a formal “Opioid Agreement,” which describes your requirements and expectations for the patient. Sample opioid agreements are available online and should be reviewed and customized to your medical practice and your prescribing philosophy. 5. D efine a ceiling dose for opioids. Death rates are increased in The importance of a pain management plan to page 38

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November 2015 Minnesota Physician

e-health

nder the United States Health Information Technology for Economic and Clinical Health (HITECH) Act enacted in 2009, the U.S. Department of Health and Human Services has promoted the adoption and better usage of electronic health record (EHR) systems and other health information technology (HIT) to improve health care quality, reduce health care costs by reducing inefficiency, and provide appropriate context-specific information and knowledge to help guide medical decision-making. In accordance with this act, the Centers for Medicare & Medicaid Services implemented the Meaningful Use EHR Incentive Program, which financially rewards and, in its later phases, penalizes physicians and hospitals who meet meaningful use criteria of EHR usage over a phased series of initiatives. These initiatives consist of adopting a certified EHR and meeting process and quality measures, including

Utilizing the electronic health record Discrepancies between intent and reality By Deanna Teoh, MD; Shalini Kulasingam, PhD; and Genevieve Melton-Meaux, MD, PhD implementation of clinical decision support (CDS) within the EHR. A cross-sectional study of all eligible providers who participated in the EHR incentive program from April 1, 2011 through May 30, 2013 (Meaningful Use Stage 1) showed 90 to 100 percent compliance for all core measures. However, a study of health care providers at Brigham and Womenâ&#x20AC;&#x2122;s Hospital in Boston and affiliated clinics showed that participation in the Meaningful Use Program did not improve adherence to specific quality of care measures for five chronic diseases. A similar study of health care

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Minnesota Physician November 2015

providers at 35 small primary care practices showed a mixed effect in adherence to nine health care system-identified clinical quality measures, including rates of hemoglobin A1C testing, cholesterol testing, and smoking cessation interventions, up to two years after EHR adoption. Additionally, many health care providers feel that use of the EHR decreases efficiency, interferes with the patient/provider relationship, and impedes delivery of quality patient care. The discrepancies between the intent of the EHR and its current reality are due at least in part to the difficulty in developing highly usable and effective tools within the EHR. Some disease processes, such as those with clear screening and/or treatment guidelines, are more suited for CDS than others. Also, CDS tools need to be relevant to the clinician and implemented in a way that fits well into the provider workflow. Additionally, alerts need to be effective, but not so numerous that providers ignore the warnings. When implemented effectively, EHR CDS often has the ability to improve adherence to evidence-based guidelines for a range of medical conditions. The adoption of new guidelines Multiple studies have shown that it takes an average of five years for clinical guidelines to be adopted into routine clinical practice. Additionally, acceptance of guidelines does not always translate into proper implementation, as guidelines tend to be complex and change frequently. The EHR should provide CDS, which bridges the gap between knowledge, practice, and patient safety. The EHR has the ability to link to guidelines and other sources

of education; however, education in and of itself tends to have little effect. Effective CDS instantaneously gathers multiple pieces of information from various sections of the patient medical record, and makes recommendations based on a synthesis of this information. For instance, the Portland VA Medical Center in Oregon implemented a CDS tool that automatically stratified postoperative patients into low, medium, and high venous thromboembolism risk based on the type of surgical procedure and other baseline risk factors and then recommended risk-appropriate thromboprophylaxis. After piloting the tool, additional improvements were made to simplify workflow pathways and reword risk assessment criteria and guidelines to improve their readability. Once the CDS tool was optimized, adherence to venous thromboembolism prophylaxis guidelines increased from 75 percent to 95 percent and guideline adherence was positively correlated with use of the CDS tool. Reducing unindicated tests In recent years, there has been increased focus on the harms of over-screening, and as a result, many national organizations have revised their guidelines to recommend less frequent screening. For example, in 2009 the United States Preventive Services Task Force recommended delaying initiation of breast cancer screening until age 50 (previous guidelines recommended starting at age 40), and extended the screening interval to every two years (previous guidelines recommended annual screening). Likewise, starting in 2006, the American Cancer Society; American Society for Colposcopy and Cervical Pathology; and the American Society for Clinical Pathology as well as the United States Preventive Services Task Force delayed initiation of cervical cancer screening to age 21 regardless of sexual history and in 2012 recommended discontinuing screening after age 65 for low-risk women. The updated guidelines also included the option of Pap test

and human papillomavirus (HPV) co-testing in women starting at age 30, but advised against the use of HPV co-testing in women younger than 30 years of age. In 2010, Loyola University Chicago revised their EHR Pap test order set to include a warning that the co-test order was not indicated for women younger than 30 years of age. A comparison of tests performed after the intervention to tests performed before the intervention showed that the proportion of inappropriate HPV co-tests decreased to 13 percent compared to a baseline of 20 percent. Following this, the same group in 2011 made additional revisions to the EHR Pap test order set in an effort to decrease unindicated screening in women younger than 21 years of age. Two EHR prompts were initiated: 1) a bright yellow pop-up alert recommending against screening whenever a Pap test was ordered in a patient <21 years of age, and 2) a revision of the Pap order

form indicating that HPV testing was not appropriate in this age group. Although the proportion of <21 year-old women receiving Pap tests decreased significantly

period during which the alert was discontinued. This study also highlights the issue of alert fatigue, defined as the desensitization to safety alerts, with

There has been increased focus on the harms of over-screening.

from a baseline of 11.3 percent to 5.4 percent after the intervention, the number of HPV tests ordered, either as primary co-testing or reflex testing in the case of an abnormal result, did not change with the EHR intervention, suggesting that the pop-up alerts have the greatest impact on health care provider practice. In a similar study performed at the UC Davis Health System, alerts decreased Pap testing in women <21 years of age, and further decreased the number of Pap tests ordered when the alert was reinstated after a

subsequent failure to respond to well-intended warnings. In order to be effective, EHR CDS

alerts need to be monitored and changed or even deactivated when, for instance, changes in guidelines become a routine part of practice. The EHR as a tool for medical research The indexing of laboratory values, radiographic tests, medications, and even social and family history has improved the speed and accuracy with which observational studies can be Utilizing the electronic health record to page 36

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Managed Care

ssentia Health and UCare have long shared a common goal: to create stronger connections with patients for improved health and reduced costs. We also share a drive to develop new ways to serve the health care needs of aging Minnesotans in our community. In fact, with the growing ranks of aging residents, we think it’s more important than ever to help our elders live independently. Given this shared commitment, leaders at our organizations began meeting about two years ago to discuss innovative ways to improve care and coverage for Medicare beneficiaries living in northern Minnesota. Our conversation coalesced around a unique partnership— EssentiaCare. Our new Medicare Advantage plan, available to older Minnesotans living in a 10-county (Aitkin, Becker, Carlton, Cass, Clay, Crow Wing, Hubbard, Itasca, Lake, and St.

Integrating care and coverage A groundbreaking Medicare partnership By Michael Van Scoy, MD, and Russel Kuzel, MD, MMM

Louis) service area in 2016 is a preferred provider organization (PPO). (Medicare Advantage plans are a type of health plan offered by a company that contracts with Medicare to provide patients with all their benefits— Part A, hospitalization; Part B, professional services; Part D, drug coverage; and additional benefits not offered by original Medicare. The insurer is accountable for costs and quality of the health plan.)

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Minnesota Physician November 2015

In creating this partnership, our organizations leveraged their unique strengths and competencies to produce an improved patient experience. As an integrated health system serving patients in Minnesota, Wisconsin, North Dakota, and Idaho, Essentia Health has distinguished itself as a high-performing health care provider and National Committee for Quality Assurance-certified accountable care organization (ACO). It has a mission of being called to make a healthy difference in people’s lives. UCare, an independent, nonprofit health plan, has provided high-quality and affordable health coverage to Medicare enrollees for nearly 20 years. UCare’s mission is to improve the health of its members through innovative services and partnerships across communities. Equal partners in all we do Our 50/50 collaboration on EssentiaCare truly sets this PPO apart. As co-owners of the plan, Essentia Health and UCare share our investment in EssentiaCare’s administration, risk, and results. This arrangement underscores our commitment to the success of the new plan and the health of our patients. We believe our partnership is pushing the boundaries of how payers and providers traditionally work together to provide patient-centered and cost-effective care. By combining care and coverage in one plan, we’re reducing the friction

that can sometimes occur between health care providers and insurance companies. We share financial risk when care costs exceed budgets and also share in savings when care costs are low. Our highly collaborative plan is a model for delivering high-quality and cost-effective care in the future. Our PPO partnership also enables low premiums, a medical home model focusing on preventive and coordinated care, and data and service integration that comes with receiving multidisciplinary health care from a single care system.

EssentiaCare patients will be key partners in their care.

How EssentiaCare works EssentiaCare blends UCare’s excellent customer service with Essentia’s high-quality clinical care. By creating a seamless, patient-friendly experience, we build on Essentia Health’s commitment as an ACO—one that engages patients in their own health while lowering costs and improving care. EssentiaCare patients will have access to Essentia Health’s extensive network of 1,500 physicians and advanced practitioners at 69 clinics and 16 hospitals. Patients will benefit from a unique care coordination model tailored to meet their health care needs. They will also have in-network access to the specialists at Mayo Clinic in Rochester for rare or complex conditions. There is no limit to the health care providers available to patients, although care received outside of the Essentia Health network will come at a higher cost sharing. Our partnership creates opportunities in data sharing that should drive our performance and benefit our patients. Information typically held in

the hands of the health plan, such as health risk assessment results, will be shared with Essentia Health, in order to reach out to higher risk members. Patients experiencing a hospital admission or transitioning to post-acute care will be supported by clinical staff within Essentia Health. Meaningful interventions such as medication reconciliation and coordinating follow-up for high-risk conditions are facilitated by the exchange of data. When quality results from UCare and Essentia Health are combined, we can more accurately identify and address the gaps. We intend to cultivate a high level of engagement, where our patient population will be encouraged to take an active role in understanding their health status. Through their participation in establishing goals and pursuing preventive measures, as well as optimizing their chronic conditions, we anticipate a greater level of satisfaction and quality. Periodic examination of claims data will reflect the program’s performance, and highlight areas of success and opportunities. Future benefit design and network adjustments, as well as clinical management, will be influenced by our combined analysis and conclusions. Engaging older patients in their care Each patient will have a dedicated team to ensure he or she is getting the right care. Treatment decisions will lie squarely with Essentia Health physicians. Our physicians will have the authority to decide which procedures, prescriptions, and tests can be ordered with less prior authorization activity. With Essentia Health sharing responsibility for the cost of care and implementing clinical guidelines to promote safety and stewardship, the need for health plan oversight lessens. For certain clinical services, this should decrease the costs and delays inherent with prior authorizations.

Because of the unique cost structure, both partners are equally focused on providing the most cost-effective and necessary care for patients. The program design will allow our Essentia Health care teams to better know and understand our patients, facilitating personal care to meet their individual needs. Moreover, the design allows us to proactively evolve the care model for patients going forward.

While building the EssentiaCare benefits, we met with Medicare beneficiaries in our community to explore the type of coverage they value. Their feedback was incorporated into the benefit design for two plans—Secure and Grand—created to fit different budgets. The Secure plan has a low monthly premium of $33 for benefits ranging from primary care and specialist visits, hospitalization, travel coverage, prescription

Our partnership is pushing the boundaries of how payers and providers traditionally work together.

EssentiaCare patients will be key partners in their care. By putting patients at the center of the care model, we are empowering them to do the best they can to get and stay healthy. We believe this type of Medicare Advantage plan also will appeal to people who want to engage in their health with us.

coverage, to dental, vision, and hearing coverage, and a fitness benefit. The Grand plan costs $113 a month for the same comprehensive health benefits, but with lower copays and coinsurance for patients. Both plans

have no copays for primary care doctor visits. Innovating for the future We are excited about the prospect of fueling innovation through this unique Medicare Advantage partnership. We see this close integration of care, coverage, cost savings, and improved health as a template for the future—both locally and nationally. With the rise of an aging population, innovative care and coverage models like EssentiaCare become increasingly valuable for improving the quality of life for older patients and their loved ones.

Michael Van Scoy, MD, is medical director of Population Care Management, and an internal medicine physician at Essentia Health. Russel Kuzel, MD, MMM, is senior vice president and chief medical officer at UCare.

When patients need additional help, they will experience seamless customer service through one phone number and one website to schedule appointments, speak to a nurse, check claims, or discuss benefits. Administrative services such as billing, claims, marketing, and sales support will be coordinated by UCare, with an eye to minimizing paperwork and simplifying Medicare for patients. Affordable care and coverage We’ve worked hard to design a health insurance product that’s affordable and meets the needs of Medicare beneficiaries living in Duluth and rural communities in northern Minnesota. The monthly premiums are lower than comparable Medicare Advantage plans because of the incentives to our patients, physicians, and UCare to contain costs through coordinated care and a focus on preventive health. November 2015 Minnesota Physician

Utilizing the electronic health record from page 33

performed. Using the EHR to implement best practice procedures also facilitates quality improvement and comparative effectiveness research. However, tools are also being developed to improve participation in clinical trials. Currently, approximately 60 percent of pediatric oncology patients are enrolled in a clinical trial, but less than 5 percent of adult oncology patients are enrolled in trials. Even in centers where clinical trials are available, patients are often missed for eligibility screening due to limited staffing and time constraints. In a study of trial-to-patient matching for pediatric oncology patients at Cincinnati Children’s Hospital, a tool using natural language processing and information extraction technology (NLP/IE) was used to identify patients who would be eligible for a clinical trial, and clinical trials for which a patient would

patient populations, it has the be eligible. Similar to IBM potential to substantially inWatson, which extracted inforcrease identification of patients mation from many reference eligible for clinical trials. sources to gather knowledge, NLP/IE is a set of technologies Summary that “unlocks” structured or As exemplified in this review, codifiable information from documents, in this case, clinical computerized decision support tools embedded in the EHR notes in the EHR. Using this have the capability of improvtechnology ing health as an initial care provider screening tool, adherence to the number Less than 5 evidence-based needed to manclinical care percent of adult ually screen to guidelines. It match historioncology patients appears that cal clinical triare enrolled in while helpful, al enrollment decision suprates was detrials. port provides creased by 85 improvement percent (from but does not 163 patients to achieve full 24 patients), and the number of adherence and that it is likely trials requiring manual review one of several important factors per patient was decreased by to improving clinician care and 90 percent (from 42 to four guideline adherence. Analysis trials per patient), both with a of EHR-associated data may negative predictive value of 100 also allow for real-time assesspercent. If this technology can be applied to other diseases and ment of outcomes pre- and

post-implementation to determine if EHR-based interventions improve patient care, and can be used to inform future guidelines as well as improve medical research. Deanna Teoh, MD, is board-certified in obstetrics and gynecology and specializes in gynecological oncology. She is an assistant professor in the department of Obstetrics, Gynecology and Women’s Health at the University of Minnesota and medical director of gynecologic oncology at Regions Hospital. Shalini Kulasingam, PhD, is associate professor of epidemiology and community health at the University of Minnesota’s School of Public Health. Genevieve MeltonMeaux, MD, PhD, is an associate professor in the Colon and Rectal Surgery department at the University of Minnesota, is a member of the core faculty of the Institute for Health Informatics, and serves as the chief health information officer for Fairview Health Systems and University of Minnesota Physicians.

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Minnesota Physician November 2015

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Fairview Health Services

St. Health Cloud VA Care System

Opportunities to fit your life

Brainerd | Montevideo | Alexandria

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

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

•• 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.

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

• 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 PRACTICE PROVIDER (with OB)

Our longstanding, independent clinic is recruiting! PRaCtiCE HigHligHts: • Employed by private group practice • Competitive base salary + production + full benefits package • Signing bonus, student loan repayment, relocation assistance • General hospital call 1:10 • Home financing assistance

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Judy M. Erdahl, Provider Relations Coordinator Email Judy.erdahl@tchc.org • 218-631-7462 • Cell 218-639-4250

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.

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(320) 255-6301 November 2015 Minnesota Physician

The importance of a pain management plan from page 31

patients who take high doses of opioids so consider a ceiling dose for the opioids you prescribe. Data from Washington state suggests that capping a maximum opioid dose at 100– 200 morphine mg equivalents per day can reduce overdose mortality. Combining appropriate non-addicting medications such as anti-inflammatories, acetaminophen, nerve stabilizing medications, and antidepressants will help to keep the opioid dose as low as possible. 6. F acilitate multidisciplinary management. Chronic pain is most effectively treated when multidisciplinary resources are utilized so consider referring your patient to a physical therapist, psychologist, psychiatrist and/or an interventional pain clinic as appropriate. Regular physical therapy combined with a home exercise program will help maximize physical function. Treating anxiety,

depression, and comorbid psychiatric conditions with psychological or psychiatric evaluation and therapy is equally important to the success of any pain management plan. Referral to an interventional pain clinic is appropriate for patients who may benefit from interventional procedures such as:

7. Emphasize Prescription Monitoring Program (PMP) database checks and urine drug screening. It is important to check the PMP database before dispensing any opioid prescription and to perform urine drug screening (UDS) at baseline and randomly during opioid therapy. According to the Centers for

Chronic pain is most effectively treated when multidisciplinary resources are utilized. • Epidural steroid injections for disc herniation • Sympathetic blocks for complex regional pain syndrome • Medial branch radiofrequency ablation for axial spine pain of facet origin • Spinal cord stimulation for intractable neuropathic pain • Implant of an intrathecal infusion pump for targeted drug delivery in patients who are refractory to or experience unacceptable side effects from oral opioids

Medicare & Medicaid Services (CMS), PMPs have resulted in improved prescribing patterns, decreased use of multiple providers and multiple pharmacies, and a reduction in substance abuse hospital admissions. Studies from Washington state and Canada have shown that PMPs in combination with UDS, patient education, pill counts, and written opioid agreements can reduce prescription opioid abuse by 50 percent. Low-risk patients may be appropriate for

urine drug screening every six months whereas higher risk patients should be screened more frequently. Conclusion Finally, be sure to follow your written plan and protocols. If you continue to prescribe opioids in the face of positive urine drug screens and multi-provider prescriptions evident in the PMP, you put your patient’s safety and your medical license at risk. If pain is not relieved and function not improved, consider weaning opioids. Weaning protocols are available and typically include reduction of opioid dose by 10 percent to 30 percent per week depending on circumstances. If a patient is actively abusing opioids, inpatient detoxification may be appropriate. David Schultz, MD, is founder and medical director of MAPS Medical Pain Clinics and MAPS Applied Research Center. He is board-certified in anesthesiology and pain medicine.

Family or Internal Medicine Physician 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

Minnesota Physician November 2015

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

www.glacialridge.org

Family Medicine Minnesota and Wisconsin We are actively recruiting exceptional board-certified family medicine physicians to join our primary care teams in the Twin Cities (Minneapolis-St Paul) and Central Minnesota/Sartell, as well as western Wisconsin: Amery, Osceola and New Richmond. All of these positions are full-time working a 4 or 4.5 day, Monday – Friday clinic schedule. Our Minnesota opportunities are family medicine, no OB, outpatient and based in a large metropolitan area and surrounding suburbs. Our Wisconsin opportunities offer with or without obstetrics options, and include hospital call and rounding responsibilities. These positions are based in beautiful growing rural communities offering you a more traditional practice, and all are within an hours’ drive of the Twin Cities and a major airport. HealthPartners continues to receive nationally recognized clinical performance and quality awards. We offer a competitive salary and benefits package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com, 952-883-5453, toll-free: 800-472-4695. EOE

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

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

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

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

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

healthpartners.com

www.acmc.com |

WORK-LIFE BALANCE

SURROUNDED BY LAKES

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 November 2015 Minnesota Physician

Rapid recovery in total joint replacement from page 23

instead of retroactively treating it as needed. Figure 3 shows the difference in pain scores (2.8/10 compared to 4.1/10) between the datasets. Total knee replacement When comparing the outcomes on length of inpatient hospital stay, patients in the rapid recovery dataset had a mean discharge day of 1.7 compared to 3.2 days. Figure 4 shows this difference. These patients would also discharge directly to their home instead of going to a skilled nursing facility for Figure 4. Hospital stay (knees) ■ Before Rapid Recovery

4 3

3.2

■ After Rapid Recovery

2 1

rehabilitation. The percentage of patients requiring a skilled nursing facility stay was similar to that for the hip replacement dataset. Pain scores were also markedly better in the rapid recovery dataset. On postoperative day 1, pain scores in the pre-rapid recovery dataset was 4.8/10 and decreased to 3.2/10 after the development of the new protocol. Figure 5 shows this change in pain scores. The outcomes of this hip and knee replacement data demonstrate that patients are able to discharge on day 1, pain scores are markedly better, and the overall health care costs are Figure 5. Postoperative day 1 pain scores (knees) 55 44

4.8

3.2

1.7

■ Before Rapid Recovery ■ After Rapid Recovery

Length of hospital stay (days)

Postop day 1 pain (out of 10)(p= 0.002)

diminished due to shorter hospital stays and less need for patients to discharge to a skilled nursing facility after surgery. A barometer on the success of any rapid recovery protocol is the readmission rate. Since the onset of rapid recovery, there has been no increase in readmission rates at either hospital. Total joint coordinator A key success to this protocol is early education and a consistent message to patients from one person. At the MCO, the total joint coordinator is responsible for educating patients that it is possible for them to only spend one night in the hospital. Additionally, this coordinator is also available, via cell phone, to answer their questions or concerns. Having one person give one answer creates continuity of care as the patient recovers. Patients often state that the total joint coordinator is their “personal concierge” through the joint replacement process.

Everything from postoperative medication refills to having the ability to drop-in to the clinic to be seen is made available through this person. Conclusion When people think of rural hospitals, they often believe these hospitals do “minor” procedures and send all the complex surgeries, such as total joint replacement, to the larger metropolitan hospitals. However, these complex operations are now done in rural hospitals, with outcomes that match or surpass industry standards. Erik P. Severson, MD, is an orthope-

dic surgeon at the Minnesota Center for Orthopaedics. Adam R. English, MSN, NP-C, is a board-certified family nurse practitioner and the total joint coordinator for the Minnesota Center for Orthopaedics at both Cuyuna Regional Medical Center and Riverwood Healthcare Center.

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

Psychiatrist

Sleep Medicine

Rochester Clinics

Rochester Southeast Clinic

Rochester Northwest Clinic

Pain Medicine

Psychiatrist– Child & Adolescence

Urology

Rochester Northwest Clinic

Rochester Southeast 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 November 2015

Hospital

can establish needed support and begin services before the patient returns home. This proactive model is a major factor in eliminating any transitional gaps that may occur from hospital to home (see Figure 1). Once the individual has been discharged from the hospital or nursing home, the support planner completes an in-home follow-up visit within three to seven days. At that time the care plan is reviewed and adjusted if necessary. After the initial visit, the support planner returns to the home one month after discharge, then quarterly, and finally only as needed once the patient is deemed to be stable. At each meeting, outcome measurements are obtained through survey questions and the Live Well at Home Rapid Screen. The support planner also asks three additional survey questions at each meeting to measure satisfaction with

the program: 1) How well do you feel you are doing living at home? 2) How confident are you in your ability to remain living at home? 3) How satisfied are you with the services you are receiving? By asking the same questions at each meeting, the support planner can identify areas that may have declined or improved since the previous meeting and adjust the care plan accordingly.

one individual was readmitted to the hospital within a 30-day period after receiving Coalition services, leaving the overall success rate for the first year at 97 percent. The Eat Well Get Well program provided 117 meals for 22 participants and Lake Region Home Health provided skilled nursing to 18 individuals within the first year. Of the 103 individuals served, 29 utilized volunteer services through the Paynesville R.O.S.E. Center or

Of the 103 participants, only one individual was readmitted to the hospital. The results The Coalition is now in its fifth quarter and has had some remarkable results after the first year of outcome measurements. The Coalition had 103 individuals enrolled in the program within the first year. Of the 103 participants, only

Family Medicine & Emergency Medicine Physicians

Great Opportunities

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

Rural Stearns Faith in Action and 29 participated in Health Promotion Classes offered through Catholic Charities. Coalition participants reported that they are more confident in their ability to live at home after becoming aware of and accessing available services.

An overwhelming majority of participants report that they are satisfied with the Coalition services. “Each partner has a unique and valued role in the success of this Coalition,” said April Stadtler, a social worker for CentraCare Health–Paynesville and one of the founding members of the Coalition. “The Coalition helps to quickly and effectively identify the needs of each individual and sets the support process in motion before they leave the hospital.” If you would like more information on Coalition services, please contact Kayla Kildahl, support planner, at (320) 247-9790 or at kildahl.kayla@ assumptionhome.com. Kayla Kildahl is a support planner and caregiver consultant at Assumption Community Services, Inc., Rural Stearns Faith in Action. She is also a member of the Rural Stearns Live Well at Home Coalition.

Join our team 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:

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

1-800-248-4921 (toll-free) Katie.Schrum@allina.com

The Live Well at Home Coalition from page 27

physicianjobs.allinahealth.org November 2015 Minnesota Physician

Integration role reversal from page 21

nurse practitioner. It had jagged borders with a very dark variegated color pattern. The location of the mole was difficult for her to view, therefore, she was unsure if there had been any change in the shape, size, or color. This lesion was very concerning, however, so a referral to Mayo Clinic Dermatology was made and EH was seen within a few weeks. The lesion was excised and confirmed to be malignant melanoma. EH was given detailed education on how to further monitor and care for her skin in the future. She continues to follow-up in the primary care clinic as well as with psychiatry and therapy. Key lessons This initiative has presented numerous challenges, ranging from securing funding for the primary clinic build-out to finding clinicians with the diverse skills necessary for working with the target populations. Many of these issues

were anticipated while others, like those below, provided key lessons during the implementation process. • The leadership team made the intentional decision early on in the planning process to have primary care staff be employees of Zumbro Valley rather than contracting with or partnering with an existing primary care clinic to provide the staff. It was believed that it would be easier to integrate the primary care staff if they were employees of Zumbro Valley and invested in the success of the integrated model and the organization without a “split loyalty.” • Zumbro Valley Health Center mental health and chemical health staff are educated, trained, and focused on their area of expertise and have not traditionally trained in the medical aspects or comorbidities that exist for individuals who have a mental illness or addiction disorder. These professionals are very focused, or “siloed,” in their areas of expertise.

• During the planning for the integration model, the leadership team reviewed the limitations of its former name—Zumbro Valley Mental Health Center—and determined to change it to better reflect the entirety of the current services and signify other health carebased services that may be added in the future. • Primary care training and experience often involves an understanding of mental illness and chemical health problems, but the opposite has not proven to be true. As a result, the mental health and chemical health staff do not have the same level of comfort interacting with the primary care team. Conclusion Studies have demonstrated that more than 34 million American adults, or 17 percent of the adult population, have comorbid medical and mental health conditions. Rates of depression and anxiety are significantly higher in people with asthma, diabetes,

Three patients. Who is at risk for diabetes?

and cardiovascular disease than for those without these conditions. Enhanced integration of behavioral health/medical services has been shown to improve outcomes in this population, and our integrated care model has provided hundreds of Zumbro Valley Health Center patients with a truly coordinated approach to their myriad needs. Margaret Lloyd, MD, is a consultant in

the Division of Cardiovascular Diseases and the Department of Internal Medicine at Mayo Clinic. She is also an assistant professor at the Mayo Clinic College of Medicine as well as board chair for Zumbro Valley Health Center. Dave Cook, MSW, LICSW, is CEO of Zumbro Valley Health Center and has more than 25 years of administrative and clinical experience. Sean Rice, MBA, directs the marketing, communications, and business development activities for Zumbro Valley Health Center and leads the marketing committee for its board of directors.

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

Minnesota Physician November 2015

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